The mainstay of treatment of anal fistula is surgical treatment.The principles for the management of anal fistula are described by the acronym SNAP, which stands for sepsis, nutrition, anatomy, and procedure according to British Medical Journal. Various methods of surgery are fistulotomy and Seton. Sphincter-saving methods are fibrin glue, endorectal advancement flap, LIFT procedure, BioLIFT, stem cells and defunctioning.

• Mainstay of treatment of anal fistula is surgical treatment.
• According to British Medical Journal, the principles for the management of anal fistula are described by the acronym SNAP, which stands for sepsis, nutrition, anatomy, and procedure.^{_The_BMJ-1|[1]}
  • Treatment of sepsis is the first step.
  • Nutrition is very important for the healing of fistula.
    • Patient should be healthy during the treatment of anal fistula.
    • In malnourished patients and patients with comorbidities, fistula heals slowly.
  • Anatomy of fistula should be tracked before starting the treatment.
    • Failure to track the secondary fistula leads to failure of treatment.
  • Selection of the appropriate procedure is key to successful management.

• According to the American Society of Colon and Rectal Surgeons, the goal of treatment to identify the internal opening and the course of all tracks relative to the sphincter muscles and then f obliterate the internal fistulous opening and any associated epithelialized tracks with minimal sphincter division.^[2]

Various methods of surgery are:^[3]

• Fistulotomy: It is used to treat simple anal fistula with normal anatomy and with no other complication.
• Seton: Used to treat complex fistula.

Sphincter-saving methods are:

• Fibrin glue: Fibrin glue is a combination of fibrinogen, thrombin, and calcium in a matrix.
  • Fibrin glue heals the fistula by first forming the clot within the track and then helping in the growth of collagen fibers and healthy tissue.^[4][5]
• Fistula plug: Fistula plug is made from porcine and small intestine mucosa.
  • It encourages host cells to grow and ultimately fill the fistula track.
  • It is resistant to infection.^[6]

• Endorectal advancement flap:^[7][8]
  • Used to stop the fistula track communicating with the bowel and cover the internal opening with the disease-free anorectal wall.
  • There are various types of endorectal advancement flap:
    • Rhomboid flaps, anorectal flaps with proximal advancement.
    • Full or partial thickness flap of the proximal rectal wall.
• LIFT procedure:
  • Ligation of the intersphincteric fistula track (LIFT): Between the internal and external anal sphincters, a skin incision is made, the fistula track is exposed within the intersphincteric space and subsequently ligated and divided.^[9]
  • BioLIFT – It is modified LIFT , a biological mesh is placed in the intersphincteric space which serves as a barrier to refistulisation.
• Stem cells:
  • Stem cells are derived from adipose cells.
  • Stem cells are infused into fistula track and helps in healing of fistula.^[10]
• Defunctioning:
  • It is done in rare cases, when there is perianal sepsis and mutiple tracts formation.
  • The bowel is defunctioned by taking out the proximal colon and colostomy is done.
  • This helps in improvement of symptoms of perianal leakage.
  • It helps in diverting the bowel contents away from the anorectum, thus, defunctioning helps in resolution of sepsis.