Complex Anorectal Fistulas

Abstract

The optimal management of complex anorectal fistulas such as recurrent fistula-in-ano, rectourethral fistula, and ileal-pouch fistula remains the subject of ongoing scientific research and academic debate. While numerous surgical procedures are available, overall there is absence of a standardized approach to the treatment of such conditions due to the lack of randomized clinical trial data, heterogeneity of patient populations reported in various studies, and wide ranges of reported outcome. When faced with a patient with anorectal fistulous disease, the aim of any intervention is to eradicate the fistula, to prevent recurrence, to minimize postoperative complications, and to preserve anal continence. The history and physical examination along with selective imaging to delineate the anatomy of the fistula are critical to individualize the patient’s treatment. When possible, simple procedures should be attempted first if there is a potential for success before more complex procedures are considered. It is important to convey to the patient the expectations and limitations of surgical treatment, including the need for multiple operations, the risk of failure, and the potential poor anorectal and urinary function.