Practice Variation in Anal Fistula Management

Treatment of anal fistula still poses the greatest challenge for anorectal surgeons. Despite the rise of sphincter-sparing surgeries, there is no clear evidence that suggests their superiority over each other. Therefore, modern guidelines acknowledge several techniques as acceptable due to lack of universal standard of care. Practice variability is caused by complex anatomy of the disease and the existence of community-wide equipoise. Fistula treatment continues to be challenging in terms of achieving the optimal balance between fistula eradication and continence preservation. Patient decision-making is guided by personal risk and benefit calculations, surgical experience, and individual patient preference. Moreover, interpretation of the existing research on this topic is complicated by different approaches to defining both clinical and radiological healing, recurrence, as well as quality-of-life parameters. Surgical practice variability in anal fistula management is due to both individualized clinical approach and the presence of significant shortcomings within the methodology of the current literature. It is critical for major societies in the field of colorectal surgery to establish a mandatory reporting on standardized outcomes, in particular the Anal Fistula Core Outcome Set and standardized imaging criteria, for eliminating unjustified variability and implementing evidence-based surgical strategies.