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PubMed This is a summary of 29 peer-reviewed journal articles Updated
Colorectal Surgery

Surgical Treatments: Balancing Cure and Control

At a Glance

Surgical treatment for an anal fistula balances curing the infection with protecting bowel continence. Simple fistulas are often treated with a fistulotomy, while complex fistulas require sphincter-sparing techniques like the LIFT procedure or an advancement flap to preserve muscle function.

Deciding on a surgical treatment for an anal fistula involves a careful balance. Your surgeon’s primary goal is to close the fistula tract permanently (the “cure rate”) while ensuring the muscles that control your bowel movements remain fully functional (the “continence rate”) [1][2].

The Treatment Decision Tree

The choice of surgery depends almost entirely on the complexity of your fistula—specifically how much of the anal sphincter muscle it involves [3][4].

For Simple (Low-Lying) Fistulas

If your fistula is “simple,” meaning it involves very little muscle, the standard of care is often a fistulotomy [5].

  • The Procedure: The surgeon cuts the tunnel open, turning it into a groove that heals from the inside out [5].
  • Success Rate: This has a very high success rate for a permanent cure [6][7].
  • The Risk: Because it involves cutting a small amount of muscle, there is a risk of changes in bowel control. Specifically, there is a risk of temporary or permanent incontinence to gas (flatus) or liquid stool, which must be seriously considered despite being statistically low in simple cases [5][6].

For Complex (High) Fistulas

If your fistula involves a significant amount of muscle, cutting it (fistulotomy) could lead to serious incontinence [1]. In these cases, surgeons use sphincter-sparing techniques [2][1]. Often, before performing these definitive surgeries, your surgeon will first perform an Examination Under Anesthesia (EUA) to safely explore the tract, drain any infection, and place a seton [8].

Procedure How It Works Key Benefit
LIFT Ties off the fistula tract in the space between the muscles [1][9]. Very low risk of incontinence; preserves muscle [10].
Advancement Flap Uses a piece of your own healthy tissue to “patch” the internal hole [11]. A time-tested standard for complex cases [12].
VAAFT Uses a tiny camera to see and clean the tract from the inside [13][14]. Minimally invasive; allows the surgeon to find hidden branches [15].
FiLaC Uses a laser fiber to “weld” the tract shut [16][17]. Safe and effective with minimal impact on continence [18].
TROPIS Emerging technique: Opens the space between muscles to drain the infection [19][20]. High success rates for complex “horseshoe” fistulas [21][22].
Plugs/Glues Fills the tract with biological material to encourage healing [1]. Minimal pain, but often has higher recurrence rates [1].

Highlighting LIFT and Advancement Flap

Two procedures are widely considered the current standard-of-care alternatives for complex cases:

  • LIFT (Ligation of Intersphincteric Fistula Tract): This is often the first choice for high transsphincteric fistulas. It is technically simpler for surgeons and remarkably safe for your muscles [1][23]. Even if it fails, it often turns a complex fistula into a simple one that is easier to treat later [24][25].
  • Advancement Flap: This is a time-tested approach where the surgeon uses a small piece of your own healthy tissue from inside the rectum to “patch” the internal opening, closing off the source of the infection [11]. It preserves the sphincter muscles and is highly effective, though it requires a delicate recovery protocol [12].

Choosing the Right Path

There is no “one size fits all” surgery. Your surgeon will use your MRI or ultrasound results to map the tract and recommend a procedure that offers the best chance of a cure with the lowest risk to your quality of life [26][27]. Complex cases, especially those associated with Crohn’s disease, may require a multi-staged approach or a combination of medical and surgical treatments [28][29].

Common questions in this guide

What is the difference between a simple and complex anal fistula?
A simple fistula involves very little of the anal sphincter muscle, making it easier to treat with a high success rate. A complex fistula involves a significant amount of the sphincter muscle, requiring specialized surgical techniques to protect your bowel control.
What is a fistulotomy and when is it used?
A fistulotomy is a procedure where the surgeon cuts open the fistula tunnel so it can heal from the inside out. It is typically the standard of care for simple fistulas because it has a very high cure rate, though it carries a small risk of affecting bowel control.
What are sphincter-sparing surgeries for anal fistulas?
Sphincter-sparing techniques are surgeries designed to close complex fistulas without cutting the anal muscle, preventing long-term fecal incontinence. Common examples include the LIFT procedure, advancement flaps, and minimally invasive options like laser therapy (FiLaC).
How successful is the LIFT procedure for an anal fistula?
The LIFT procedure is highly effective and remarkably safe for preserving muscle function in complex fistulas. Even if the procedure does not completely cure the condition on the first try, it often simplifies the tract, making follow-up treatments much easier.
How will my surgeon decide which fistula surgery is right for me?
Your surgeon will likely use an MRI or ultrasound to map the fistula tract and determine how much muscle is involved. They will balance the goal of a permanent cure with the critical priority of protecting your long-term bowel continence.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Is my fistula considered simple or complex, and which surgical procedure best addresses that classification?
  2. 2.How much of my sphincter muscle will be affected by the surgery you are recommending?
  3. 3.If we choose a sphincter-sparing technique like LIFT or a Flap, what is your personal success rate for healing this type of fistula?
  4. 4.In my specific case, what is the estimated risk of long-term fecal incontinence?
  5. 5.If the first procedure does not fully heal the fistula, what would be the next step or fallback plan in my treatment?
  6. 6.How much time should I expect to take off from work to ensure proper recovery?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (29)
  1. 1

    Comparative study between intersphinecteric ligation of perianal fistula versus conventional fistulotomy with or without seton in the treatment of perianal fistula: A prospective randomized controlled trial.

    Al Sebai OI, Ammar MS, Mohamed SH, El Balshy MA

    Annals of medicine and surgery (2012) 2021; (61()):180-184 doi:10.1016/j.amsu.2020.12.014.

    PMID: 33489105
  2. 2

    Ligation of Intersphincteric Fistula Tract for Fistula in Ano: Lessons Learned From a Decade of Experience.

    Malakorn S, Sammour T, Khomvilai S, et al.

    Diseases of the colon and rectum 2017; (60(10)):1065-1070 doi:10.1097/DCR.0000000000000880.

    PMID: 28891850
  3. 3

    Fascia Lata Biological Plug: A Novel Technique for Treating Anal Fistulae.

    Moustafa A, Ebrahim AK, Saad R, et al.

    Cureus 2024; (16(12)):e75437 doi:10.7759/cureus.75437.

    PMID: 39660226
  4. 4

    The management of cryptoglandular fistula-in-ano.

    Sammut M, Skaife P

    British journal of hospital medicine (London, England : 2005) 2020; (81(1)):1-9 doi:10.12968/hmed.2019.0353.

    PMID: 32003630
  5. 5

    Fistulotomy versus Fistulectomy for Fistula-in-Ano: A Randomized Prospective Study.

    Hiremath SCS, Patil R

    Surgery journal (New York, N.Y.) 2022; (8(4)):e336-e340 doi:10.1055/s-0042-1758633.

    PMID: 36425406
  6. 6

    Comparison of Postoperative Wound Healing in Fistulectomy and Fistulectomy With Marsupialization in Patients With Low Fistula-in-Ano.

    Aziz AT, Shabbir S, Bashir H, et al.

    Cureus 2025; (17(8)):e89414 doi:10.7759/cureus.89414.

    PMID: 40918846
  7. 7

    Fistulotomy versus fistulectomy for simple fistula-in-ano: a systematic review and meta-analysis of randomized controlled trials.

    Quinn R, Peacock A, Lendzion RJ

    ANZ journal of surgery 2025; (95(6)):1074-1090 doi:10.1111/ans.70095.

    PMID: 40125894
  8. 8

    The Essential Role of a Multidisciplinary Approach in Inflammatory Bowel Diseases: Combined Medical-Surgical Treatment in Complex Perianal Fistulas in CD.

    Geldof J, Iqbal N, Warusavitarne J, Hart A

    Clinics in colon and rectal surgery 2022; (35(1)):21-31 doi:10.1055/s-0041-1740035.

    PMID: 35069027
  9. 9

    [The past, presence and future of ligation of intersphincteric fistulous tract for the treatment of fistula in ano].

    Shao W

    Zhonghua wei chang wai ke za zhi = Chinese journal of gastrointestinal surgery 2015; (18(12)):1200-2.

    PMID: 26703998
  10. 10

    Effective and long-term outcome following ligation of the intersphincteric fistula tract (LIFT) for transsphincteric fistula.

    Chen HJ, Sun GD, Zhu P, et al.

    International journal of colorectal disease 2017; (32(4)):583-585 doi:10.1007/s00384-016-2723-2.

    PMID: 27878618
  11. 11

    Long-term healing after complex anal fistula repair in patients with Crohn's disease.

    Mujukian A, Truong A, Fleshner P, Zaghiyan K

    Techniques in coloproctology 2020; (24(8)):833-841 doi:10.1007/s10151-020-02238-1.

    PMID: 32537672
  12. 12

    Comparison of Healing Time, Recurrence Rate, Incontinence, and Quality of Life Following Endorectal Advancement Flap versus Cutting Seton Insertion for Trans-Sphincteric High Type Anal Fistula: A 5-Year Retrospective Cohort Study.

    Safarpour MM, Gorgi K, Zeinalpour A, et al.

    Middle East journal of digestive diseases 2025; (17(2)):117-122 doi:10.34172/mejdd.2025.416.

    PMID: 40994807
  13. 13

    Video-Assisted Anal Fistula Treatment (VAAFT) in Cryptoglandular fistula-in-ano: A systematic review and proportional meta-analysis.

    Garg P, Singh P

    International journal of surgery (London, England) 2017; (46()):85-91 doi:10.1016/j.ijsu.2017.08.582.

    PMID: 28882770
  14. 14

    [Preliminary efficacy of video-assisted anal fistula treatment for complex anal fistula].

    Liu H, Xiao Y, Zhang Y, et al.

    Zhonghua wei chang wai ke za zhi = Chinese journal of gastrointestinal surgery 2015; (18(12)):1207-10.

    PMID: 26704000
  15. 15

    Video-Assisted Anal Fistula Treatment (VAAFT) for Complex Anal Fistula: A Preliminary Evaluation in China.

    Jiang HH, Liu HL, Li Z, et al.

    Medical science monitor : international medical journal of experimental and clinical research 2017; (23()):2065-2071 doi:10.12659/msm.904055.

    PMID: 28456815
  16. 16

    Radially Emitting Diode Laser Closure of Transsphincteric Fistula-in-Ano.

    Kelley SR, Vierkant RA, Russell JM, et al.

    Diseases of the colon and rectum 2024; (67(12)):1555-1563 doi:10.1097/DCR.0000000000003501.

    PMID: 39239958
  17. 17

    A systematic review and meta-analysis of the safety and efficacy of fistula laser closure.

    Elfeki H, Shalaby M, Emile SH, et al.

    Techniques in coloproctology 2020; (24(4)):265-274 doi:10.1007/s10151-020-02165-1.

    PMID: 32065306
  18. 18

    Closure of Fistula-in-Ano Using a Radial-Emitting Laser Probe: Initial Experience in Lagos, Nigeria.

    Olajide TO, Bode CO

    Journal of the West African College of Surgeons 2023; (13(3)):101-106 doi:10.4103/jwas.jwas_108_23.

    PMID: 37538211
  19. 19

    Transanal opening of intersphincteric space (TROPIS) - A new procedure to treat high complex anal fistula.

    Garg P

    International journal of surgery (London, England) 2017; (40()):130-134 doi:10.1016/j.ijsu.2017.02.095.

    PMID: 28259693
  20. 20

    Modified Parks' Technique and TROPIS Procedure for Treatment of Complex Anal Fistulas: Similar Concept and Different Technique.

    Emile SH

    Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 2021; (25(6)):1640-1641 doi:10.1007/s11605-021-05009-x.

    PMID: 33835364
  21. 21

    Transanal opening of the intersphincteric space (TROPIS): a novel procedure on the horizon to effectively manage high complex anal fistulas.

    Garg P, Mongia A

    Annals of coloproctology 2024; (40(1)):74-81 doi:10.3393/ac.2022.01263.0180.

    PMID: 38414123
  22. 22

    Transanal opening of intersphincteric space (TROPIS) treatment for high complex anal fistula: a systematic review and meta-analysis.

    Zhou P, Lu J, Sun Y, Wang J

    International journal of surgery (London, England) 2025; (111(10)):7301-7311 doi:10.1097/JS9.0000000000002880.

    PMID: 40693967
  23. 23

    THE LIGATION OF THE INTERSPHINETRIC TRACT PROCEDURE OF THE PERIANAL FISTULA: CASE REPORT.

    Stosic M, Stojanovic I, Mihajlovic S

    Medicinski pregled 2016; (69(9-10)):298-301 doi:10.2298/mpns1610298s.

    PMID: 29693853
  24. 24

    Systematic review and meta-analysis of endorectal advancement flap and ligation of the intersphincteric fistula tract for cryptoglandular and Crohn's high perianal fistulas.

    Stellingwerf ME, van Praag EM, Tozer PJ, et al.

    BJS open 2019; (3(3)):231-241 doi:10.1002/bjs5.50129.

    PMID: 31183438
  25. 25

    Ligation of Intersphincteric Fistula Tract: a Sphincter-Sparing Option for Complex Fistula-in-Ano.

    Lange EO, Ferrari L, Krane M, Fichera A

    Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 2016; (20(2)):439-44 doi:10.1007/s11605-015-2947-4.

    PMID: 26394877
  26. 26

    Magnetic Resonance Imaging (MRI): Operative Findings Correlation in 229 Fistula-in-Ano Patients.

    Garg P, Singh P, Kaur B

    World journal of surgery 2017; (41(6)):1618-1624 doi:10.1007/s00268-017-3886-x.

    PMID: 28097414
  27. 27

    The role of magnetic resonance imaging in the preoperative evaluation of anal fistulas.

    Vo D, Phan C, Nguyen L, et al.

    Scientific reports 2019; (9(1)):17947 doi:10.1038/s41598-019-54441-2.

    PMID: 31784600
  28. 28

    The anal fistula plug in Crohn's disease patients with fistula-in-ano: a systematic review.

    Nasseri Y, Cassella L, Berns M, et al.

    Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2016; (18(4)):351-6 doi:10.1111/codi.13268.

    PMID: 26749385
  29. 29

    Increasing experience with the LIFT procedure in Crohn's disease patients with complex anal fistula.

    Wood T, Truong A, Mujukian A, et al.

    Techniques in coloproctology 2022; (26(3)):205-212 doi:10.1007/s10151-022-02582-4.

    PMID: 35103901

This page explains anal fistula surgical options for educational purposes. Your colorectal surgeon is the best source for recommending the right procedure based on your specific case.

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