The internal sphincter in anorectal malformations: morphologic investigations in neonatal pigs

The knowledge of sphincter anatomy in anorectal malformations is still inadequate and contradictory. Therefore, morphologic investigations were carried out in 33 neonatal piglets with congenital anal atresias. Of the 24 male animals 12 had high anomalies with a rectourethral fistula. The remaining 12 piglets had low anomalies; in nine cases we were able to demonstrate an anocutaneous fistula. Of the nine female animals, six had high anomalies with a rectovaginal fistula. The three female piglets with low anomalies had an anovestibular or an anocutaneous fistula. In all animals we could demonstrate a normal internal sphincter, which surrounded the proximal part of the fistulae. The position of the internal sphincter therefore depended on the localization of the fistula orifice into the rectal pouch. This differed greatly. The form of the internal sphincter also differed greatly. Sometimes the muscle had the form of a tube or an acute-angled funnel as in healthy piglets. However, mostly the internal sphincter was spread out wide and had the form of a disc or a flat dish. The proximal region of the fistulae in anal atresias has most features of a normal anal opening: (1) it is surrounded by an internal sphincter, (2) the rectal pouch in the region of the internal sphincter as well as the fistulae are hypoganglionotic, (3) the proximal fistula region is lined by transitional epithelium, and (4) it contains anal glands. We, therefore, consider that the fistula should be designated as an ectopic anal canal. The most important result was the demonstration of a normal internal sphincter even in high and intermediate anomalies of anal atresias.(ABSTRACT TRUNCATED AT 250 WORDS)     

The anal fistula claw: the OTSC clip for anal fistula closure

Aim Surgical closure of high or complex anal fistulae is often a difficult challenge. A special Nitinol clip, the OTSC clip (Ovesco AG), was evaluated for fistula closure in a porcine model. Method A total of 20 fistulae were created in 10 animals by seton insertion. Four weeks after fistula induction the setons were removed: one internal fistula opening per animal was left untreated as control whereas the other opening was closed by the OTSC clip using a specially developed transanal clip applicator. The safety and technical feasibility of the clip application were tested. Another 4 weeks later, fistulae were macroscopically assessed for closure. For histological examination, the anorectum including the fistula tract was excised en bloc. Results Four weeks after clip placement, all external and internal fistula openings were macroscopically closed. The clip application site presented with an increased scarring. Microscopically, 40% of residual tracts and a more intense chronic inflammation were seen in the untreated control fistulae. After clip placement, 10% of the fistulae persisted associated with a higher density of collagen fibres indicating a better fistula scarring and healing. No unexpected side‐effects or complications caused by the clip were observed. Conclusion Fistula closure using the OTSC clip represents a promising sphincter‐preserving minimally invasive procedure. This study demonstrated the safety and feasibility of the ‘anal fistula claw’ for fistula closure. In spite of limitations of the porcine model the results justify clinical applications and further investigations.     

Clinical Correlation and MRI Finding in the Management of Fistula in Ano

Fistula is considered to be any abnormal passage which connects two epithelial surfaces. Parks fistula classification demonstrates the biggest practical significance and divides fistulae into inter-sphincteric, trans-sphincteric, supra-sphincteric, and extra-sphincteric. Diagnostic method options are retrograde (RTG) fistulography, computed tomography (CT) fistulography, and magnetic resonance imaging (MRI) of pelvic organs. The purpose of the study is to correlate clinical examination and operative findings with the findings of MRI and to draw efficacy of MRI as a preoperative diagnostic tool in the management of fistula in ano. This study was performed at the Surgery Department and MRI unit of the Radiology Department of JLNH and RC, Bhilai, from January 2014 to July 2015. Patients with perianal fistulae were included in our prospective study. All patients underwent high-spatial resolution MR imaging. MR imaging findings were correlated with the intraoperative surgical finding. MR imaging shows 7 fistulous patients with side branching and 16 with abscess cavity which was 100% intraoperatively correlated. Fifty-six patients out of 60 completely correlated with MRI for primary track which was clinically significant. MRI had 96% sensitivity and 100% specificity for primary tract and internal opening and 100% sensitivity and specificity for abscess and multiple tracks. MRI is useful in successful treatment of perianal fistulae by providing more accurate anatomical information about the amount of sphincter above the track and the position and level of the internal opening, thereby increasing the likelihood of successful surgical treatment. So, MRI is the very important preoperative investigation tool for fistula in ano.     

New techniques in the treatment of common perianal diseases: stapled hemorrhoidopexy, botulinum toxin, and fibrin sealant

There have been several recent advances in the treatment of common perianal diseases. Stapled hemorrhoidopexy is a procedure of hemorrhoidal fixation, combining the benefits of rubber band ligation into an operative technique. The treatment of anal fissure has typically relied upon internal sphincterotomy; however, it carries a risk of incontinence. The injection of botulinum toxin represents a new form of sphincter relaxation, without division of any sphincter muscle; morbidity is minimal and results are promising. For the treatment of fistula in a fistulotomy remains the gold standard, however, it carries significant risk of incontinence. Use of fibrin sealant to treat fistulae has been met with variable success. It offers sealing of the tract, and then provides scaffolding for native tissue ingrowth.     

Histological identification of epithelium in perianal fistulae: a prospective study

Aim A procedure often performed following fistulotomy and advancement flap is curettage of the fistula tract after fistulotomy or after closing the internal opening. Epithelialization of the fistula tract might prevent closure of the fistula tract. The aim of this study was to assess the incidence and origin of epithelialization of the fistula tract in patients with perianal fistulae undergoing fistulotomy. Method Only patients with low perianal fistulae that were surgically treated by fistulotomy were included. Surgical biopsies were taken from the fistula tract from three different locations; on the proximal side at the internal opening, in the middle of the fistula tract and near the distal end close to the external opening. Results In the study period, 18 patients with low perianal fistulae were included. In 15 of the 18 patients, squamous epithelium was found at least in one of the biopsies taken from the fistula tract. Epithelium was predominantly found near the internal opening. There was no relation between the duration of fistula complaints and the amount of epithelialization (P = 0.301). The amount of epithelium was not related to the presence of a history of fistula surgery (P = 1.000). Conclusion This study demonstrated epithelialization in the fistula tract in the majority of the patients surgically treated by fistulotomy for low perianal fistulae. Curettage of perianal fistulae must therefore be considered an essential step in the surgical treatment of perianal fistula.     

一次性根治术治疗多发性肛瘘临床观察

为观察Parks分类对多发性肛瘘一次性根治手术的指导意义,对32例多发性肛瘘根据Parks分类采用不同手术方式。32例患者全部治愈,术后随访3～6个月,未发现明显并发症。对于多发性肛瘘其手术成功的关键是做好瘘管的解剖定位,即了解肛瘘穿经外括约肌不同平面是正确处理肛瘘的前提,它可以有效减轻手术过程中对括约肌的损害。同时正确的处理中央间隙和内口是降低复发率的关键。     

Ligation of the intersphincteric fistula tract in low transsphincteric fistulae: a new technique to avoid fistulotomy

Aim To date fistulotomy is still the treatment of choice for patients with a transsphincteric fistula passing through the lower third of the external anal sphincter, because it is a simple, effective and safe procedure with a minimal risk of incontinence. However, data suggest that the risk of impaired continence following division of the lower third of the external anal sphincter is not insignificant, especially in female patients with an anterior fistula and patients with diminished anal sphincter function. It has been shown that ligation of the intersphincteric fistula tract (LIFT) is a promising sphincter‐preserving technique. Therefore, we questioned whether LIFT could replace fistulotomy in patients with a low transsphincteric fistula. Method A consecutive series of 22 patients with a low transsphincteric fistula of cryptoglandular origin underwent LIFT. Continence scores were determined using the Rockwood Fecal Incontinence Severity Index. Results Median follow‐up was 19.5 months. Primary healing was observed in 18 (82%) patients. In the four patients without primary healing, the transsphincteric fistula was converted into an intersphincteric fistula. These patients underwent subsequent fistulotomy with preservation of the external anal sphincter. The overall healing rate was 100%. Six months after surgery, the median incontinence score was not changed significantly. Conclusion Low transsphincteric fistulae can be treated successfully by LIFT, without affecting faecal continence. Division of the lower part of the external anal sphincter is no longer necessary in the treatment of low transsphincteric fistulae, which is essential for patients with compromised anal sphincters.     

Mucosal flap in the treatment of anal fistula]

A technique of sliding flap repair for the treatment of anal fistulae is described. This technique may prevent sphincter damage. Fifty-five consecutive fistulae have been treated: 23 transsphincteric, 26 intersphincteric, 3 suprasphincteric and 3 rectovaginal fistulae. The fistulous tract is excised and cored out. The intersphincteric space is opened: any gland or inflammatory tissue is removed. The internal opening is excised. The gaps in the internal, as well as in the external, sphincter are closed. The endo-anal wound is closed, using a sliding flap of anorectal mucosa. The ischiorectal wound is left open. Healing has been achieved in every case but one within three weeks, without sphincteric functional defect. Only 3 recurrences have been observed in a mean follow-up of 24 months.     

Incidence, diagnosis, and treatment of enteric and colorectal fistulae in patients with Crohn's disease.

OBJECTIVE: The authors review their experience, evaluating the incidence and examining the various modalities employed in the diagnosis and treatment of patients with Crohn's disease complicated by fistulae. SUMMARY BACKGROUND DATA: Although common, internal and external fistulae in Crohn's disease may pose challenging problems to the surgeon. METHODS: Of 639 patients who underwent surgical treatment at the University of Chicago between 1970 and 1988 for complications of Crohn's disease, 222 patients (34.7%) were found to have 290 intra-abdominal fistulae. RESULTS: A fistula was diagnosed preoperatively in 154 patients (69.4%), intraoperatively in 60 (27%), and only after examination of the specimen in 8 (3.6%). The fistula represented the primary or single indication for surgical treatment in 14 patients (6.3%) and one of several indications in the remaining patients. Of 165 patients with an abdominal mass or abscess, 69 (41.8%) had a fistula. All patients underwent resection of the diseased intestinal segment; 160 (73.1%) with primary anastomosis and the remaining 62 with a temporary or permanent stoma. The fistula was directly responsible for a stoma in only 16 patients (7.2%) and was never responsible for a permanent stoma. Resection of the diseased bowel achieved en bloc removal of the fistula in 145 cases. Removal of 93 additional fistulae required resection of the diseased bowel segment along with closure of a fistulous opening on the stomach or duodenum (n = 14), bladder (n = 35), or rectosigmoid (n = 44). When the fistula drained through a vaginal cuff (n = 4), the opening was left to close by secondary intention; when the fistula opened through the abdominal wall (n = 46), the fistulous tract was debrided. In the remaining two entero-salpingeal fistulae, en bloc resection of the involved salpinx accomplished complete removal of the fistula. There was a dehiscence of one duodenal and one bladder repair; 14 patients (6%) experienced postoperative septic complications and one patient died. CONCLUSIONS: Fistulae are diagnosed preoperatively in 69% of cases and can be suspected in as many as 42% of patients with an abdominal mass. Fistulae are the primary or single indication for surgical treatment and are directly responsible for a stoma only in a few patients. Treatment, based on resection of the diseased bowel and extirpation of the fistula, can be accomplished with minimal morbidity and mortality.     

Treatment of anal fistulas

The authors describe the traditional operative technique for correction of anal fistulae and analyse the outcome of surgical treatment. During a 5-years period between 1994 and 1998, 286 patients underwent surgery for anal fistula in the department--more than one--third of this population presented with recurrent disease. During the operation, the extrasphincteric segment of the anal fistula is excised and the margin of the sinus is marsupialized. Introducing a rubber band through the sinus tract eliminates lesions that penetrate the sphincter. As the tied band shears through the encircled sphincter muscle, the rate of transsection is controlled individually, by adjusting the tightness of the rubber band as necessary. The inner opening of the fistula is often difficult to identify and consequently, excision may be incomplete. This is a serious pitfall that commonly leads to recurrence. According to the authors' experience, flushing the fistula tract with hydrogen peroxide is the most effective methods for pinpointing the inner meatus. Using this technique, postoperative recurrence was detected in 30 patients (10%). Moderate impairment of anal continence had been observed in 57 patients (20%); however, this never progressed to permanent incontinence.     

Anal fistula plug and fibrin glue versus conventional treatment in repair of complex anal fistulas

Introduction

High transsphincteric fistulas are difficult to treat because fistulotomy of involved sphincter muscle results in incontinence. We compare our outcomes for anal fistula plug, fibrin glue, advancement flap closure, and seton drain insertion.

Methods

This is a retrospective study of patients treated for high transsphincteric anal fistulas. The primary outcome was full healing at 12 weeks postoperatively.

Results

Between 1997 and 2008, 232 patients with anal fistula were identified in the St. Paul's Hospital Anal Fistula Database. Postoperative healing rates at the 12-week follow-up for the fistula plug, fibrin glue, flap advancement, and seton drain groups were 59.3%, 39.1%, 60.4%, and 32.6%, respectively (P < .0001).

Conclusions

Closure of the primary fistula opening using a biological anal fistula plug and anal flap advancement result in similar fistula healing rates in patients with high transsphincteric fistulae. These 2 strategies are superior to seton placement and fibrin glue. Given the low morbidity and relative simplicity of the procedure, the anal fistula plug is a viable alternative treatment for patients with high transsphincteric anal fistulas.     

Fibrin glue in the management of anal fistulae

OBJECTIVE: Fibrin glue has been used as a sphincter sparing approach for the treatment of anal fistulae for two decades. However, there is uncertainty about its short and long-term efficacy. The objective of this review was to ascertain the role of fibrin glue in the management of anal fistulae, including assessment of recurrence rates, continence disturbance and other complications. METHODS: We searched Medline (January 1966 to February 2004), the Cochrane database, and EMBASE using the terms anal fistulae, fistula-in-ano, and fibrin glue. Relevant papers from the reference lists of these articles and from the authors' personal collections were also reviewed. A systematic review of all articles relating to the use of fibrin glue in the treatment of anal fistulae was performed. This included 19 studies. Reviewers performed data extraction independently. Outcomes evaluated included recurrence rates, continence disturbance, septic complications, adverse drug reactions, and duration of follow-up. Heterogeneity of the clinical trials made direct comparisons difficult and meta-analysis impossible. RESULTS: The success rates reported in published studies range from 0% to 100%. Differences in patient selection (including fistula aetiology and type), treatment protocols, and follow-up duration may contribute to such diverse results. CONCLUSIONS: Fibrin glue is simple to use, has a minimal morbidity and should not affect later treatment options in the event of its failure. It is therefore theoretically attractive as a first line treatment in the management of those types of anal fistula in which it has been shown to work. However, further research into 'biological' glues is merited and these subject to randomised controlled study.     

PERFACT procedure to treat supralevator fistula-in-ano: A novel single stage sphincter sparing procedure

AIM: To prospectively perform the PERFACT procedure in supralevator anal fistula/abscess.METHODS: Magnetic resonance imaging was done preoperatively in all the patients. Proximal cauterization around the internal opening, emptying regularly of fistula tracts and curettage of tracts(PERFACT) was done in all patients with supralevator fistula or abscess. All types of anal fistula and/or abscess with supralevator extension, whether intersphincteric or transsphincteric, were included in the study. The internal opening along with the adjacent mucosa was electrocauterized. The resulting wound was left open to heal by secondary intention so as to heal(close) the internal opening by granulation tissue. The supralevator tract/abscess was drained and thoroughly curetted. It was regularly cleaned and kept empty in the postoperative period. The primary outcome parameter was complete fistula healing. The secondary outcome parameters were return to work and change in incontinence scores(Vaizey objective scoring system) assessed preoperatively and at 3 mo after surgery.RESULTS: Seventeen patients were prospectively enrolled and followed for a median of 13 mo(range 5-21 mo). Mean age was 41.1 ± 13.4 years, M:F-15:2. Fourteen(82.4%) had a recurrent fistula, 8(47.1%) had an associated abscess, 14(82.4%) had multiple tracts and 5(29.4%) had horseshoe fistulae. Infralevator part of fistula was intersphincteric in 4 and transsphincteric in 13 patients. Two patients were excluded. Eleven out of fifteen(73.3%) were cured and 26.7%(4/15) had a recurrence. Two patients with recurrence were reoperated on with the same procedure and one was cured. Thus, the overall healing rate was 80%(12/15). All the patients could resume normal work within 48 h of surgery. There was no deterioration in incontinence scores(Vaizey objective scoring system). This is the largest series of supralevator fistula-in-ano(SLF) published to date. CONCLUSION: PERFACT procedure is an effective single step sphincter saving procedure to treat SLF with minimal risk of incontinence.     

Periurethral injection of autologous fat for the treatment of post-fistula repair stress incontinence: A preliminary report

The aim of the study was to asses the effectiveness of periurethral injection of autologous fat for the treatment of stress incontinence caused by inherent sphincter weakness in women following the repair of obstetric urogenital fistulae. Ten patients with symptomatic stress incontinence following repair of vesicovaginal or urethrovaginal fistula of obstetric origin were assessed clinically, by cystourethroscopy, and by Valsalva leak-point pressure (VLPP). Four showed some degree of bladder neck mobility and were treated by bladder neck suspension procedures. Six appeared to have pure sphincter weakness and were treated by periurethral injection of autologous fat. For logistic reasons, the initial follow-up was undertaken 2 weeks postoperatively, including clinical assessment and VLPP. Two patients were subjectively cured, 2 improved and 2 perceived no change in their symptoms following the procedure. The symptomatic changes correlated with the operative appearance, and with the subsequent changes in VLPP. Although numbers are small and follow-up short, we feel that these preliminary results justify further investigation of the technique in this most difficult group of patients.EDITORIAL COMMENT: The authors report an original concept for the treatment of intrinsic sphincter deficiency following obstetrical vesicovaginal fistula repair. Although preliminary, based on the authors' experience with a small group of patients and with minimal follow-up, this pilot study paves the way for future work in this area. The patients served have limited options for treatment from several aspects, including the severity of their incontinence, tissue health in the urogenital area, overall health, limited availability of other surgical options and general inaccessibility of medical care. The use of autologous fat for periurethral injection in this population of patients, where medical resources are limited, represents a simple, minimally invasive and relatively inexpensive option with possibly realistic success rates. Further investigation on the use of this technique to treat post-vesicovaginal fistula repair of intrinsic sphincter deficiency is needed to fully assess its applicability and success.     

Potential clinical implications of direction of a trans-sphincteric anal fistula track

BACKGROUND: The longitudinal direction of a trans-sphincteric anal fistula track through the anal sphincter complex may have implications regarding fistulotomy. METHODS: The angle of the track of trans-sphincteric fistulas relative to the longitudinal axis of the anal canal was measured before operation by means of magnetic resonance imaging (MRI) in 46 patients. This was compared with the findings at operation. RESULTS: The track passed cranially as well as laterally at an acute angle (less than 90 degrees ) in 23 patients while it passed either transversely or caudally at an obtuse angle (90 degrees or more) in the remaining 23. The internal opening was significantly higher in relation to the dentate line (above in eight patients, at the dentate line in 14 and below in one patient) when the track was acute than when it was obtuse (above in one, at the dentate line in 17 and below in five patients) (P = 0.004). The fistula track crossed the sphincter at a median angle of 35 degrees, 95 degrees and 132 degrees from internal openings sited above, at and below dentate line level respectively (P = 0.002). CONCLUSION: Fistula tracks passed cranially and laterally through the sphincter complex in half of these patients, and were most acutely angled on MRI when internal openings were situated above the dentate line. Preoperative MRI might alert surgeons to the potential hazard of fistulotomy being more extensive than anticipated from simple palpation of the level of the internal opening.     

复发性肛瘘的诊治(附45例报告)

目的：提高肛瘘的一次性治愈率．减少肛瘘术后复发率．分析肛瘘再手术的原因。方法：1998年10月-2003年10月收治曾在外医院行肛瘘手术后又复发肛瘘病例45例．用亚甲蓝和过氧化氢混合液作外口注射染色加探针寻找内口．切开瘘道清除腐朽坏死及瘢痕组织后．抗生素冲洗伤口后作一期缝合．内口切开引流或切开挂线引流。术后针对不同原因采用中西医结合治疗．外加中药薰洗、坐浴。结果：45例全部临床治愈．治愈率达100％。结论：肛瘘手术完全能一次治愈。关键在于治疗过程中应注意内口(原发感染灶)与合并症的正确处理。     

Partial fistulotomy and multiple setons in high anal fistulae

Setons are employed in high perianal fistulae. Our study aimed to use multiple setons in addition to a partial fistulotomy in high perianal fistulae involving the sphincter complex to combine the effects of cutting and drainage of the fistulous tract. This prospective study included 16 patients over a period of 4 years who presented with high perianal fistulae. The internal opening was identified and tract laid open till the dentate line. Four prolene threads were passed along the remainder of the tract and taken out through the external opening. One was tied tightly while the others were tightened every 7 days. No patients developed major faecal incontinence. Fistula recurred in one patient within a year and one patient had occasional incontinence to flatus. Multiple setons after partial fistulotomy is an effective treatment for high anal fistulae with low incidence of incontinence and recurrence and adequate patient satisfaction.     

A decade of selective use of adjustable cutting seton combined with fistulotomy for anal fistula

Previous studies have demonstrated that the division of sphincter muscle in the treatment of anal fistula may precipitate fecal incontinence. Cutting setons may pose a particular risk of unrecoverable injury to the sphincter apparatus. To evaluate if the use of an adjustable cutting seton mitigates this risk, we performed a retrospective review of all patients operated on for anal fistulae in a 10-year period by a single surgeon. Adjustable cutting setons (consisting of heavy silk ligature with patient-controllable tension) were used selectively. Forty-seven patients met the study criteria. Ninety-four per cent of the fistulae treated were transsphincteric. All of the fistulae were treated with at least partial fistulotomy. Ninety-nine per cent of patients were followed to completion of treatment. One (2%) patient subsequently developed fecal incontinence, and four (9%) developed a recurrent or persistent fistula in the same location. Adjustable cutting setons have been used in our practice with a high success rate and low risk of complications. Our data support adjustable cutting setons as a useful tool in the surgeon's repertoire for treating fistulae that involve the anal sphincter complex.     

Risk factors for recurrence and incontinence after anal fistula surgery

Objective Fistula‐in‐ano continues to raise problems that require important therapeutic decisions. Our aim was to evaluate its recurrence and incontinence risk factors. Method We analysed a series of 279 patients who had undergone anal fistula surgery with long‐term follow‐up. Results 42.7% of the fistulae were considered complex and 46% had been referred from other institutions. There was delayed healing or recurrence in 7.2% patients, which appeared at a median of 4 months. The factors associated with recurrence were the type of fistula (extrasphincteric/suprasphincteric), nonidentification of internal opening (IO), recurrent or complex fistulae (CF), and associated chronic abscess. Only CF and nonidentification of IO were statistically significant in the multivariate analysis. Preoperative incontinence was a risk factor for postoperative incontinence, as were suprasphincteric, recurrent and CF. The age and gender of the patient did not influence postoperative continence, nor did the surgeon or surgical technique appear as a risk factor, although after excluding preoperative incontinent patients, fistulotomy was the technique that showed a higher risk of incontinence. Multivariate analysis only confirmed previous incontinence as a RF. Conclusion The overall recurrence rate is acceptable, but high fistulae continue to be difficult to treat. IO identification is also essential for obtaining good results. It is important to identify the patients with preoperative incontinence as they are at a greater risk of deterioration after surgery.     

Anal fistula plug in the treatment of anal fistula: Local experience in Chinese patients

Background: Anal fistula plug was recently introduced as an alternative treatment for anal fistula. However, there is, so far, no published data on the use of the anal fistula plug both locally and in the Chinese population. Methods: From January 2007 to July 2008, consecutive Chinese patients with transphincteric or suprasphincteric anal fistula scheduled for elective surgery were enrolled. Anal fistula plug was used if examination under anaesthesia reviewed an internal opening. Baseline manometry pressure study was carried out for patients with recurrent fistulae. The operative technique was standardized. Measured outcomes included healing and recurrence rates, operating time, length of stay, and time for patients to return to work or normal activity. Results: Eleven patients underwent anal fistula plug placement, with a median follow up of 19 months. Five had completely healed fistulae, including three patients with recurrent fistulae. The success rate was 45 per cent. In the three patients with recurrent fistulae, no significant difference was demonstrated in the resting pressure between preoperative and postoperative values. There is an observable trend that proportionally more recurrent fistulae were healed by anal fistulae plug placement when compared to primary fistulae (100% vs 25%); the difference, however, did not reach statistical significance (P = 0.06, Fisher's exact test). At the conclusion of this study, no recurrence was noted in the five patients with confirmed healing. Conclusions: Our preliminary experience indicates anal fistula plug placement is safe and non-invasive. However, the efficacy appears lower than initially reported. Based on our data the routine use of an anal fistula plug cannot be recommended. In our opinion, anal fistula plug placement can be considered in patients with more complex, high fistulae and in those who have recurrent fistulae despite previous surgery. It provides a non-invasive alternative in these patients, in whom postoperative incontinence is a real concern.