The best surgical strategy for anal fistula based on a network meta-analysis

OBJECTIVE: To determine a superior surgical treatment for anal fistula through a network meta-analysis and to provide the best direction for development in this field. METHODS: We conducted a systematic literature search of the PubMed, Embase and Cochrane Library databases and extracted data from randomized controlled trials, which compared healing time, incontinence and recurrence associated with surgical strategies for anal fistula. A network meta-analysis was conducted using ADDIS software by evaluating the 3 parameters. Cumulative probability values were utilized to rank the strategies under examination. Inconsistencies were also tested using node-splitting models. RESULTS: Twenty articles with 1663 patients were included. Fistulotomy plus marsupialisation had the shortest healing time (P = 0.69). Seton placement was the best procedure to avoid postoperative incontinence (P = 0.66). Fistulectomy exhibited the lowest recurrence rate (Probability P = 0.40). In general, fistulotomy plus marsupialisation and surgical ligation plus biomaterial plugging revealed superior clinical efficacy. Node-splitting model testing revealed that no significant inconsistency existed in this research. CONCLUSIONS: Fistulotomy plus marsupialisation exhibited preliminary superior surgical utility for anal fistula. Additionally, combination of surgical treatment with biomaterials may provide better clinical efficacy. These techniques may warrant consideration for future development in this field.