The principle of the anal fistula therapy is to permanently heal the fistula without compromising the patient’s continence. The chosen surgical method is often a dilemma between these two poles. A long period of time is needed to register most recurrences. All methods can disturb continence, even the sphincter preserving ones. The grade of disturbance is in most cases low though. Simple fistulas, like subanodermal and low intersphincteric, are successfully treated with fistulotomy and patients mostly retain their continence. Seton pretreatment before fistulotomy may primary heal the fistula and prevent perianal sepsis, but it also impairs negatively the recurrence and incontinence rate. When indicated, fistulotomy should be performed during the first surgery. If this result is affected by the presence of the abscess, it remains questionable. Randomized controlled studies could clear the role of the seton pretreatment before fistulotomy. Higher intersphincteric and transsphincteric fistulas may not laid open, as this would cause a greater injury of the sphincter and therefore a higher grade of incontinence. The advancement flap results also a relatively high recurrence and incontinence rate despite the sphincter conservation. Some patients can be cured only with a temporary loose seton although the cryptoglandular focus is not eliminated. However this spontaneous healing can be observed without the seton as well. The small number of patients precludes definite conclusions. Newer methods such as the anal fistula plug may be an alternative and their long-term results should be studied in the future.
