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Pankaj Garg,1 Sohail Singh Sodhi,2 Navdeep Garg3 1Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula, Haryana, India; 2Department of General Surgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India; 3Department of General Surgery, Government Medical College and Hospital, Chandigarh, IndiaCorrespondence: Pankaj GargDepartment of Colorectal Surgery, Garg Fistula Research Institute, 1042, Sector 15, Panchkula, Haryana 134113, IndiaFax +91-172-2594556Email drgargpankaj@yahoo.comAbstract: Anal fistulae can be a very difficult disease to manage. The management of complex fistulae is even more challenging. The risk to the fecal continence mechanism due to damage to the anal sphincters and refractoriness to the treatment (high recurrence rate) pose the two biggest challenges in the management of this disease. Apart from these, there are several other challenges in the treatment of complex fistulae. The intriguing and uphill task is that satisfactory solutions to most of these challenges are still not known, and there is hardly any consensus on whatever treatment solutions are available. To summarize, there is no gold-standard treatment available for treating complex anal fistulae, and the search for a satisfactory treatment option is still on. In this review, the endeavor has been to discuss and highlight recent path-breaking updates in the management of complex anal fistulae.Keywords: anal fistula, recurrence, incontinence, classification, fistulotomy, sphincter