Fistula-in-Ano Guidelines

Updated: Jul 29, 2022
  • Author: Juan L Poggio, MD, MS, FACS, FASCRS; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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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.