Anal fistulas are still a huge challenge for surgeons because of their high incidence, high recurrence rate, prolonged healing time and possible complications such as fecal incontinence. Even though many surgical options have been described, we still do not have the standardized procedure. Patients who suffered from this problem have a low quality of life because of constant anal pain and soiling from anal tracts. Aside from cryptoglandular etiology, fistulas associated with Crohn’s disease are separate entity that requires a multidisciplinary approach. This chapter will be an overview of modern approaches in anal fistula treatment regardless of etiology with special consideration on how to avoid adverse outcomes and to improve patients’ quality of life.