Reoperative surgery for persistent anal fistulae

Failure of treatment of a primary anal fistula is rarely life threatening, but the cost to the patient in terms of pain, discomfort, and interruption of daily life is substantial. Complex or recurrent fistulas must be methodically evaluated so a successful treatment strategy can be developed, and therapy completed, ideally without compromising fecal continence. Advanced imaging can be useful in identifying complex tracts and accumulated sepsis but is rarely indicated in the setting of a primary fistula. Multiple methods to repair complex, recurrent fistulas have been described with varying success rates. Diversion of the fecal stream is often employed after repeat repair of a fistula but is not universally beneficial. Treatment must be individualized according to pre-existing patient factors, number of internal openings, and condition of the tissues in and around the anus.