Innovative management of anal fistula by the use of the anal fistula plug: hype or help?

Impressed by the initial success rates of 80% of the anal fistula plug for the closure of cryptoglandular and Crohn's associated anorectal fistulas, preliminary results from centers world-wide showed a healing rates between 24% and 88%. When compared to traditional flap repair for closing high anorectal fistulas, impairement of continence may be decreased using the plug procedure. Analyzing the different experiences of the plug procedure ranging from promising to disappointing results, a variety of issues such as bowel preparation, treatment of fistula tract, closure of the internal opening, and postoperative management have to be considered. Furthermore, the ''ideal'' indication has still to be defined. At the moment, all results which have been published only provide short-term results, and the question whether the plug procedure is appropriate and effective in Crohn's disease cannot be answered definitely. Finally, the question how to proceed in patients with plug dislodgement or failure remains unclear. In general, the introduction of the plug has accelerated a ''new'' discussion on the optimal treatment of complex fistulas. Further analysis is needed to explain the definite role of this innovative technique in comparison to traditional surgical techniques.