Setons are a useful method in complex anterior anal fistula crossing less than 50 % of the anterior EAS, especially in women. A seton consists of tying an inert thread around the muscle following the fistulous tract to keep adequate drainage. It is tightened gradually according to the status of wound healing. The results are satisfactory, with minor sphincter damage and without major change in the incontinence score if comparing values before and after the operation [11], although there is some debate regarding postoperative continence in some of the limited manometric and clinical data that are available concerning the use of cutting setons [12].

Both methods are promising therapies that minimize incontinence risk. Initially, some authors reported success rates of 60–64 % [13, 14], but Buchanan et al. [15] conducted a prospective trial and demonstrated that only 14 % of cases remained healed after 16 months’ follow-up. Some other publications also have reported that long-term results have been disappointing [16, 17], with rates as low as 16 % [18, 19]. Concerning the fistula plug, the initial results were ­promising, with a success rate of 87 % [20], but the ­long-term results range between 29 and 48 % [17].

The use of an endorectal advancement flap is an attractive alternative for the treatment of anterior complex fistulas, especially in women, because it is aimed at avoiding the risk of severe injury to the anterior EAS, thereby preventing fecal incontinence. It shows the advantage of closing the internal opening and does not divide the sphincter; it is able to be combined with overlapping sphincter reconstruction if necessary. It involves mobilization of at least mucosa and submucosa and can include the internal anal sphincter and the rectal wall. Adequate blood supply is ensured by being sure that the base of the mobilized flap is twice the width of the apex. The flap must be advanced downward without tension, with the suture obliterating the internal opening. The external opening is left open to ensure satisfactory drainage. Successful healing rates have been reported in between 55 and 98 % of patients [21–28]. Kodner et al. [23] reported a 93 % success rate in 107 patients operated on for the treatment of low rectovaginal, anterior anoperineal, and posterior anoperineal fistulas, whereas Mizrahi et al. [27] reported a 59.6 % success rate in 94 patients, correlating poor healing with the presence of Crohn’s disease and showing a significantly higher recurrence rate (57.1 %) when compared with cryptoglandular disease fistulas (33.3 %). In addition, cancer and irradiation and a rectovaginal fistula diameter greater than 2.5 cm have been shown to be predictive factors for poor outcome [25, 29]. Although the sphincter muscles are not transected, minor incontinence has been reported in 31 % of cases and major incontinence has been reported in up to 12 % of patients [21, 23, 25, 30, 31].

Originally described and published by Rojanasakul et al. [32], LIFT involves maneuvering a probe through the fistula tract and marking the skin over the intersphincteric space when the probe is in place. An incision is made in the intersphincteric groove and the fistula tract is identified in this space with the probe in situ. Once the tract is dissected free, it is encircled and the probe can be removed. Next, the fistula tract is divided and ligated. The external opening is left open and the tract is curetted. The internal opening is gently curetted as well and formally closed. The skin incision is closed with interrupted absorbable sutures. Rojanasakul et al. reported a 94 % success rate in 17 patients; however, subsequent studies of the technique have reported successful healing of the fistula in 57–89 % of patients [33–37]. More recently, Ellis [37] proposed ligation of the intersphincteric fistula tract reinforced with a bioprosthetic graft (the BioLift procedure) and reported a success rate of 94 % in 31 patients presenting with complex anal fistula.

Anterior sagittal anorectoplasty has been reported in some centers in India and Asia as well as in the United States, South America, and Europe as both a primary [58–61] and a secondary procedure [62]. Preliminary on-table cutaneous electromyography is advisable for the determination of the correct positioning of the neoanus [63]. A racket-shaped incision is performed around the neoanus and extended toward the vagina, following the fistula tract (Fig. 37.2a). The rectum is separated from the vagina by a combination of blunt and sharp dissection, taking care to preserve the integrity of the rectal wall (Fig. 37.2b). There are often dense adhesions of the rectum to the vagina at the fistula site; however, once this is crossed, rectovaginal separation is comparatively easy in both anovestibular and the rectovestibular anomalies (Fig. 37.2c). On occasion, damage may occur to the vaginal wall during separation, although this is easily sutured when the rectal mobilization is complete. The end of the dissection is indicated when the rectum lies without tension 5 mm beyond the skin of the perineum (Fig. 37.2d). The striated muscle complex is delineated by electrostimulation and the rectum anchored to this active area of the sphincter. The perineal body is reconstructed by suturing the tissue between the rectum and vagina in layers (Fig. 37.2e, f). Finally, the fourchette is reconstructed, an anoplasty is performed, and the incision is closed primarily (Fig. 37.2g).

Since the inception of anterior sagittal anorectoplasty, the basic management of vestibular fistula has remained unchanged; however, the rate of complications has decreased by 7 % overall [60]. The factors responsible for the improvement of results include better surgical technique and dissection with growing experience, less tissue trauma, adequate rectal mobilization, and an absence of hemorrhage leading to hematoma [60, 61]. The availability of lactulose to keep the stool soft during the immediate postoperative period is also a factor responsible for the improved results. It is advisable that these patients undergo cesarean delivery in the future in an effort to prevent damage to the perineal body incurred during vaginal delivery [59].