Principles and contemporary management of anal fistulas

Anal fistulas are chronic pathological connections between the anal canal and perineal skin. By either persistently discharging or intermittently occluding, causing recurrent abscess formation, they can significantly impact on the lives of those afflicted. Anal fistulas often pass through the anal sphincter complex, responsible for maintaining continence to rectal contents (gas, liquid or solid stool); therefore, treatment is aimed not only at fistula eradication but also at preserving sphincteric function. To date, fistulotomy remains the most effective way of eradicating the pathology, but division of those sphincter muscle fibres enclosed by the tract renders the patient at risk of incontinence. For those in whom fistulotomy is not recommended, alternative strategies exist, including techniques aimed at minimizing sphincter disruption, ′sphincter−conserving′ methods or the placement of a long−term loose draining seton. This article reviews the literature on all aspects of anal fistulas, and hopefully p...