European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula

Abstract

AimThe primary aim of the European Society of Coloproctology (ESCP) Guideline Development Group (GDG) was to produce high‐quality, evidence‐based guidelines for the management of cryptoglandular anal fistula with input from a multidisciplinary group and using transparent, reproducible methodology.MethodsPreviously published methodology in guideline development by the ESCP has been replicated in this project. The guideline development process followed the requirements of the AGREE‐S tool kit. Six phases can be identified in the methodology. Phase one sets the scope of the guideline, which addresses the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula in adult patients presenting to secondary care. The target population for this guideline are healthcare practitioners in secondary care and patients interested in understanding the clinical evidence available for various surgical interventions for anal fistula. Phase two involved formulation of the GDG. The GDG consisted of 21 coloproctologists, three research fellows, a radiologist and a methodologist. Stakeholders were chosen for their clinical and academic involvement in the management of anal fistula as well as being representative of the geographical variation among the ESCP membership. Five patients were recruited from patient groups to review the draft guideline. These patients attended two virtual meetings to discuss the evidence and suggest amendments. In phase three, patient/population, intervention, comparison and outcomes questions were formulated by the GDG. The GDG ratified 250 questions and chose 45 for inclusion in the guideline. In phase four, critical and important outcomes were confirmed for inclusion. Important outcomes were pain and wound healing. Critical outcomes were fistula healing, fistula recurrence and incontinence. These outcomes formed part of the inclusion criteria for the literature search. In phase five, a literature search was performed of MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews by eight teams of the GDG. Data were extracted and submitted for review by the GDG in a draft guideline. The most recent systematic reviews were prioritized for inclusion. Studies published since the most recent systematic review were included in our analysis by conducting a new meta‐analysis using Review manager. In phase six, recommendations were formulated, using grading of recommendations, assessment, development, and evaluations, in three virtual meetings of the GDG.ResultsIn seven sections covering the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula, there are 42 recommendations.ConclusionThis is an up‐to‐date international guideline on the management of cryptoglandular anal fistula using methodology prescribed by the AGREE enterprise.

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“…Although some of these morbidities may partly be associated with specific patient and disease characteristics ( 7 ), the safety of clipping anal fistulae remains a topic of debate. It is therefore not surprising that no recommendation could be made for the use of OTSC in the management of fistula- in-ano in the recently published European guidelines for the management of cryptoglandular fistula ( 8 ).…”

Postoperative pain following laser fistula closure versus ligation of the intersphincteric fistula tract: A prospective double‐blinded randomized controlled trial

“…2,3 Even now, there is no "gold-standard" in the treatment of anal fistulas. 4,5 The goals in treating an anal fistula include draining septic foci, eradicating tracts, maintaining continence, and preventing recurrences. 6 Options for surgery are numerous with selection based on fistula type, acuity of presentation, surgeons' expertise, risk of incontinence and increasingly, and patient preference.…”