Evolution of anal fistula management: From traditional surgery to contemporary minimally invasive approaches

Anal fistula represents a complex surgical challenge affecting approximately 1–2/10,000 individuals globally, characterised by abnormal epithelialised connections between the anal canal and perianal skin. This comprehensive narrative review examines the evolving landscape of anal fistula management through a systematic analysis of contemporary evidence for established and emerging therapeutic modalities. A structured literature search was conducted across PubMed, Scopus and Web of Science databases (2000–2025), focusing on surgical techniques, minimally invasive interventions and patient outcomes. While fistulotomy maintains its position as the gold standard for simple, low-complexity fistulas with success rates exceeding 85%, the management of complex fistulas has undergone a significant transformation. Modern sphincter-preserving techniques, including the ligation of the intersphincteric fistula tract procedure and endorectal advancement flaps, demonstrate healing rates of 60–85% while minimising continence complications. Contemporary non-surgical interventions encompass fibrin glue injection, adipose-derived mesenchymal stem cell therapy and bioengineered fistula plugs, showing variable success rates of 40–75% depending on fistula complexity and patient selection. Emerging technologies, including laser fistula closure and video-assisted anal fistula treatment, represent the frontier of minimally invasive care, with early success rates of 50–70%. Critical analysis reveals that optimal outcomes require personalised, multimodal approaches combining surgical technique optimisation with targeted biologic therapies. Current evidence supports the selective integration of innovative minimally invasive technologies within individualised treatment algorithms, though standardisation of protocols and long-term outcome assessment remain critical research priorities.