Integrating traditional Chinese medicine with modern surgery: A comprehensive approach to complex anal fistula

Abstract

Complex anal fistula remains a formidable clinical challenge due to its intricate anatomy, high recurrence rates, and risk of functional impairment. Conventional surgical approaches, including fistulotomy, seton placement, and sphincter-sparing procedures such as ligation of intersphincteric fistula tract or video-assisted anal fistula treatment, provide variable outcomes and are often associated with delayed wound healing or incontinence. Recently, the integration of traditional Chinese medicine (TCM) into surgical management has gained attention for its potential to enhance wound repair, modulate inflammatory responses, and reduce postoperative recurrence. TCM modalities - including herbal formulations, topical applications, and acupuncture - not only accelerate granulation tissue formation but also regulate immune homeostasis by influencing pathways such as phosphatidylinositol 3-kinase/protein kinase B, hypoxia-inducible factor-1, and ransforming growth factor-β/mothers against decapentaplegic homolog. Clinical evidence suggests that combining syndrome differentiation-based TCM therapies with surgical interventions achieves synergistic effects, improving healing rates and preserving anorectal function. In this editorial, we comment on the article by Liu et al published in the recent issue of the World Journal of Gastrointestinal Surgery. This editorial synthesizes current surgical strategies and highlights the emerging role of TCM in complex anal fistula treatment, emphasizing the importance of individualized, multidisciplinary approaches. By bridging modern surgical precision with traditional holistic regulation, integrative therapy holds promise for advancing patient outcomes and establishing new standards in anorectal surgery.

Key Words: Complex anal fistula; Surgical treatment; Traditional Chinese medicine; Integrated therapy; Wound healing; Inflammation regulation

Core Tip: The management of complex anal fistulas requires a comprehensive approach that integrates modern surgical techniques with traditional Chinese medicine. Combining precise anatomical interventions with traditional Chinese medicine’s holistic modulation of inflammation and tissue repair can significantly improve healing rates, reduce recurrence, and preserve anorectal function, ultimately enhancing patient recovery and quality of life.

This editorial refers to “Enhanced surgical management of complex anal fistulas via integrated traditional Chinese medicine: A retrospective cohort study” by Liu et al, 2025; https://doi.org/10.4240/wjgs.v17.i11.110143.

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INTRODUCTION

Complex anal fistula represents a significant challenge in colorectal and anal surgery due to its intricate pathological characteristics, including multiple fistulous tracts, involvement of the anal sphincter complex, and surrounding tissue inflammation. These features not only complicate surgical management but also contribute to a high recurrence rate and postoperative complications such as delayed wound healing and fecal incontinence, which severely impair patients’ quality of life[1]. According to the 2020 Chinese Expert Consensus on the Diagnosis and Treatment of Anal Fistula, complex fistulas are defined by extensive sphincter involvement, multiple tracts, or recurrent disease. The consensus emphasizes accurate anatomical classification, the principle of sphincter preservation whenever feasible, and individualized treatment planning based on tract configuration and patient comorbidities. It also acknowledges the growing role of integrative approaches that combine modern surgical precision with traditional Chinese medicine (TCM)-based wound modulation, reflecting a trend toward multimodal, patient-centered management in China[1]. The complexity arises from the anatomical involvement of the internal and external anal sphincters, which necessitates a delicate balance between effective fistula eradication and preservation of sphincter function. Conventional surgical approaches are broadly categorized into sphincter-cutting procedures, such as fistulotomy and fistulectomy, and sphincter-sparing techniques, including ligation of intersphincteric fistula tract, advancement flaps, and novel minimally invasive interventions like video-assisted anal fistula treatment[1,2]. Despite advances in surgical techniques, single-modality treatments often fall short in addressing the multifaceted pathophysiology of complex anal fistulas, resulting in suboptimal healing rates and functional outcomes. For instance, repeated surgical interventions may exacerbate sphincter damage, leading to persistent incontinence, as illustrated in cases of recurrent high transsphincteric fistulas where combined approaches involving sphincteroplasty, fecal diversion, and biological sealants have been employed to preserve function while controlling disease[2]. This underscores the necessity for comprehensive treatment paradigms that integrate multiple therapeutic modalities tailored to individual patient anatomy and disease severity.

In this context, TCM offers a valuable complementary perspective grounded in holistic and syndrome-differentiation principles. TCM emphasizes systemic regulation, aiming to restore internal homeostasis and enhance the body’s intrinsic healing capabilities. Its therapeutic repertoire includes herbal formulations, acupuncture, topical applications, and fumigation, which collectively exert anti-inflammatory, immunomodulatory, and tissue-reparative effects[3,4]. Importantly, while mechanistic studies have identified modulation of key biological pathways such as phosphatidylinositol 3-kinase/protein kinase B, hypoxia-inducible factor-1, and ransforming growth factor-β/mothers against decapentaplegic homolog as potential mechanisms underlying these effects, we note that these data are largely extrapolated from experimental wound-healing and inflammation models rather than directly derived from human anal-fistula tissues. This distinction underscores the translational rather than disease-specific nature of current mechanistic evidence. Nevertheless, these pathways provide valuable insight into how TCM interventions may accelerate postoperative wound healing and reduce complications by enhancing angiogenesis and tissue remodeling[4]. Moreover, TCM interventions have demonstrated efficacy in regulating macrophage polarization, a critical determinant of inflammatory resolution and tissue regeneration. The dynamic balance between pro-inflammatory M1 and anti-inflammatory M2 macrophages is pivotal for optimal wound healing, and TCM formulations have been shown to favorably influence this balance, promoting an environment conducive to repair and functional recovery[5,6]. These immunomodulatory properties extend beyond local effects, reflecting the systemic approach of TCM in restoring yin-yang equilibrium and enhancing immune homeostasis, which is particularly beneficial in patients with comorbidities that impair healing, such as diabetes mellitus[7].

The integration of TCM concepts with modern surgical techniques represents a promising frontier in the management of complex anal fistulas. By combining precise anatomical and imaging-guided surgical interventions with TCM’s holistic modulation of inflammation and tissue repair, a synergistic effect can be achieved that addresses both the local pathological lesions and the systemic milieu influencing healing. For example, the use of TCM external washing decoctions postoperatively has been investigated in randomized controlled trials, showing potential to improve wound healing rates and reduce inflammatory mediator levels in diabetic patients undergoing anal fistula surgery[7]. Additionally, topical agents such as Zibai ointment have been reported to regulate apoptosis-related factors (B-cell lymphoma/Leukemia-2 gene and Bcl-2-associated X protein), thereby promoting granulation tissue formation and accelerating wound closure[8]. Furthermore, novel TCM-based biological compounds have demonstrated antibacterial and immunoregulatory activities, which can mitigate postoperative infections and facilitate mucosal repair[6,9]. The application of such integrative strategies is supported by emerging molecular insights into the mechanisms by which TCM components influence key signaling pathways and immune cell phenotypes relevant to fistula healing.

Given these considerations, a comprehensive editorial of surgical strategies for complex anal fistulas that incorporates TCM principles and therapies is timely and necessary. In this editorial, we comment on the article by Liu et al published in the recent issue of the World Journal of Gastrointestinal Surgery. This editorial aims to systematically evaluate the current evidence on the combined use of TCM and modern surgical approaches, focusing on their mechanistic rationale, clinical efficacy, and potential to reduce recurrence and improve functional outcomes (Figure 1). By elucidating the interplay between surgical anatomy, immunological regulation, and TCM-mediated biological effects, we seek to provide a theoretical framework and practical guidance for clinicians aiming to optimize treatment paradigms. Furthermore, this editorial synthesizes representative evidence without conducting a quantitative meta-analysis and emphasizes the integration of modern surgery with TCM principles, a promising approach in the management of complex anal fistula. This synthesis will identify gaps in the current literature and propose directions for future research, including the development of standardized protocols, multi-center clinical trials, and translational studies to validate and refine integrative treatment models for complex anal fistulas. Ultimately, advancing such comprehensive strategies holds promise for enhancing patient quality of life and achieving durable fistula closure with sphincter preservation.

Figure 1 A comprehensive treatment strategy for complex anal fistulas, integrating modern surgical techniques and traditional Chinese medicine. LIFT: Ligation of intersphincteric fistula tract; TROPIS: Transanal opening of the intersphincteric space; FOISSF: Fistula occlusion with internal sphincter flap; VAAFT: Video-assisted anal fistula treatment; TCM: Traditional Chinese medicine.

OVERVIEW OF ANATOMICAL, SURGICAL, AND TREATMENT CHALLENGES IN COMPLEX ANAL FISTULA

Anatomical and pathological features of complex anal fistula

Complex anal fistulas are characterized by intricate anatomical involvement, frequently encompassing multiple fistulous tracts and significant portions of the anal sphincter complex, particularly the internal and external anal sphincters. This multifocal tract involvement predisposes patients to sphincter dysfunction, raising the risk of fecal incontinence following surgical intervention. The fistulous tracts are often surrounded by chronic inflammatory tissue marked by persistent infection, fibrosis, and granulation, which complicates surgical management and impedes healing. Pathologically, the formation and persistence of complex anal fistulas involve a multifactorial mechanism: Initial local infection of anal glands leads to abscess formation and subsequent fistula tract development; immune dysregulation contributes to chronicity; and impaired tissue repair mechanisms hinder closure of the fistula. Elevated proinflammatory adipokines such as leptin and resistin, alongside decreased anti-inflammatory adiponectin, have been implicated in sustaining local inflammation and disrupting epithelial-to-mesenchymal transition integrity within the fistula tract, further complicating healing[10,11]. Moreover, the internal anal opening plays a pivotal role in disease pathogenesis, serving as the primary source of ongoing infection and inflammation. Anatomical studies underscore the importance of detailed imaging and understanding of the fistula’s relationship to the sphincter complex and adjacent structures to guide effective treatment[12,13]. Collectively, these anatomical and pathological features underscore the complexity of managing these fistulas, as interventions must balance eradication of infected tracts with preservation of sphincter function to minimize morbidity.

Current surgical treatments and their limitations

Modern surgical management of complex anal fistulas encompasses a range of traditional and emerging techniques, each with distinct advantages and limitations. Conventional procedures such as fistulotomy and fistulectomy effectively remove the fistulous tract but often involve division of the anal sphincter muscles, leading to a substantial risk of postoperative fecal incontinence, especially in complex fistulas where extensive sphincter involvement is common[12,14]. Seton placement, both conventional drainage and sphincter-sparing rerouting setons, offers a means to control infection and promote fibrosis while preserving sphincter integrity; however, prolonged treatment duration and recurrence remain concerns[15]. Newer sphincter-preserving techniques such as ligation of the intersphincteric fistula tract, transanal opening of the intersphincteric space, and fistula occlusion with internal sphincter flap have demonstrated promising healing rates with minimal impact on continence, yet their efficacy varies with fistula complexity and patient selection[16-18]. Minimally invasive approaches including video-assisted anal fistula treatment, fistula plug implantation, and laser ablation aim to reduce tissue trauma and preserve function but often suffer from higher recurrence rates and inconsistent long-term outcomes[19-21]. Additionally, biological therapies such as mesenchymal stem cell injections have emerged as adjuncts or alternatives, particularly in Crohn’s disease-associated fistulas, offering immunomodulatory effects but requiring further validation[22,23]. Postoperative complications including delayed wound healing, infection, and functional impairment remain significant challenges, limiting the universal applicability of any single surgical modality. Thus, despite advances, no gold-standard treatment exists, and individualized approaches balancing cure rates with preservation of continence are essential.

Challenges in modern treatment of complex anal fistula

The management of complex anal fistulas is fraught with multiple challenges stemming from the heterogeneity of disease presentation and the delicate balance between eradication of the fistula and preservation of anal sphincter function. The diverse anatomical configurations and variable involvement of sphincter muscles preclude the establishment of standardized treatment protocols, necessitating tailored surgical strategies based on detailed preoperative assessment including high-resolution imaging[13,24]. High recurrence rates remain a persistent problem, often attributed to incomplete eradication of the internal opening or residual sepsis, as well as the presence of multiple or branching tracts that may be missed during surgery[14,25]. Functional impairment, particularly fecal incontinence, is a major concern, especially after procedures that compromise sphincter integrity, underscoring the need for sphincter-sparing techniques and careful postoperative evaluation[15,25]. Furthermore, complex fistulas associated with Crohn’s disease pose additional therapeutic dilemmas due to the underlying inflammatory milieu and impaired healing capacity, often necessitating combined medical and surgical approaches[26,27]. The limitations of current surgical methods have stimulated interest in adjunctive and novel therapies, including biological agents, stem cell therapy, and regenerative medicine, aiming to improve healing rates and reduce morbidity, although robust evidence and long-term data remain limited[22,23]. Consequently, addressing these challenges requires multidisciplinary collaboration, integration of emerging therapies, and further high-quality clinical trials to optimize outcomes and develop consensus guidelines for this complex condition.

TCM IN ANAL FISTULA MANAGEMENT

TCM syndrome differentiation theory and its guiding significance for anal fistula

TCM conceptualizes anal fistula within the broader categories of “anal fistula” and “hemorrhoids”, attributing its pathogenesis primarily to the invasion and persistence of “damp-heat toxin” and “qi and blood stasis.” This etiological framework emphasizes that the accumulation of pathogenic dampness and heat toxins, combined with impaired circulation of qi and blood, leads to local tissue inflammation, obstruction, and chronic fistula formation. The TCM syndrome differentiation approach involves a comprehensive assessment of the patient’s systemic and local manifestations to identify specific patterns such as damp-heat accumulation, qi stagnation, blood stasis, or deficiency of qi and blood. Therapeutic interventions are then tailored accordingly to restore the balance of the zang-fu organs, clear heat and toxins, activate blood circulation, and promote the smooth flow of qi. To enhance clinical specificity, we have incorporated representative examples of classical formulas and acupoint combinations associated with common syndrome patterns. For instance, in cases dominated by damp-heat toxin, the principle of clearing heat and detoxification is applied using formulas such as Huanglian Jiedu decoction or Xianfang Huoming decoction, in combination with acupoints Chengshan (bladder meridian of foot-taiyang 57) and Erbai (extra points-upper extremity 2) to promote drainage and reduce inflammation. In patterns characterized by qi stagnation and blood stasis, treatments emphasizing the activation of blood circulation and dispersion of stasis - such as Taohong Siwu decoction with acupoints Sanyinjiao (spleen meridian of foot-Taiyin 6) and Geshu (bladder meridian of foot-Taiyang 17) - are adopted to relieve pain and facilitate tissue repair. When deficiency syndromes prevail, supplementation of qi and nourishment of blood become central, typically employing Buzhong Yiqi decoction alongside acupoints Zusanli (stomach meridian of foot-Yangming 36) and Guanyuan (conception vessel 4) to strengthen vitality and enhance wound healing. This integration of syndrome differentiation with specific therapeutic prescriptions and acupoint selection provides a tangible framework linking traditional diagnostic reasoning with practical interventions. Such elaboration clarifies the internal logic of TCM-based individualized management for international readers, aligning with the pathophysiological understanding of anal fistula in TCM and provides a dynamic framework for individualized management that integrates systemic regulation with local lesion control, ultimately aiming to improve clinical outcomes and reduce recurrence[4,28]. A summary of common TCM syndrome patterns related to complex anal fistula and their corresponding therapeutic principles is provided in Table 1.

Table 1 Common traditional Chinese medicine syndromes related to complex anal fistula and corresponding therapeutic principles.

Syndrome pattern	Typical manifestations	Therapeutic principle
Damp-heat accumulation	Red swelling, purulent discharge, fever	Clear heat, drain dampness, detoxify
Qi stagnation and blood stasis	Painful induration, dark-red granulation	Invigorate blood, disperse stasis
Qi deficiency and blood deficiency	Pale granulation, prolonged healing	Tonify qi, nourish blood

Role of TCM in external and internal applications for promoting wound healing

The therapeutic efficacy of TCM in complex anal fistula management extends significantly to its external and internal applications, both of which contribute to accelerated wound healing through multifaceted pharmacological actions. Various herbal components, such as Coptidis rhizome (Huanglian), Scutellaria baicalensis (Huangqin), and Salvia miltiorrhiza (Danshen), possess potent anti-inflammatory, antimicrobial, and tissue regenerative properties. These herbs have been demonstrated to inhibit pathogenic bacteria, reduce local inflammation, and stimulate granulation tissue formation, which are critical factors in promoting wound repair. Externally, TCM formulations are often administered as sitz baths, decoctions, or topical applications that cleanse the wound site, mitigate edema and exudation, and foster the proliferation of healthy granulation tissue. Clinical studies have shown that phased Chinese herbal sitz baths based on “Fuzheng Quxie” theory significantly reduce wound symptoms such as pain and swelling, shorten incision healing time, and improve anorectal function, likely mediated by increased serum growth factors like transforming growth factor-β, epidermal growth factor, and basic fibroblast growth factor[28]. Internally, oral administration of TCM enhances systemic immune modulation and improves microcirculation, thereby augmenting the body’s self-repair mechanisms. Herbs used internally may regulate immune responses, reduce oxidative stress, and optimize metabolic pathways involved in tissue repair, as evidenced by metabolomics studies revealing modulation of amino acid and lipid metabolism pathways in ulcerative colitis models treated with TCM formulations[29]. The synergistic use of internal and external TCM therapies thus creates a conducive environment for wound healing by addressing both local pathological factors and systemic deficiencies, ultimately improving clinical efficacy and patient recovery in complex anal fistula cases[4,28].

Acupuncture and other TCM physical therapies as adjunctive treatments

Acupuncture and other physical therapies rooted in TCM serve as valuable adjuncts in the comprehensive treatment of complex anal fistulas by modulating neurophysiological pathways and enhancing local tissue metabolism. Acupuncture exerts its therapeutic effects primarily through regulation of the neuroendocrine system, which leads to analgesia, reduction of inflammation, and improved local blood circulation. By stimulating specific acupoints, acupuncture can alleviate pain associated with anal fistula and promote tissue repair by increasing oxygen and nutrient delivery to the affected area. Additionally, physical modalities such as Chinese herbal fumigation and washing, as well as cupping therapy, complement acupuncture by facilitating local detoxification, reducing edema, and enhancing microcirculatory dynamics. These therapies help to accelerate the resolution of inflammatory exudates and promote the metabolic clearance of necrotic tissue, thereby creating favorable conditions for wound healing. Integration of these traditional physical therapies with modern rehabilitation techniques further optimizes postoperative recovery, improving functional outcomes and quality of life for patients undergoing surgery for complex anal fistulas. Clinical evidence supports that combining acupuncture and herbal physical therapies with surgical interventions not only reduces postoperative complications such as pain and infection but also enhances overall treatment efficacy through synergistic mechanisms[4,28]. This integrative approach exemplifies the holistic philosophy of TCM, emphasizing the restoration of balance and harmony within the body to facilitate natural healing processes.

INTEGRATION OF TCM AND MODERN SURGICAL TECHNIQUES IN COMPREHENSIVE TREATMENT STRATEGIES

Individualized treatment planning and multidisciplinary collaboration

The design of treatment plans for complex anal fistula must be individualized, taking into account both the specific clinical condition of the patient and the results of TCM syndrome differentiation. This personalized approach allows for tailoring surgical interventions and TCM therapies to optimize outcomes. Multidisciplinary collaboration is essential, involving colorectal surgeons, TCM practitioners, rehabilitation therapists, and nursing staff to ensure comprehensive care. Such teamwork enables the integration of preoperative preparation, intraoperative techniques, and postoperative TCM-based conditioning to dynamically adjust the treatment regimen according to patient response and disease progression. For example, in complex anal fistulas, surgical options such as fistulotomy, ligation of the intersphincteric fistula tract, or stem cell therapy are selected based on anatomical and pathological features, while TCM principles guide the choice of herbal formulations and external therapies to promote healing and reduce inflammation[13,23]. The individualized plan is continuously refined through multidisciplinary meetings, where clinical data and patient feedback are reviewed, enabling a holistic approach that addresses both the local lesion and systemic health. This paradigm aligns with precision medicine concepts, emphasizing minimal invasiveness, maximal organ preservation, and optimal functional recovery[30,31]. Furthermore, the involvement of TCM practitioners in perioperative management, including acupuncture anesthesia and herbal medicine, has been shown to reduce surgical stress and enhance immune function, supporting faster recovery[32,33]. Therefore, individualized treatment planning combined with multidisciplinary collaboration forms the cornerstone of integrating TCM and modern surgical techniques for complex anal fistula management.

Postoperative management and recurrence prevention assisted by TCM

Postoperative management in complex anal fistula treatment benefits significantly from the adjunctive use of TCM, which facilitates wound healing, reduces infection, and lowers recurrence risk. These findings are consistent with recent clinical evidence showing that integrating TCM with surgical management can further enhance healing rates and reduce recurrence in complex anal fistula patients[34]. The application of herbal decoctions and topical preparations can promote granulation tissue growth and prevent scar formation, as demonstrated in clinical studies on wound care after anal fistula surgery[3]. TCM therapies enhance the body’s immune response and improve the local microenvironment, thereby mitigating inflammation and fostering tissue repair. For instance, herbal formulas with heat-clearing and detoxifying properties, combined with qi-replenishing agents, have been shown to modulate inflammatory cytokines and oxidative stress markers, contributing to improved postoperative outcomes[33,35]. Regular follow-up incorporating TCM syndrome differentiation allows for dynamic adjustment of treatment, enabling early detection and management of recurrence signs. This approach has been validated in studies where individualized TCM treatments reduced recurrence rates and improved quality of life in patients with idiopathic granulomatous mastitis and other chronic inflammatory conditions, suggesting applicability to anal fistula care[36,37]. Moreover, integrating TCM with Western postoperative care has been associated with reduced adverse events, enhanced patient comfort, and higher satisfaction rates[38]. Collectively, these findings underscore the value of TCM-assisted postoperative management in preventing recurrence and promoting sustained healing in complex anal fistula patients.

Clinical research and evidence support

Recent clinical research increasingly supports the superiority of comprehensive treatment regimens that integrate TCM with modern surgical techniques over surgery alone in managing complex anal fistulas. Systematic reviews and meta-analyses reveal that combined approaches can shorten healing times and reduce recurrence rates significantly[39,40]. For example, stem cell therapies augmented by TCM show promising healing rates in Crohn’s disease-associated anal fistulas, with improved long-term outcomes compared to conventional treatments[23,41]. Furthermore, randomized controlled trials have demonstrated that TCM characteristic rehabilitation management during postoperative chemotherapy improves immune function and reduces inflammatory responses, which could translate into better surgical recovery and lower fistula recurrence[33]. Despite these encouraging results, the literature highlights the need for more high-quality, multicenter randomized controlled trials to validate the long-term efficacy and safety of integrated treatment strategies[39,40]. Additionally, evidence-based guidelines increasingly recommend multidisciplinary collaboration and incorporation of TCM principles to optimize patient outcomes[42,43]. Future research should focus on standardizing TCM interventions, elucidating molecular mechanisms, and developing consensus protocols to facilitate broader clinical adoption. In summary, current evidence advocates for the integration of TCM with modern surgical techniques as a comprehensive and effective approach to complex anal fistula treatment, while emphasizing the necessity for further rigorous clinical validation.

Limitations and practical challenges in integrative therapy

Despite the promising prospects of combining TCM with modern surgical techniques, several limitations and practical challenges remain before such integrative strategies can be widely adopted. First, standardization of herbal formulations is a major concern: Variations in source materials, processing methods, and dosage can lead to inconsistent pharmacological effects. Second, potential drug–herb interactions, particularly between postoperative antibiotics, analgesics, and multi-component herbal decoctions, require careful pharmacovigilance to ensure patient safety. Third, the subjectivity inherent in syndrome differentiation introduces practitioner-dependent variability, which complicates reproducibility and large-scale clinical validation. Moreover, most existing studies are limited by small sample sizes, short follow-up durations, and heterogeneous interventions, making it difficult to draw definitive conclusions about efficacy and safety. Lastly, effective multidisciplinary collaboration remains logistically challenging, as coordination between surgeons, TCM practitioners, and nursing teams demands clear role delineation, communication, and institutional support. Addressing these limitations will require standardization of herbal products, rigorous randomized controlled trials, and the establishment of integrated clinical pathways to ensure both scientific rigor and patient safety.

CONCLUSION

In conclusion, complex anal fistulas present significant treatment challenges due to their intricate anatomy and high recurrence rates. Integrating TCM with modern surgical techniques offers a promising approach, enhancing wound healing, reducing inflammation, and improving long-term outcomes. A multidisciplinary, individualized treatment plan can optimize recovery, reduce recurrence, and preserve anorectal function, ultimately improving patient quality of life.