Case report of combined application of three sphincter-preserving approaches in complex perianal fistula

The presence of a complex fistula is associated with a high recurrence rate. Lay-open technique with fistulotomy is imperatively contraindicated in cases of complex fistulas due to the 40% risk of early or delayed onset of anal incontinence. Combining different sphincter-preserving approaches aims to significantly reduce the chance of recurrence and preserve the quality of life. We present a case of a 34-year-old woman with a complex perianal fistula. We applied a combination of sphincter-sparing approaches by FiLAC, LIFT and TAFR. The follow-up period is 11 months without incontinence and recurrence. Despite the conflicting data published in the literature the combination of minimally invasive approaches for the treatment of secondary branches, interruption of the fistula tract, and thorough eradication of the internal opening of a highly complex fistula provides the greatest opportunity for achieving maximum success, i.e. minimizing the risk of recurrence while maintaining sphincter continence.