Which treatment for anal fistula? Cut or cover, plug or paste, loop or lift

Anorectal fistulas are common maladies. The challenge in therapy of perianal fistulas balances between the best possible cure and the preservation of continence. Complex fistulous disease challenges even the most experienced surgical specialists. The management options in these groups of patients are inadequate, with treatment often requiring multiple procedures, causing a risk for continued symptoms and fecal incontinence. This has lead to a serious search for newer and safer treatment options. Use of different types of setons and advancement flaps have their own advantages and pitfalls. Invasive methods with high rates of incontinence have given way to sphincter-sparing methods that have a much lower associated morbidity. Treatment with fibrin glue is an attractive option whenever continence might be endangered by operative procedures. Initial results with fistula plugs are promising but need further critical observations. Recently, the ligation of fistula tract had shown few promising results though it will be too early to comment on its long-term efficacy.