Flaps, Glues, and Plugs—A View From the East

Complex fistulas are difficult to treat. The options available are advancement flaps, fibrin glue, and, of late, anal fistula plug (AFP). A sizable proportion of the published studies are from the US and Europe. The results from these studies were analyzed and compared to the results of the published literature from the east (Asia and Australia). The overall success rate ranges from 46% to 100% for advancement flaps, 14% to 78% for fibrin glue, and 24% to 87% for AFP technique. However, the present data is insufficient to conclude the superiority of either (ie, fibrin glue or AFP procedure) over the other. So, depending on the surgeon's preference, either of the two procedures may be recommended as the first line of approach to tackle complex fistulas. Advancement flap procedure is associated with higher morbidity and involves a significant risk of incontinence/worsening continence (0%-52%). Therefore, under the circumstances, advancement flap procedure should probably be recommended only after the lesser invasive procedures (fibrin glue and AFP) have failed.