Anal fistula is a rather common condition in coloproctology and its management remains a challenge. Achieving healing without continence disturbance represents two relevant outcome measures from the patients’ perspective. These patient′s’ expectations are not always easy to meet, especially in cases with complex fistulae. Multiple fistula tracts, high trans-sphincteric fistula involving more than one-third of the sphincter apparatus as well as perineal fistula in Crohńs disease are well-known examples of complex fistulae. Low healing rates associated with high failure and/or recurrence rates are unfortunately common for such complex fistulae. Also, the risk of continence impairment following surgical management of such complex fistulae is high in comparison with cases with simple fistulae. Maintaining the integrity of the sphincter apparatus during surgical management of fistula-in-ano represents the most important aspect in preventing post-operative continence disturbance. This goal can be reached by choosing sphincter-preserving surgical options.

The recently published European Society of ColoProctology (ESCP) guidelines for the diagnosis and management of cryptoglandular fistula could not spell out a definite recommendation on the use of OTSC in the closure of anal fistula based on the available evidence and experts’ opinion. This more or less “no recommendation” may be interpreted as a sign of caution regarding this intervention, at least for practitioners in Europe.

An interesting aspect of this study by Deng et al. may be the physical and chemical composition of the clip. While the OTSC used in the Western world is nitinol-based, that used in this study was a nickel–titanium alloy. Therefore, may be the composition of the clip is the game changer. As Aristotle once said: “what we have to learn to do, we learn by doing.” The results reported in this study from China should not be neglected by practitioners in the Western world, especially with respect to the “no recommendation” in the newly published European guidelines. The scientific community has the obligation to constantly explore and update the available evidence in their area of expertise. At times we just must learn by doing and the future will tell.

PA: Conceptualization, Writing – original draft, Writing – review & editing.

The author declares that no financial support was received for the research, authorship, and/or publication of this article.

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The author declared that he was an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.

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