Current State-of-the Art of Anal Fistula Surgery in Germany.

Surgery for anal fistula and abscess is as old as mankind. More than 2000 years ago already procedures were performed and described in old manuscripts. In modern times anal fistula is still a big issue for colorectal surgeons. Only surgery has the ability to heal the patient. The cryptoglandular aetiology: in these glands a septic process starts and this leads to the formation of abscess and fistula. The abscess is the acute, the anal fistula the chronic manifestation of the same disease. Patients with recurrent abscess will have only relieve, when the underlying fistula has been dealt with. Most fistulas are superficial: fistulotomy results in a low recurrence rate and only minor problems concerning faecal continence. The complex fistulas are those, in which fistulotomy produces faecal incontinence. Therefor sphincter saving procedures have been developed. These techniques are described and the pros and cons are discussed. In Germany rectal advancement flap and fistulectomy with primary anal sphincter repair have found their place in the German guideline. In the last 30 years many new techniques have been developed, some are still being used, some are abandoned. Surgery for anal fistula is demanding: recurrence and faecal incontinence rates should be low. On the other hand: the more recurrences a patient had, the higher the chance of a new recurrence AND the higher the chance of faecal incontinence. Every new septic process in the anal region does not improve anal and pelvic floor function. The colorectal surgeon dealing with complex anal fistula should have more than one option to offer and discuss these with the patient.