EP318 - The Evolution of Anal Fistula Treatment: From Major Surgery to Image-Guided Minimally Invasive and Non-Invasive Techniques

Purpose/Background: The definitive treatment for anal fistula has long faced a fundamental dilemma: balancing radical cure against the risk of anal incontinence. Traditional fistulotomy, while effective, carries incontinence rates up to 40%. This has driven a paradigm shift in treatment philosophy from "major incision" toward "minimally invasive" and "non-invasive" approaches, centered on preserving sphincter function. This review synthesizes the current status and evidence for core minimally invasive and non-invasive techniques.

Methods/Interventions: A systematic review of contemporary sphincter-preserving techniques was conducted. The interventions analyzed include biomaterial-based occlusion (e.g., Anal Fistula Plug, selective fibrin glue), energy platform-assisted closure (e.g., Fistula Laser Closure - FiLaC™), and video-assisted interventional therapy (Video-Assisted Anal Fistula Therapy - VAAFT). The analysis focused on their mechanisms, application precision (e.g., under fistuloscopic guidance), and functional outcomes.

Results/Outcomes: These advanced techniques demonstrate high precision in managing fistula tracts while minimizing sphincter damage. Reported success rates vary: FiLaC™ shows a 63% overall success rate, which can be elevated to 95.5% when combined with an advancement flap. VAAFT exhibits a weighted average recurrence rate of 17.7%, with superior internal orifice identification (>93%). The Anal Fistula Plug, while having minimal incontinence risk, shows high recurrence (up to 47.7%). Crucially, all these techniques reduce the risk of postoperative anal incontinence to near zero, significantly improving patient quality of life. However, significant variability in efficacy exists across studies and centers.

Conclusion/Discussion: Image-guided minimally invasive techniques represent a significant advancement in anal fistula treatment, successfully decoupling therapeutic efficacy from functional damage. They form a modern arsenal enabling precision, individualized therapy. Despite their benefits, challenges remain, including substantial efficacy variation, a scarcity of high-level evidence from randomized trials, steep learning curves, and cost concerns. Future directions must focus on technique integration and optimization, conducting high-quality comparative studies, and exploring novel technologies to solidify a standardized, precision-based approach to fistula management.