Current State-of-the Art of Anal Fistula Surgery in Germany

Surgery for anal fistulas and abscesses is as old as humankind. Procedures were performed more than 2000 years ago, described in ancient manuscripts. In modern times, anal fistulas remain a significant issue for colorectal surgeons. Only surgery can heal the patient. A septic process starts within an anal cryptogland, forming an abscess in the acute phase and a fistula in the chronic phase. Patients with recurrent abscesses will only have relief when the underlying fistula has been dealt with. Most fistulas are superficial: fistulotomy results in a low recurrence rate with only minor problems concerning fecal continence. Complex fistulas are those in which fistulotomy produces fecal incontinence. Therefore, sphincter-saving procedures have been developed. These techniques are described, and the pros and cons are discussed. In German guidelines, rectal advancement flap and fistulectomy with primary anal sphincter repair have found their place. In the last 30 years, many new techniques have been developed; some are still being used, while others have been abandoned. Surgery for anal fistula is demanding: recurrence and fecal incontinence rates should be low. On the other hand, the more recurrences a patient has, the higher the chance of a new recurrence and the higher the chance of fecal incontinence. Every new septic process in the anal region may worsen anal and pelvic floor function. The colorectal surgeon dealing with a complex anal fistula should have more than one option to offer and discuss with the patient