LAUSR

Human beings have long suffered from anal fistulae with some of the earliest references dating as far back as the Code of Hammurabi (Twentieth Century B.C.) and Hippocrates (Fourth Century B.C.) who described the use of linen and horsehair in the manner of a cutting seton [1]. Not much changed until recently when we have seen the rise of several new sphincter-sparing techniques in the management of complex anal fistulae including their selective use in patients with Crohn’s disease. As the list of choices grows with new techniques including the use of a diode laser fibre, silver nitrate, various bioprosthetic or synthetic fistula plugs, collagen pastes, fibrin glue, advancement flaps of different types, intersphincteric track ligation, clips and even stem cells, so too does our understanding of the pathophysiology of the condition [2]. Whilst managing the internal opening, the fistula track and the resulting epithelialisation have been the focus of most of these sphincter-sparing techniques, we also have known that part of the reason they fail is that they do not do enough individually to address these factors collectively. A recent workshop on anal fistulae highlighted this and discussed the unfavourable host environment impairing healing and contributing to fistula persistence potentially related to an underlying immunopathology, a microbiological abnormality and/or a failure of wound repair [3]. Unfortunately only a few of these new techniques, the most evident being stem cells, work on these non-anatomical domains. Further, as many others have also pointed out, what these sphincter-sparing approaches have in common are both a broad range of reported healing rates and a difficulty for subsequent authors replicating the often impressive initial results reported by those pioneering them. While these differences are often put down to the inherent biases in the underlying evidence, there could be another reason. Some of these more technically difficult procedures for example, ligation of the intersphincteric fistula tract (LIFT) or advancement flaps, can be difficult to consistently replicate even with reasonable case volumes. As we wait for confirmation of the mature results reported by these pioneers we continue to aim for a technique, or perhaps more likely a bundle of techniques, that addresses the multifactorial nature of the condition and provides as close to a 100% healing rate as possible with low or even zero complication, incontinence and recurrence rates. Arguably, the one sphincter-sparing approach that appears to come closest to these ideals would be LIFT [4]. And when LIFT is combined with the fistula plug, we see a significant improvement in reported healing rates pushing us closer to our ideal [5]. Despite these encouraging results, the LIFT technique still has its limitations as it primarily benefits those patients with transsphincteric fistulae where the track is relatively straight, and the internal opening is not too large or too high. Like most of the other techniques, it is less effective for the truly complex supraor extrasphincteric fistulae or those with more than one track or internal opening. Thankfully, we see these in a minority of patients. This emphasises the importance of understanding exactly what type of fistula we are operating on, as technique selection for these patients is critical. We know from multiple quality of life studies that our patients with fistulae suffer, and those that have complex fistulae tend to experience worse incontinence. Even if their incontinence score is not significantly worse, they will still suffer from depression and social isolation. Given these intricacies, understanding what type of patient has the complex fistula is also crucial [6]. Most of us would tailor our management. We would offer a technique with a lower healing rate and low risk factor profile to the patient highly averse to incontinence with limited fistula symptoms for only a short period of time. At the other end of the spectrum, for the patient who has been suffering longer with worse symptoms and previous surgeries, we would be more likely to offer a technique with a higher healing rate yet higher risk factor profile. Their resulting incontinence may still be part of an overall improvement from their baseline. Surgeon’s levels of comfort in managing these fistulae vary since they can be a notoriously challenging condition. As more sphincter-preserving techniques have been developed we need to decide which of these techniques we are going to offer and in which we need to improve our skills before delivering them to our patients. Whilst talking to colleagues, attending conference master classes, and visiting specialist centres can all help, some of us may also be limited by our local resources. We may be unable to secure the upfront funding to invest in the necessary equipment. Similarly, some of us may believe strongly in LIFT and advancement flaps but feel that for a patient willing to travel referral to an expert centre may offer them the best healing rate and lowest risk profile. We owe it to our patients with complex anal fistulae to provide the best advice and the best surgery. That will require careful tailoring of treatment to the individual, using a range or combination of techniques, and