Abstract
BackgroundManagement of anal fistula (AF) remains challenging with many controversies. The purpose of this study was to explore current surgical practice in the management of AF with a focus on technical variations among surgeons.MethodsAn online survey was conducted by inviting all surgeons and physicians on the membership directory of European Society of Coloproctology and American Society of Colon and Rectal Surgeons. An invitation was extended to others via social media. The survey had 74 questions exploring diagnostic and surgical techniques.ResultsIn March 2018, 3572 physicians on membership directory were invited to take part in the study 510 of whom (14%) responded to the survey. Of these respondents, 492 (96%) were surgeons. Respondents were mostly colorectal surgeons (84%) at consultant level (84%), age ≥ 40 years (64%), practicing in academic (53%) or teaching (30%) hospitals, from the USA (36%) and Europe (34%). About 80% considered fistulotomy as the gold standard treatment for simple fistulas. Endorectal advancement flap was performed using partial- (42%) or full-thickness (44%) flaps. Up to 38% of surgeons performed ligation of the intersphincteric fistula tract (LIFT) sometimes with technical variations. Geographic and demographic differences were found in both the diagnostic and therapeutic approaches to AF. Declared rates of recurrence and fecal incontinence with these techniques were variable and did not correlate with surgeons’ experience. Only 1–4% of surgeons were confident in performing the most novel sphincter-preserving techniques in patients with Crohn’s disease.ConclusionsProfound technical variations exist in surgical management of AF, making it difficult to reproduce and compare treatment outcomes among different centers.
Highlights
Descriptions of anal fistula (AF) are found in the oldest known medical literature [1]
A total of 3708 individuals were approached by email via membership directories of the two above-mentioned colorectal societies (n = 3541) and via social media invitation (n = 167)
A total of 194 (39%) and 48 (10%) surgeons came from North and South Americas, respectively, 170 (35%) from Europe, 57 (12%) from Asia, 17 (3%) from Australia and New Zealand, and only 2 (0.4%) from Africa, for a total of 66 countries involved
Summary
Descriptions of anal fistula (AF) are found in the oldest known medical literature [1]. The purpose of this study was to explore current surgical practice in the management of AF with a focus on technical variations among surgeons. Methods An online survey was conducted by inviting all surgeons and physicians on the membership directory of European Society of Coloproctology and American Society of Colon and Rectal Surgeons. Results In March 2018, 3572 physicians on membership directory were invited to take part in the study 510 of whom (14%) responded to the survey. Of these respondents, 492 (96%) were surgeons. Up to 38% of surgeons performed ligation of the intersphincteric fistula tract (LIFT) sometimes with technical variations. 1–4% of surgeons were confident in performing the most novel sphincter-preserving techniques in patients with Crohn’s disease. Conclusions Profound technical variations exist in surgical management of AF, making it difficult to reproduce and compare treatment outcomes among different centers
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