title: Complex anal fistula remains a challenge for colorectal surgeon.
abstract: OBJECTIVE
  Anal fistula is a common proctological problem to both patient and physician throughout surgical history. Several surgical and sphincter-sparing approaches have been described for the management of fistula-in-ano, aimed to minimize the recurrence and to preserve the continence. We aimed to systematically review the available studies relating to the surgical management of anal fistulas.
  
  
  METHODS
  A Medline search was performed using the PubMed, Ovid, Embase, and Cochrane databases to identify articles reporting on fistula-in-ano management, aimed to find out the current techniques available, the new technologies, and their effectiveness in order to delineate a gold standard treatment algorithm.
  
  
  RESULTS
  The management of low anal fistulas is usually straightforward, given that fistulotomy is quite effective, and if the fistula has been properly evaluated, continence disturbance is minimal. On the contrary, high complex fistulas are challenging, because cure and continence are directly competing priorities.
  
  
  CONCLUSIONS
  Conventional fistula surgery techniques have their place, but new technologies such as fibrin glues, dermal collagen injection, the anal fistula plugs, and stem cell injection offer alternative approaches whose long-term efficacy needs to be further clarified in large long-term randomized trials.
authors.affiliation: Department of Surgery, San Francesco Hospital, Via Mannironi, 08020, Nuoro, Italy, fede.cadeddu@libero.it.
authors.forename: F
authors.initials: F
authors.lastname: Cadeddu
authors.forename: F
authors.initials: F
authors.lastname: Salis
authors.forename: G
authors.initials: G
authors.lastname: Lisi
authors.forename: I
authors.initials: I
authors.lastname: Ciangola
authors.forename: G
authors.initials: G
authors.lastname: Milito
mesh_terms: D001705:Bioprosthesis; D017115:Catheter Ablation / Q000379:methods*; D003094:Collagen / Q000627:therapeutic use; D005242:Fecal Incontinence / Q000517:prevention & control; D005260:Female; D015718:Fibrin Tissue Adhesive / Q000627:therapeutic use*; D006801:Humans; D015552:Injections, Intralesional; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D011379:Prognosis; D012003:Rectal Fistula / Q000473:pathology* / Q000601:surgery*; D012008:Recurrence; D018570:Risk Assessment; D012720:Severity of Illness Index; D033581:Stem Cell Transplantation / Q000379:methods; D013524:Surgical Flaps; D016896:Treatment Outcome
chemical_list: D015718:Fibrin Tissue Adhesive; D003094:Collagen