Fistulous Track Research Articles

A Comparative Study in the Management of Fistula in ANO

Abstract: Background- Fistula in ano is an abnormally communication between rectum or anal canal to skin around the anus. Fistula in ano is mostly seen after an anorectal abscess. According to Ayurveda “bhagandra” is formed after “guda pidika”. The principle of management of fistula are eradication of infected anal crypt and fistulous track and preserved function of sphincter. Methods- this is a randomized comparative study 30 case of fistula in ano presenting at opd of national resource center of kshar sutra in sir suderlal hospital institute of medical science Banaras Hindu university. from 15 patients were treated with IFTAK and 15 patients were treated with modified LIFT.

Congenital Dermoid Fistula of the Anterior Chest Region: A Case Report

Congenital Dermoid Fistula of the Anterior Chest Region (CDFACR) is a subcutaneous fistula that ends caudally in the subcutaneous tissue close to the sternoclavicular joint, originating from the skin at the anterior border of the sternocleidomastoid. The fistulous track is lined by keratinised stratified squamous epithelium with hair follicles, sebaceous glands and sweat glands. It presents clinically as a cutaneous pit, sinus, or infected mass. It is rare and can be complicated by recurrent infection and abscess formation. Before surgery, imaging the complete extent of the sinus is essential to prevent recurrence. Authors hereby, report a case of a 20-year-old male presenting with discharge from the anterior chest wall. On radiological and histopathological examination, it was diagnosed as a congenital dermoid fistula. In the present report, authors present a case of CDFACR confirmed through comprehensive evaluation, including sonography, Computed Tomography (CT) sinography, Magnetic Resonance Imaging (MRI) and histopathology. The present case also represents the first documented instance of CDFACR from India, highlighting the importance of multimodal imaging in the diagnosis and management of this rare congenital anomaly.

Single Case study on Horse Shoe Fistula with Partial Fistulectomy followed by Kshara Sutra Procedure

Bhagandara is enumerated under Astamahagada[1] and it is a Chedana Sadya Vyadi, clinically which can be correlated to Fistula-In-Ano. It is a communicating track lined by unhealthy granulation tissue; opens internally in the anal canal or rectum and perianal region. Commonly this disease develops after spontaneous bursting or inappropriate surgical drainage of an abscess. It then remains open with pus discharge.[2] The incidence of a Fistula-in-Ano developing from an anal abscess ranges from 26% to 38%, the prevalence rate of Fistula-in-Ano is 8.6 cases per 100,000 population worldwide, in men the prevalence rate is 12.3 cases per 100,000 population and in women it is 5.6 cases per 100,000 population.[3] Depending upon the extent and nature of Fistulous tracks, Acharya Sushruta has described different type of incision in the management of Bhagandara. Here in this article a small attempt has been made to throw light on Sushrutokta Chedana Karma in Bhagandara.

A single institution experience in the treatment of fistula in ano using diode laser (fistula laser closure): short-term outcomes

Introduction Management of the perianal fistula has been always a challenge for colorectal surgeons especially when the external sphincter is involved. Several minimally invasive procedures emerged as an alternative to the traditional surgical approach as fibrin glue injection, ligation of the intershpincteric track (LIFT) and injection of platelet-rich plasma (PRP). Recently, the use of diode laser in proctology has emerged as an alternative to conventional surgical treatment. The laser beam causes shrinkage and sealing of the fistulous track that depends on the power and the duration of laser light application. Patients and methods This study was carried out on 69 patients with perianal fistula in the Gastrointestinal Surgery Unit, General Surgery Department, Tanta University Hospitals, during the study period from February 2021 to December 2022. Patients underwent fistula laser closure (FILAC) using a diode laser, radial fibers, wavelength 1470 nm, and 10 watts of power. Results Sixty nine patients underwent fistula laser closure. The success rate was 74%. There was significance between recurrence and posterior position of the fistulous track of the intersphincteric type. Also, there was significance between recurrence and cases who had a caliber track more than 7 mm but there was no significance between recurrence and length of the track. The procedure was associated with minimal postoperative pain, long period of postoperative discharge, short hospital stay, and early return to normal activities. Conclusion Diode laser is a safe minimally invasive and effective procedure for the treatment of straight non branched short track fistula with some considerations as the caliber track should not exceed 7 mm and the posterior intersphincteric fistula should be treated by lay open fistulotomy. The procedure is also associated with less postoperative pain, early return to normal activities, and minimal recurrence rate but high cost remains a limitation.

Management of Complex Fistula-in-ano by Interception of Fistula Track with Application of Ksharasutra (IFTAK): A Novel Technique

Abstract Objective Despite all the technological advances, successful management of complex fistula-in-ano is still a challenge due to recurrence and incontinence. The present study evaluates the outcomes of a novel technique, Interception of Fistula Track with Application of Ksharasutra (IFTAK) in terms of success rate and degree of incontinence. Methods In the present prospective study, 300 patients with complex fistula-in-ano were treated by the IFTAK technique, whose surgical steps include: incision at the anterior or posterior midline perianal area, identification and interception of the fistulous track at the level of the external sphincter, rerouting the track (and extensions) at the site of interception, and application of a ksharasutra (medicated seton) in the proximal track (from the site of interception to the internal opening) that is laid open gradually, with the resulting wound healing with minimum scarring. The distal track is allowed to heal spontaneously. Results There were 227 trans-sphincteric and 73 intersphincteric varieties of fistula with supralevator extension in 23 cases, of which 130 were recurrent fistulas, 29 had horseshoe track, while 25 had blind fistula with no cutaneous opening. The mean duration of the ksharasutra application was 8.11 ± 3.86 weeks with an overall success rate of 93.33% at the 1-year follow-up. A total of 3.67% of the cases reported with a mild impairment of continence on the Wexner incontinence scoring system. Pre- and postoperative anal manometry evaluation showed minimal reduction in median basal and squeeze pressures. Conclusion The IFTAK technique is a minimally invasive, daycare surgical procedure for the management of complex fistula-in-ano with low recurrence and minimal sphincter damage.

Cardiac arrest due to massive aspiration from a broncho-esophageal fistula: A case report

BACKGROUNDTracheo and broncho esophageal fistulas and their potential complications in adults are seldom encountered in clinical practice but carries a significant morbidity and mortality.CASE SUMMARYWe present a case of a 39-year-old otherwise healthy man who presented to our hospital after ingestion of drain cleaner substance during a suicidal attempt. He unexpectedly suffered from cardiac arrest during his stay in the intensive care unit. The patient had developed extensive segmental trachea-broncho-esophageal fistulous tracks that led to a sudden and significant aspiration event of gastric and duodenal contents with subsequent cardiopulmonary arrest. Endoscopic evaluation of extension of fistulous track proved a slow and delayed progression of disease despite initial management with esophageal stenting for his caustic injury.CONCLUSIONThe aim of this case presentation is to share with the reader the dire natural history of trachea-broncho-esophageal fistulas and its delayed progression. We aim to illustrate pitfalls in the endoscopic examination and provide further awareness on critical care monitoring and management strategies to reduce its morbidity and mortality.

MR Imaging Evaluation of Perianal fistulae

Background: Perianal fistula is a troublesome condition both for patient and surgeon with significant morbidity and challenging treatment. MRI is considered as the technique of choice for preoperative evaluation of perianal fistulae, as it provides accurate anatomical information for appropriate surgical treatment, decreasing the incidence of recurrence and allowing side effects such as fecal incontinence to be avoided. The study aimed to describe the role of magnetic resonance imaging (MRI) in the diagnosis and classification of perianal fistulae.
 Methods: This retrospective study looked at 52 patients referred to the radiology department with a clinical diagnosis of perianal fistula. MRI grading of anal fistula done according to St. James’s University Hospital classification.
 Results: The MRI showed 46 internal openings in 44 patients; two patients had more than one. The internal opening was mostly at the 6 o’clock position in 59.9% patients, followed by 7 o’clock and 5 o’clock position in 11.3% of patients. According to the St. James’s University Hospital classification, 21 (47.7%) patients had grade 1, 11 (25%) patients had grade 2, 2 (4.5%) had grade 3, 7 (15.9%) had grade 4, and 4 (9%) had grade 5 fistulae. Twenty-five patients had associated abscesses. The most common location of the abscess was in the perianal region (8 patients).
 Conclusions: MR imaging examinations is a highly accurate imaging method for preoperative evaluation perianal fistula. It provides precise information of the fistulous track, along with its relationship to pelvic structures and plays crucial role for surgical planning.

Gastrocutaneous fistula after laparoscopic cholecystectomy: An unforeseen mishap

A middle-aged woman presented to us with complaints of purulent discharge which was coming from the epigastric port site for two years following laparoscopic cholecystectomy, which was performed at an outside hospital for asymptomatic gall stone disease. Computed tomography and magnetic resonance imaging (MRI) confirmed the fistulous sinus track communicating with the anterior body wall of the stomach. At re-laparotomy, the sistulous sinus track was found and excised with primary repair of the defect in the stomach wall. The patient had an uneventful post-operative recovery and was doing well on follow-up. This was the second such case reported in literature where a common surgical procedure like laparoscopic cholecystectomy has led to the formation of gastrocutaneous fistula, which is a rare complication and was successfully managed.

Fistula in Ano-An Entity with Enigmas: what to do and what not to do

Background: Fistula-in-ano is the leading complication of perineal sepsis. Usually, a fistula has an external opening, a track, and an internal opening. Following infection and/or an abscess,External opening may appear acutely or with delayed appearance in a chronic manner. Management protocol for a fistula includesassessment of the extent of fistulous track &its relation to the anal sphincter muscle, control of infection,and finally, surgical treatment of the fistula & follow up. The principles in management of anal fistula aredrainage of infection or necrotic tissue, closure of internal opening of fistula tract, and removal of fistulous tract with preservation of sphincter function. The objectives of the studyis to compare the per operative and post-operative complications, mean hospital stay in the treatment of fistula in ano with treatment options like fistulotomy, fistulectomy, and setons. Methods: This is a comparative, prospective study of 60 patients who presented with their complaints to the Surgerical Outpatient department and who were admitted under the Department of General Surgery, P K Das Institute of Medical Sciences, Vaniamkulum, Palakkad, Kerala. Patients who met the inclusion criteria were included in this clinical study. Of the 60 patients selected for the sudy, 20 patients were surgically treated by fistulectomy, 20 by seton, 20 by fistulotomy over a period of 2 years. Results: Most common age of presentation is 21-30 years and more common in males then females (M:F= 2.3:1 ). Most common per operative complication was bleeding which was seen more in patients undergoing fistulectomy. 36% of the patients wound healed in less than 1 week, 22% of patients wound healed in 1 to 2 weeks,15% of patients wound healed in 2 to 3 weeks, 9% of the patients wound healed in 3 to 4 weeks. Conclusion: Fistula in ano is cured by various methods of surgery and higher antibiotics, local antibiotics with good post-operative wound management, like sitz bath without closing the wound and frequent/regular follow up.Seton technique is better compare to fistulectomy and which is better than fistulotomy.

English

BACKGROUND Perianal fistulas account for a substantial discomfort and morbidity to the patient thus affecting productive man hours and quality of life. Accurate pre-operative assessment of course of the primary fistulous track and secondary extension or abscesses is required for successful surgical management of anal fistulas. The purpose of this study was to diagnose and classify pre-operative perianal fistulas. METHODS This is a cross-sectional study at Department of Radiodiagnosis in a tertiary level hospital of southern Rajasthan from November 2018 to November 2020. The study included a total of 50 patients referred to department of radiology for magnetic resonance imaging (MRI). Statistical analysis was done using chi square test and student t test. RESULTS Out of these patients, 56 % were having secondary tract on MRI, 12 % patients were having abscess and 4 % were having horseshoe abscess on MRI. The commonest type of ano-rectal fistula encountered in the study was Grade -II seen in 32 %. CONCLUSIONS MRI is a highly accurate, rapid and non-invasive tool in pre-operative evaluation of the perianal and anal fistulas. MRI evaluation and classification of perianal fistulae has a high degree of diagnostic accuracy. The use of MRI for the diagnosis and classification of perianal fistula can provide reliable information which has both pre-operative and prognostic value. St James University Hospital classification, which is an MR imaging-based grading system for perianal fistula is very useful for effective radiological-surgical communication thus contributing to improved patient care and reduced rate of recurrence. KEYWORDS MR Fistulogram, Perianal Fistula, Anal Fistula, Fistula Classification, Fistulography

Management of of complex fistula-in-ano by a IFTAK technique - case report

Ksharsutra is a Medicated seton which is made by coating the Barbour thread with 21 coatings of Kshara i.e. an herbal alkaline powder, turmeric and latex of Euphorbia nerrifolia. Ksharsutra application is a minimal invasive well established procedure in management of fistula-in-ano. Research on Ksharsutra started since 1968 and it is being used till date with high success rate. In this case report the patient was asymptomatic before 15 years but then a boil developed at perianal region which spontaneously bursted and pus discharge was seen from the boil. Patient was diagnosed with Grade 5 St. James’s university hospital classification of perianal fistulae. This was a case of high anal horse shoe fistula. In this case Fistulectomy or Fistulotomy would cause incontinence. So in this case the Ksharsutra was used but with a modification of classical technique called as IFTAK (Interception of fistulous track with application of Ksharsutra) technique. In which a window was created at 6o’ clock and intersphincteric tract was identified and in that tract Ksharsutra was placed. This technique cures such types of complex Fistula in ano with minimal tissue damage and duration of healing is also reduced.

Novel Animal Model from Goat Ano Rectum and Pumpkin for Training of Surgeons in Management of Fistula in Ano

There is no perfect treatment for different types of fistulae in ano. Training in fistula management carries a long learning curve; an animal model from goat anal canal and rectum was prepared for training of surgeons in the management of benign anorectal diseases, especially fistula in ano. Simple material was used for creating this animal model. The hindgut portion of the goat was fixed in pumpkin. A hole was created in the pumpkin, and the pulp was removed to make space for the goat specimen. Anatomy was explained after dissection and fistulae were artificially created for simulation purposes. Model was used for training in a workshop conducted at our hospital, and feedback was taken from the participants on its utility, in learning anatomy of the area, primary sphincter repair, and use of endoscope and LASERs for fistula management. Model costs only rupees 500/-. Anatomy of the goat anal canal and rectum is quite similar to human beings. All the participants could appreciate the anal canal anatomy, different perianal spaces and sphincters were demonstrated, and fistulectomy and primary sphincter repair were taught. Consultant and participants appreciated the use of endoscope and LASERs in fistulous tracks in a simulated environment. All the consultants and participants strongly recommended the use of this model for future hands-on workshops. Our model was more realistic for practicing suturing in closed anal space, demonstration of perianal spaces, fistulae, and their management.

Two-staged surgical approach along with Ksharasutra therapy in the management of complex, non-specific, posterior, horse-shoe-shaped fistula-in-ano: A case report

Bhagandara is one of the Ashtamahagada (~eight grave diseases) that resembles with the anal fistula in modern parlance. Many surgical techniques are available in modern practice though management of the fistula is challenging due to its high recurrence rate and associated complications. This study aims to diagnose a case of fistula-in-ano and to treat the case by two-staged surgical approach along with Ksharasutra. A 28-year-old male patient came to out patient department (OPD) of Shalya tantra with complaints of painful swelling with pus discharge from perianal region, which was diagnosed as complex, nonspecific, posterior horse-shoe shaped fistula-in-ano with approximately 80 mm long track. The condition is not only difficult but also takes a longer period for complete cure with varied success rate, hence, two-staged surgical approach along with Ksharasutra has been employed. The fistulous track was completely healed by almost 13 weeks. Follow-up was done for the next three months. There was no recurrence of the condition, and normal sphincter tone was achieved. The result of the present case is encouraging, and the patient was treated effectively without any complications and without disturbing his daily social life.

Uses of FiLaC laser as a sphincter-preserving technique in closure of fistula tract in Upper Egypt

Aim Treatment of anal fistula as one of anorectal disease is difficult. Anal incontinence and recurrence of fistula are fearful morbidities of surgeons. Many techniques for sphincter preservation such as internal sphincter fistula tract attachment, anorectal flap application, and bioprosthetic plugs have been tried to overcome the complications. This article aimed to estimate the safety and efficacy of the FiLaC method in the management of fistulous tract. Patients and methods A total of 26 patients (22 males, four females) who underwent FiLaC diode laser treatment between October 2019 and October 2020 were admitted at the Surgical Department, Al Azhar University Hospital, Assiut, and Al-Rowad Hospital, Assiut. They were retrospectively analyzed for age and sex, BMI, American Society of Anesthesiologist score, duration of operation, fistula types, complications, and patient satisfaction. FiLaC a 15-W laser probe with a wavelength of 1470 nm and a power of 100–120 J/cm was applied to the fistulous track under the spinal anesthesia. Results The number of male patients were 22 and female patients were four, and the mean age was 35.55±10.32 years. The mean time of operation was 18.37±5.27 min. Intraoperative complications were not recorded. The period of follow-up was 12 months. A total of 23 (88.46%) patients recovered. There were three (11.53%) failures. Satisfaction score of the patients was 4.62±1.07. Conclusion FiLaC laser for the use of closure of fistulous tract is an effective, safe, minimally invasive technique for preservation of the anal sphincter, with a high success rate.

The use of rerouting operation in the treatment of high arching transsphincteric and suprasphincteric anal fistula: an observational study

Background Perianal fistula is a common disease that has no medical treatment, and cure is only achieved by surgery. Fistulotomy is associated with minimal recurrence; however, incontinence is not uncommonly reported. Many sphincter-saving procedures can avoid fecal incontinence; however, they are associated with significantly higher recurrence. Anal fistula rerouting, described in 1985, entailed staged transposition of the fistulous track to the intersphincteric or submucous space, after which fistulotomy was done. Apparently, minimal recurrence and minimal incontinence could be achieved; however, the operation did not gain much popularity. Patients and methods This prospective study reports the results of rerouting operation in 54 (45 males; age 22–69 years) with high arching transsphincteric and suprasphincteric fistulae. All patients underwent two-stage rerouting operation: in stage I, the track was transposed to the intersphincteric space, and in stage II, the intersphincteric fistula was laid open. Main outcome measures were as follows: continence was assessed using Wexner score after complete healing of the first-stage and second-stage wounds, and every 3 months thereafter for 1 year. Recurrence was defined as persistent purulent discharge from an external opening or from the anal canal. The least follow-up was 9 months. Results Three (5.5%) patients had recurrence; two were treated by fistulotomy and the other refused further intervention. Four (7.4%) patients had minor incontinence. One patient developed track gangrene that was treated by track excision and completed staged rerouting successfully. Conclusions Rerouting operation for high arching transsphincteric and suprasphincteric fistulae is associated with low recurrence and minimal incontinence.

English

BACKGROUND Magnetic resonance imaging is known to demonstrate the perianal anatomy accurately. MR Fistulography with saline as contrast agent has been described to facilitate the detection of fistula tracks. We wanted to study the diagnostic accuracy, sensitivity, specificity, positive and negative predictive values of magnetic resonance fistulography using saline as a contrast agent using surgical findings as a reference standard. METHODS Fifty-nine clinically diagnosed cases of perianal fistulae who were sent for preoperative MR imaging of the perianal fistulae were included in the study. MR imaging after instillation of saline was obtained in these patients through a cannula inserted into the external opening. T2 and STIR images in axial and coronal planes were studied. Diagnostic indices were calculated using surgical findings as reference standard. RESULTS MR imaging with saline instillation demonstrated a sensitivity of 97.92 % in the detection of primary tracks. The sensitivity in determination of internal opening, secondary tracks, abscesses and horseshoe tracks were 98.04 %, 95.24 %, 100 % and 100 % respectively. MRI had 100 % specificity in detection of primary tracks, internal opening, secondary tracks, abscesses and horseshoe tracks before and after instillation of saline. The sensitivity was found to be more in participants who did not have active perianal discharge at the time of MR examination. CONCLUSIONS MRI with instillation of saline into the fistulous track is highly accurate for the presurgical evaluation of perianal fistula with respect to accurate depiction of primary track, secondary track, abscess and horseshoe extensions. It can serve as a cheaper alternative to MR examination using I.V. Gadolinium based contrast agents or MR Fistulography using Gadolinium agents. KEYWORDS Magnetic Resonance Imaging (MRI), Perianal Fistula, Saline, Pre-Operative Assessment, Fistulography, Horseshoe, Internal Opening, Secondary Tracks

P1468 a rare cause of chest pain:sudden rupture of aortic valsalva sinus aneurysm

Abstract Introduction Sinus of Valsalva aneurysms (SOVAs) occur when there is a congenital defect in the aortic media and incomplete fusion of distal bulbar septum (primitive bulbus cordis) and truncal ridges. These aneurysms usually rupture into the right side of the heart, with the right ventricle being the most common. Case Presentation A 32 year old male patient who presented to our facility with an attack of ulcerative colitis activity ,elevated inflammatory markers and thrombocytosis. During hospital stay, he developed sudden onset of retrosternal compressing chest pain. On examination he was afebrile with a blood pressure of 130/80 mm Hg and pulse rate 110 beats per minute. He had soft systolic and early diastolic murmurs with normal chest auscultation; there was no haemodynamic discrepancy between left and right sides or stigmata of endocarditis. His ECG showed sinus rhythm with no ST segment changes, and chest x ray was normal. Full blood count revealed thrombocytosis & normochromic normocytic anemia , cardiac enzymes were normal, blood cultures were sterile. A 2D transthoracic echocardiography (TTE) revealed dilated left ventricular dimensions , there is an aneurysm of the right sinus of Valsalva which is communicating with the right ventricle (RV)confirmed by color Doppler and negative contrast seen inside RV during bubble study. 3D TTE showed a small fistulous track between the right sinus and RV. The patient refused surgical or percutaneous closure. Conclusion Congenital RSVAs account for 0.1–3.5% of congenital heart defects.It has a higher incidence in Asian versus Western populations with male to female ratio 3:1. SOVAs arise from the right sinus of Valsalva in 80–85% of these cases and from the noncoronary sinus in 5–15%. They rarely arise from the left sinus, as the left coronary cusp embryologically is not derived from bulbar septum. This is distinct from acquired SOVAs, which can occur in any of the sinuses Traditionally, surgical closure has been the mainstay of treatment for RSOVAs, with an operative mortality rate of <5% and excellent long-term outcomes. Abstract P1468 Figure. RSOVA

Urinary bladder fistulae and the role of CT cystography: a pictorial review.

Various conditions such as inflammation, malignancy, surgical manipulations, and radiation therapy can lead to the development of urinary bladder fistulae. Although many of these fistulae are suspected clinically, imaging plays a major role in confirmation and planning of subsequent treatment. Computed tomography (CT) cystoscopy provides useful details regarding the fistulous track and the anatomy of the region. This article aims to provide a succinct review of bladder fistulae and the role of CT cystography in their management.

Seton in Treating ComplexAnorectal Fistula-Our Experience

Background : Complex anorectal fistula may be endowed by the level at which the primary tract crosses the sphincters, the presence of secondary extensions or the difficulties faced in the treatment. Existing different treatment modalities like local advancement flap, LIFT procedure, fistulotomy and use of seton. Surgeons are afraid of incontinence in treating complex anorectal fistula. The aim of treatment of anal fistula is to cure the disease avoiding faecal incontinence. Among different procedures, Seton, a thread of foreign material, passed through the fistulous track and encircling sphincter mass thereby severing the muscle gradually without allowing it to spring apart and replacing the cut by the line of fibrosis thus avoiding incontinence, is an acceptable method practiced world wide. The purpose of the study is to evaluate and share our experience with others about the result of using seton in the treatment of complex anal fistula in our setting.
 Method: Between January 2003 and December 2008, I have taken the 1st 100 patients underwent surgery for complex anal fistula in Colorectal Surgery Unit of Bangabandhu Sheikh Mujib Medial University, Dhaka. It involved initial identification and partial laying open of the fistulous tract. A tight seton is placed around the external sphincter and is not removed until the internal orifice has migrated towards the perianal skin.
 Results: Out of 100 patients with mean age 43 years (range 19-65 years) 6 female and rest male underwent the procedure of seton. The median follow-up was 28.6 (24-36) months. The mean time of wound healing was 9.5 weeks (range 6-15). Recurrence occurred in two patient (2%). Continence disorders of flatus and loose stool were noted in 14 patients (14%). The duration with the seton in place was 56 days (range 20-190).
 Conclusion: The technique shows excellent results in the treatment of complex anal fistulous with preservation of faecal continence.
 Journal of Surgical Sciences (2013) Vol. 17 (1) : 14-17

FISTULOTOMY FOR THE SURGICAL TREATMENT OF PERIANAL FISTULA OF CRYPTOGLANDULAR ORIGIN

Perianal fistula usually results from a non-specific infection of the cryptic glands located at the anal dentate line. Identification of the exact course of a perianal fistula and the extent of anal sphincteric complex involvement are of paramount importance, in order to design the therapeutic and interventional approach and achieve the best results without impairment of the anorectal function. Several interventional methods are in use for the surgical treatment of CPF, including fistulotomy, insertion of cutting “seton”, core fistulectomy, ligation of the intersphincteric fistulous track (LIFT), rectal advancement flap, injection of fibrin glue at the fistulous track, insertion of fistulous plug, and obliteration of the fistulous track with the use of Laser. In clinical practice a combination of the aforementioned methods can be used, in particular for the complex-high or recurrent fistulae.