ASCRS Guidelines for Anal Fistulas

In August 2022, the American Society of Colon and Rectal Surgeons (ASCRS) published clinical practice guidelines^[24]that included the following recommendations for fistula-in-ano:

Endorectal advancement flap procedures are recommended for patients with anal fistulas. For those who have a simple anal fistula and normal anal sphincter function, a lay-open fistulotomy may be used.
Minimally invasive surgery that involves endoscopy or laser closure may be used to treat anal fistulas. The short-term healing rates have been promising; however, the long-term healing and recurrence rates remain unknown.
Because of the generally poor healing rates associated with fistula plugs and fibrin glue, they are considered relatively ineffective treatments for anal fistulas.
For patients with complex cryptoglandular anal fistulas, a cutting seton may be appropriate; however, this technique can lead to functional impairment.
A combination of surgery and drug therapy is recommended for the management of anorectal fistulas associated with Crohn disease. The best-studied drugs in this setting are infliximab and adalimumab.
Endorectal advancement flaps and ligation of the intersphincteric fistula tract are options for the management of anal fistulas in patients with Crohn disease. Draining setons may also be used for long-term control of fistulizing anorectal Crohn disease.
For select patients with Crohn disease who have refractory anorectal fistulas, local treatment with mesenchymal stem cells is considered effective and safe. However, this approach is not widely available.

Questions

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Media Gallery

Anatomy of the anal canal and perianal space.
Fistula-in-ano. Goodsall rule.
Parks classification of fistula-in-ano.
Schematic of intersphincteric and low transsphincteric fistulotomy.
Schematic of high transsphincteric fistulotomy with seton.

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Author

Juan L Poggio, MD, MS, FACS, FASCRS Professor of Surgery, Department of Surgery, Lewis Katz School of Medicine at Temple University; Colon and Rectal Surgeon, Department of Surgery, Cancer Treatment Centers of America; Colon and Rectal Surgeon and General Surgeon, Division of Colon and Rectal Surgery, Department of Surgery, Temple University Hospital and Jeanes Hospital

Juan L Poggio, MD, MS, FACS, FASCRS is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons, Association for Academic Surgery, Pennsylvania Society of Colon and Rectal Surgeons

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine

John Geibel, MD, MSc, DSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Acknowledgements

Oscar Joe Hines, MD Assistant Professor, Department of Surgery, University of California at Los Angeles School of Medicine

Oscar Joe Hines, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Endocrine Surgeons, American College of Surgeons, Association for Academic Surgery, Society for Surgery of the Alimentary Tract, and Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

David L Morris, MD, PhD, FRACS Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology

Disclosure: RFA Medical None Director; MRC Biotec None Director

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Dennis F Zagrodnik II, MD, FACS Consulting Staff, Premier Surgical of Wisconsin, SC

Dennis F Zagrodnik II, MD, FACS is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, Phi Beta Kappa, Society of American Gastrointestinal and Endoscopic Surgeons, Southeastern Surgical Congress, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

Fistula-in-Ano Guidelines

ASCRS Guidelines for Anal Fistulas

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