Treatment of the stula often requires surgical intervention, though this should be performed only once all other conditions have been optimized. Fistulas resulting from obstetric injury should not be surgically repaired for at least 3–6months. Not only will a small fraction of these heal on their own, but time to reduce the inammation is impor­tant for a successful denitive repair. As men­tioned above, local sepsis must be controlled, meaning that abscesses must be drained and immature stula tracts should have a loose drain­ing seton placed to facilitate drainage (Figure 14.1d). Patients with Crohn’s disease should be started on a biologic agent, as studies have demonstrated that a proportion (nearly 50%) of Crohn’s-related stulas will heal with medical treatment alone (Figure14.1e). For patients with severe perianal Crohn’s and RVF who are unlikely to heal with even the best local repair, manage­ment may stop at medication and draining seton. If the patients have good quality of life with this, this limited approach is preferable to chasing aggres­sive surgical intervention which can disrupt fecal continence and lead to permanent stoma. Some women require temporary fecal diversion to help control sepsis. The stoma may be kept in place to facilitate healing following the denitive repair, particularly if the repair requires a more extensive approach such as resection and anastomosis. Hyperbaric oxygen may be useful for brotic and poorly vascularized tissues (Figure14.1f).