<p class="ql-block"><br></p><p class="ql-block"> </p><p class="ql-block">一、引言</p><p class="ql-block"> </p><p class="ql-block">肛瘺是肛腸外科常見(jiàn)的難治性疾病，由肛管或直腸與肛周皮膚相通的慢性感染性管道構(gòu)成，常繼發(fā)于肛周膿腫破潰或切開(kāi)引流后。傳統(tǒng)治療手段如單純瘺管切開(kāi)術(shù)、掛線(xiàn)療法雖能清除病灶，但存在損傷括約肌導(dǎo)致肛門(mén)失禁“創(chuàng)面愈合緩慢”“疼痛劇烈”及“復(fù)發(fā)率高”等弊端1。安阿玥教授作為我國(guó)肛腸外科領(lǐng)域的領(lǐng)軍人物，通過(guò)數(shù)十年臨床實(shí)踐與理論探索，創(chuàng)新提出“肛瘺切開(kāi)引流根治術(shù)”與“主灶切開(kāi)對(duì)口引流根治術(shù)”，以“損傷小、療程短、痛苦小、恢復(fù)快”為核心特點(diǎn)，構(gòu)建了符合現(xiàn)代微創(chuàng)外科理念的肛瘺治療體系，為肛瘺的精準(zhǔn)化、功能保護(hù)性治療提供了新路徑。</p><p class="ql-block"> </p><p class="ql-block">二、肛瘺的病理生理與傳統(tǒng)治療的局限性</p><p class="ql-block"> </p><p class="ql-block">肛瘺的發(fā)生遵循“隱窩腺感染理論”：肛管齒線(xiàn)區(qū)的肛腺因阻塞引發(fā)感染，炎癥向周?chē)g隙蔓延形成肛周膿腫，膿腫破潰或切開(kāi)后即形成肛瘺2。典型肛瘺由內(nèi)口（多位于齒線(xiàn)肛隱窩處）、瘺管（連接內(nèi)口與外口的管道，可呈直形、彎曲形或分支狀）、外口（肛周皮膚的破潰口）三部分組成。</p><p class="ql-block"> </p><p class="ql-block">傳統(tǒng)肛瘺治療面臨多重困境：</p><p class="ql-block"> </p><p class="ql-block">1. 單純瘺管切開(kāi)術(shù)：需將整個(gè)瘺管及周?chē)：劢M織完全切開(kāi)，雖能實(shí)現(xiàn)病灶開(kāi)放引流，但對(duì)于高位或復(fù)雜瘺管，過(guò)度切開(kāi)括約肌易導(dǎo)致肛門(mén)控便功能障礙，尤其是對(duì)氣體、稀便的控制能力受損3。</p><p class="ql-block">2. 掛線(xiàn)療法：利用橡皮筋或絲線(xiàn)的機(jī)械壓迫作用緩慢切割括約肌，雖能在一定程度上保護(hù)括約肌功能，但存在“療程長(zhǎng)（通常需2-4周）”“患者疼痛明顯”“橡皮筋脫落前后創(chuàng)面刺激大”等問(wèn)題；且對(duì)于分支較多的復(fù)雜瘺管，引流的徹底性不足4。</p><p class="ql-block">3. 復(fù)發(fā)率與并發(fā)癥：傳統(tǒng)方法對(duì)感染主灶的清除常不徹底，加之瘺管分支引流不暢，導(dǎo)致術(shù)后復(fù)發(fā)率可達(dá)10%-20%；同時(shí)，術(shù)后出血、創(chuàng)面延遲愈合等并發(fā)癥也較為常見(jiàn)5。</p><p class="ql-block"> </p><p class="ql-block">三、安阿玥教授肛瘺手術(shù)體系的理論基礎(chǔ)</p><p class="ql-block"> </p><p class="ql-block">安阿玥教授的手術(shù)理念源于對(duì)肛瘺解剖“病理生理”的深入理解，以及對(duì)微創(chuàng)外科“精準(zhǔn)損傷、最大保留功能”原則的踐行，其理論支撐涵蓋解剖學(xué)、病理生理學(xué)、生物力學(xué)與微創(chuàng)醫(yī)學(xué)等多個(gè)維度。</p><p class="ql-block"> </p><p class="ql-block">（一）解剖學(xué)基礎(chǔ)：括約肌復(fù)合體與瘺管的空間關(guān)系</p><p class="ql-block"> </p><p class="ql-block">肛門(mén)括約肌復(fù)合體由內(nèi)括約?。ㄆ交?，負(fù)責(zé)靜息狀態(tài)下的控便）、外括約?。ü趋兰?，主管主動(dòng)控便）及肛提肌等組成，各肌群在肛管周?chē)纬蓪哟畏置鞯娜S結(jié)構(gòu)6。根據(jù)Parks肛瘺分型（1976年提出），肛瘺可分為“括約肌間型”“經(jīng)括約肌型”“括約肌上型”“括約肌外型”，其中前兩者占比超80%7。</p><p class="ql-block"> </p><p class="ql-block">安阿玥教授強(qiáng)調(diào)，肛瘺治療的關(guān)鍵在于“精準(zhǔn)識(shí)別感染主灶與瘺管的空間走向”，尤其是括約肌間間隙（位于內(nèi)、外括約肌之間的潛在腔隙，是感染擴(kuò)散的核心通路）。通過(guò)保護(hù)括約肌復(fù)合體的完整性，既能清除病灶，又能最大程度保留肛門(mén)控便功能。例如，對(duì)于括約肌間型肛瘺，“主灶切開(kāi)”可直接處理位于括約肌間的感染核心，避免向更深層的外括約肌延伸損傷。</p><p class="ql-block"> </p><p class="ql-block">（二）病理生理學(xué)機(jī)制：感染源根除與引流優(yōu)化</p><p class="ql-block"> </p><p class="ql-block">肛瘺的核心病理是“感染-膿腫-瘺管”的惡性循環(huán)，因此治療需同時(shí)實(shí)現(xiàn)“感染源根除”與“瘺管充分引流”。</p><p class="ql-block"> </p><p class="ql-block">1. 感染源根除：安阿玥教授提出“主灶”概念，即肛瘺的感染起始部位（多為齒線(xiàn)處的感染肛腺及相鄰瘺管）。手術(shù)中需精準(zhǔn)定位內(nèi)口，徹底清除主灶區(qū)域的炎性肉芽、壞死組織及感染肛腺，從源頭阻斷感染的持續(xù)產(chǎn)生8。</p><p class="ql-block">2. 引流優(yōu)化：對(duì)于存在分支或盲端的瘺管，單純切開(kāi)主灶可能導(dǎo)致分支內(nèi)膿液淤積，因此“對(duì)口引流”通過(guò)在瘺管分支或遠(yuǎn)端合理設(shè)置輔助切口，形成“主灶-輔助切口”的雙向或多向引流通道，確保膿性分泌物、壞死組織能及時(shí)排出，避免局部感染殘留9。這種“主灶根治+對(duì)口引流”的策略，既解決了感染源頭問(wèn)題，又保障了瘺管全程的引流通暢，為創(chuàng)面愈合創(chuàng)造了有利的無(wú)菌環(huán)境。</p><p class="ql-block"> </p><p class="ql-block">（三）微創(chuàng)與生物力學(xué)原理：損傷控制與愈合促進(jìn)</p><p class="ql-block"> </p><p class="ql-block">安阿玥教授的手術(shù)體系深度契合微創(chuàng)外科理念，體現(xiàn)為“有限損傷”與“功能保護(hù)”的平衡：</p><p class="ql-block"> </p><p class="ql-block">1. 損傷控制：通過(guò)精準(zhǔn)的“主灶切開(kāi)”替代“瘺管全切開(kāi)”，大幅減少了正常組織（尤其是括約?。┑膿p傷范圍。例如，對(duì)于經(jīng)括約肌型肛瘺，若瘺管走行靠近外括約肌淺層，可僅切開(kāi)主灶及部分淺層括約肌，而保留深層括約肌的完整性，避免肛門(mén)控便功能的嚴(yán)重破壞。</p><p class="ql-block">2. 生物力學(xué)優(yōu)化：手術(shù)切口的形態(tài)與位置設(shè)計(jì)充分考慮肛周組織的生物力學(xué)特性。肛周皮膚及括約肌的張力分布具有方向性，弧形或斜行的切口設(shè)計(jì)可降低切口對(duì)張力的直接承受，減少術(shù)后疼痛與瘢痕攣縮10。同時(shí)，開(kāi)放的引流創(chuàng)面通過(guò)“自溶性清創(chuàng)”（依靠組織滲出液中的酶溶解壞死組織）與“肉芽組織自然填充”實(shí)現(xiàn)愈合，避免了過(guò)度清創(chuàng)對(duì)創(chuàng)面愈合速度的負(fù)面影響。</p><p class="ql-block"> </p><p class="ql-block">四、安阿玥教授核心手術(shù)技術(shù)詳解</p><p class="ql-block"> </p><p class="ql-block">（一）肛瘺切開(kāi)引流根治術(shù)</p><p class="ql-block"> </p><p class="ql-block">適用范圍：主要用于低位單純性肛瘺（瘺管位于外括約肌淺層以下，無(wú)復(fù)雜分支）。</p><p class="ql-block">操作要點(diǎn)：</p><p class="ql-block"> </p><p class="ql-block">1. 定位內(nèi)口與主灶：采用指診、探針探查或肛鏡下美藍(lán)染色等方法，明確內(nèi)口位置及主灶范圍。內(nèi)口多位于齒線(xiàn)附近的肛隱窩處，主灶常表現(xiàn)為紅腫、質(zhì)硬的炎性組織區(qū)。</p><p class="ql-block">2. 主灶切開(kāi)：沿探針指引，將內(nèi)口至外口之間的主灶區(qū)域（包括感染肛腺、瘺管及周?chē)仔越M織）完全切開(kāi)，形成開(kāi)放的梭形創(chuàng)面，確保創(chuàng)面基底新鮮、引流通暢。</p><p class="ql-block">3. 創(chuàng)面處理：清除創(chuàng)面上的壞死組織與肉芽，修剪創(chuàng)緣使呈“V”形（利于引流與愈合），術(shù)后每日行中藥熏洗、換藥，促進(jìn)肉芽組織生長(zhǎng)與創(chuàng)面愈合。</p><p class="ql-block"> </p><p class="ql-block">技術(shù)特點(diǎn)：手術(shù)操作直接、簡(jiǎn)潔，通過(guò)徹底開(kāi)放主灶實(shí)現(xiàn)感染控制；因損傷范圍局限于低位括約肌，對(duì)肛門(mén)功能影響極小，術(shù)后疼痛輕，愈合時(shí)間通常為2-3周。</p><p class="ql-block"> </p><p class="ql-block">（二）主灶切開(kāi)對(duì)口引流根治術(shù)</p><p class="ql-block"> </p><p class="ql-block">適用范圍：適用于高位肛瘺“復(fù)雜肛瘺”（存在多個(gè)分支瘺管或盲端）。</p><p class="ql-block">操作要點(diǎn)：</p><p class="ql-block"> </p><p class="ql-block">1. 主灶精準(zhǔn)處理：同“肛瘺切開(kāi)引流根治術(shù)”，徹底切開(kāi)內(nèi)口所在的主灶區(qū)域；若主灶涉及部分高位括約?。ㄈ缤饫s肌深層），可采用“開(kāi)窗法”（僅切開(kāi)括約肌表面的筋膜與部分肌纖維，形成引流窗口），避免完全切斷括約肌。</p><p class="ql-block">2. 對(duì)口引流設(shè)計(jì)：對(duì)于遠(yuǎn)離主灶的瘺管分支或盲端，在其表面皮膚作小切口（輔助切口），切口大小以能容納引流條、確保分泌物排出為度（通常為0.5-1cm）。輔助切口與主灶創(chuàng)面之間通過(guò)瘺管腔道相通，形成“主灶創(chuàng)面-瘺管-輔助切口”的引流通路。</p><p class="ql-block">3. 術(shù)后管理：主灶創(chuàng)面與輔助切口均需定期換藥，主灶創(chuàng)面重點(diǎn)關(guān)注肉芽生長(zhǎng)與感染控制，輔助切口則以保持引流通暢為核心；待主灶創(chuàng)面愈合后，輔助切口多可自行閉合。</p><p class="ql-block"> </p><p class="ql-block">技術(shù)特點(diǎn)：通過(guò)“主灶根治+多口引流”，既解決了高位/復(fù)雜肛瘺的感染源頭問(wèn)題，又避免了因完全切開(kāi)高位括約肌導(dǎo)致的失禁風(fēng)險(xiǎn)；同時(shí)，多個(gè)小切口的設(shè)計(jì)大幅減輕了患者疼痛，愈合時(shí)間較傳統(tǒng)掛線(xiàn)療法縮短約1/3（通常為3-4周）。</p><p class="ql-block"> </p><p class="ql-block">五、臨床療效與機(jī)制研究</p><p class="ql-block"> </p><p class="ql-block">多項(xiàng)臨床研究驗(yàn)證了安阿玥教授手術(shù)體系的優(yōu)勢(shì)：</p><p class="ql-block"> </p><p class="ql-block">1. 療效指標(biāo)：在一項(xiàng)納入200例復(fù)雜肛瘺患者的研究中，采用“主灶切開(kāi)對(duì)口引流根治術(shù)”后，治愈率達(dá)95.5%，復(fù)發(fā)率僅4.5%，術(shù)后肛門(mén)失禁發(fā)生率為0（對(duì)照組傳統(tǒng)掛線(xiàn)療法復(fù)發(fā)率12.0%，失禁發(fā)生率8.0%）11。</p><p class="ql-block">2. 疼痛與愈合時(shí)間：視覺(jué)模擬評(píng)分（VAS）顯示，術(shù)后1周患者疼痛評(píng)分平均為3.2分（傳統(tǒng)療法為5.8分）；創(chuàng)面愈合時(shí)間平均為21天（傳統(tǒng)療法為35天）12。</p><p class="ql-block">3. 機(jī)制探索：從組織學(xué)角度，安阿玥手術(shù)體系通過(guò)保留更多正常括約肌組織，維持了肛管靜息壓與最大收縮壓的穩(wěn)定（術(shù)后肛管壓力測(cè)定顯示，靜息壓平均為70.2cmH?O，收縮壓平均為125.6cmH?O，與正常人群無(wú)顯著差異）13；同時(shí)，對(duì)口引流促進(jìn)了創(chuàng)面局部血運(yùn)改善與炎性因子（如TNF-α、IL-6）的快速清除，加速了肉芽組織的增殖與上皮化進(jìn)程14。</p><p class="ql-block"> </p><p class="ql-block">六、學(xué)術(shù)影響與未來(lái)展望</p><p class="ql-block"> </p><p class="ql-block">安阿玥教授的肛瘺手術(shù)體系不僅在國(guó)內(nèi)得到廣泛推廣，還被納入《中國(guó)肛瘺診療指南（2021版）》15，成為我國(guó)肛瘺微創(chuàng)治療的核心技術(shù)之一。其“主灶根治+功能保護(hù)+優(yōu)化引流”的理念，也為國(guó)際肛腸外科領(lǐng)域提供了“東方經(jīng)驗(yàn)”，推動(dòng)了肛瘺治療從“破壞性根治”向“功能性治愈”的轉(zhuǎn)變。</p><p class="ql-block"> </p><p class="ql-block">未來(lái)，隨著影像學(xué)技術(shù)（如腔內(nèi)超聲、MRI）在肛瘺定位中的精準(zhǔn)化應(yīng)用，以及生物材料（如可降解引流管、創(chuàng)面修復(fù)凝膠）的輔助，安阿玥手術(shù)體系有望進(jìn)一步實(shí)現(xiàn)“個(gè)體化治療”：針對(duì)不同瘺管類(lèi)型、括約肌受累程度的患者，制定更精準(zhǔn)的“主灶切開(kāi)范圍”與“對(duì)口引流方案”，進(jìn)一步提升療效、縮短療程，為肛瘺患者帶來(lái)更大獲益。</p><p class="ql-block"><br></p> <p class="ql-block">Innovation and Clinical Application of Prof. An A-yue's Anal Fistula Surgery System: A New Paradigm of Minimally Invasive Therapy for Anal Fistula</p><p class="ql-block"> </p><p class="ql-block">1. Introduction</p><p class="ql-block"> </p><p class="ql-block">Anal fistula is a common and refractory disease in colorectal surgery, featuring a chronic infectious tract connecting the anal canal/rectum to perianal skin, often secondary to perianal abscess rupture or incision drainage. Traditional treatments (e.g., simple fistulotomy, seton placement) can clear lesions but suffer from drawbacks like sphincter-damage-induced fecal incontinence, slow wound healing, severe pain, and high recurrence 1. Prof. An A-yue, a leading figure in Chinese anorectal surgery, innovated two techniques via decades of practice: radical incision and drainage for anal fistula and radical primary focus incision with counter-drainage. These approaches, characterized by “minimal damage, short course, less pain, and rapid recovery”, establish a minimally invasive treatment system for precise and function-preserving anal fistula management.</p><p class="ql-block"> </p><p class="ql-block">2. Pathophysiology of Anal Fistula and Limitations of Traditional Treatments</p><p class="ql-block"> </p><p class="ql-block">Anal fistula pathogenesis follows the cryptoglandular infection theory: obstruction of dentate-line anal glands triggers infection, which spreads to form perianal abscesses that rupture/are incised into fistulas 2. A typical fistula comprises an internal opening (anal crypt near the dentate line), a fistula tract (straight/curved/branched duct), and an external opening (perianal skin破潰口).</p><p class="ql-block"> </p><p class="ql-block">Traditional treatments face dilemmas:</p><p class="ql-block"> </p><p class="ql-block">- Simple fistulotomy: Requires full incision of the fistula and scar tissue. For high/complex fistulas, excessive sphincter incision causes continence dysfunction (especially for gas/loose stools) 3.</p><p class="ql-block">- Seton therapy: Uses rubber/silk to slowly cut the sphincter, preserving function partially but causing “l(fā)ong course (2–4 weeks)”, severe pain, and insufficient drainage for complex branched fistulas 4.</p><p class="ql-block">- Recurrence/complications: Incomplete clearance of the infectious “primary focus” and poor branch drainage lead to 10–20% recurrence, plus complications like postoperative bleeding and delayed healing 5.</p><p class="ql-block"> </p><p class="ql-block">3. Theoretical Basis of Prof. An’s Surgery System</p><p class="ql-block"> </p><p class="ql-block">Prof. An’s concept stems from understanding anal fistula anatomy/pathophysiology and the minimally invasive principle of “precise damage + maximum function preservation”, supported by anatomy, pathophysiology, biomechanics, and minimally invasive medicine.</p><p class="ql-block"> </p><p class="ql-block">3.1 Anatomical Basis: Sphincter Complex and Fistula Spatial Relationship</p><p class="ql-block"> </p><p class="ql-block">The anal sphincter complex includes the internal sphincter (smooth muscle, rest continence), external sphincter (skeletal muscle, active continence), and levator ani, forming a layered 3D structure 6. Per the Parks classification (1976), fistulas are “intersphincteric”, “transsphincteric” (accounting for >80%), “suprasphincteric”, or “extrasphincteric” 7.</p><p class="ql-block"> </p><p class="ql-block">Prof. An emphasizes “precise identification of the infectious primary focus and fistula tract”, especially the intersphincteric space (core infection-spread pathway). Protecting sphincter integrity allows lesion clearance while preserving continence (e.g., intersphincteric fistulas are treated by “primary focus incision” to avoid deep external sphincter damage).</p><p class="ql-block"> </p><p class="ql-block">3.2 Pathophysiological Mechanism: Infection Eradication + Drainage Optimization</p><p class="ql-block"> </p><p class="ql-block">Anal fistula’s core pathology is the “infection-abscess-fistula” vicious cycle, requiring infection source eradication and sufficient fistula drainage:</p><p class="ql-block"> </p><p class="ql-block">- Infection source eradication: The “primary focus” (infected dentate-line anal glands/fistula tracts) is precisely located and fully debrided to block infection recurrence 8.</p><p class="ql-block">- Drainage optimization: “Counter-drainage” sets auxiliary incisions at fistula branches/blind ends, forming “primary focus–auxiliary incision” channels to prevent pus accumulation and residual infection 9. This “primary focus radical treatment + counter-drainage” ensures source control and smooth drainage for sterile wound healing.</p><p class="ql-block"> </p><p class="ql-block">3.3 Minimally Invasive + Biomechanical Principles: Damage Control + Healing Promotion</p><p class="ql-block"> </p><p class="ql-block">The system balances “l(fā)imited damage” and “function protection”:</p><p class="ql-block"> </p><p class="ql-block">- Damage control: “Primary focus incision” replaces “full fistula incision”, reducing normal tissue (especially sphincter) damage (e.g., transsphincteric fistulas near superficial external sphincters are treated with partial rather than full sphincter incision).</p><p class="ql-block">- Biomechanical optimization: Arc/oblique incisions match perianal tissue tension distribution, reducing pain and scar contracture 10. Open wounds heal via “autolytic debridement” (enzyme-mediated necrotic tissue dissolution) and “granulation tissue filling”, avoiding excessive debridement’s negative impact on healing.</p><p class="ql-block"> </p><p class="ql-block"><br></p> <p class="ql-block">4. Core Surgical Techniques</p><p class="ql-block"> </p><p class="ql-block">4.1 Radical Incision and Drainage for Anal Fistula</p><p class="ql-block"> </p><p class="ql-block">- Indications: Low-position simple fistulas (tract below superficial external sphincter, no complex branches).</p><p class="ql-block">- Operative steps:</p><p class="ql-block">1. Localize internal opening/primary focus: Via digital exam, probe, or methylene blue staining (internal opening = anal crypt near dentate line; primary = red/swollen/inflammatory tissue).</p><p class="ql-block">2. Incision of primary focus: Fully incise the primary (infected glands/fistula/inflammatory tissue) to form an open fusiform wound for smooth drainage.</p><p class="ql-block">3. Wound management: Debride necrotic tissue/granulation, trim wound edges into a “V” shape, and use TCM fumigation/dressing changes for healing.</p><p class="ql-block">- Features: Direct, minimal sphincter damage, mild pain, 2–3-week healing.</p><p class="ql-block"> </p><p class="ql-block">4.2 Radical Primary Focus Incision with Counter-Drainage</p><p class="ql-block"> </p><p class="ql-block">- Indications: High-position/complex fistulas (multiple branches/blind ends).</p><p class="ql-block">- Operative steps:</p><p class="ql-block">1. Precise primary focus treatment: Fully incise the internal opening’s primary focus; for high sphincters (e.g., deep external sphincter), use a “windowing method” (partial fascia/muscle incision for drainage, no full sphincter division).</p><p class="ql-block">2. Counter-drainage design: Make small auxiliary incisions (0.5–1 cm) at distant branches/blind ends, connecting to the primary focus wound via the fistula tract for multi-directional drainage.</p><p class="ql-block">3. Postoperative management: Dress primary/auxiliary wounds (primary = granulation/infection control; auxiliary = drainage maintenance); auxiliary incisions close after primary wound healing.</p><p class="ql-block">- Features: Solves high/complex fistula infection while avoiding incontinence; multiple small incisions reduce pain, healing time ~3–4 weeks (1/3 shorter than traditional seton therapy).</p><p class="ql-block"> </p><p class="ql-block">5. Clinical Efficacy and Mechanism</p><p class="ql-block"> </p><p class="ql-block">Studies verify the system’s advantages:</p><p class="ql-block"> </p><p class="ql-block">- Efficacy: In 200 complex fistula patients, “primary focus incision + counter-drainage” achieved 95.5% cure, 4.5% recurrence, and 0% incontinence (vs. 12% recurrence and 8% incontinence with traditional seton therapy) 11.</p><p class="ql-block">- Pain/healing: Postoperative 1-week VAS pain score = 3.2 (vs. 5.8 for traditional therapy); average healing time = 21 days (vs. 35 days) 12.</p><p class="ql-block">- Mechanism: Preserving sphincter tissue maintains anal resting pressure (70.2 cmH?O) and systolic pressure (125.6 cmH?O, similar to normal) 13; counter-drainage improves blood flow and clears inflammatory factors (e.g., TNF-α, IL-6) to accelerate granulation/epithelialization 14.</p><p class="ql-block"> </p><p class="ql-block">6. Academic Influence and Future Prospects</p><p class="ql-block"> </p><p class="ql-block">Prof. An’s system is widely promoted in China and included in the Chinese Guidelines for Anal Fistula Diagnosis and Treatment (2021) 15, becoming a core minimally invasive technique. Its “primary focus radical treatment + function protection + optimized drainage” concept provides “Oriental experience” for global colorectal surgery, shifting fistula treatment from “destructive cure” to “functional cure”.</p><p class="ql-block"> </p><p class="ql-block">Future advancements (e.g., endoanal ultrasound/MRI for precise localization, degradable drainage tubes/wound repair gels) will enable “individualized treatment” (tailored primary focus incision/counter-drainage for different fistula types/sphincter involvement), further improving efficacy and shortening courses.</p>