title: To LIFT or to flap? Which surgery to perform following seton insertion for high anal fistula?
abstract: BACKGROUND
  The ideal surgery following seton insertion for high anal fistulas remains debatable.
  
  
  OBJECTIVE
  This study aimed to compare the success between the endorectal advancement flap and the ligation of intersphincteric fistula tract techniques as the definitive procedure following seton placement.
  
  
  METHODS
  This study is a retrospective review.
  
  
  METHODS
  This study was conducted at the Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, between April 2006 and July 2011.
  
  
  METHODS
  After seton placement for high anal fistulas, 31 and 24 patients underwent the endorectal advancement flap and the ligation of intersphincteric fistula tract procedures.
  
  
  METHODS
  Failure was defined as the nonhealing of the surgical wounds or persistent discharge at the external opening.
  
  
  RESULTS
  We identified 31 patients with a median age of 49 (range, 19-74) years in the endorectal advancement flap group. The median interval from the seton procedure to the flap procedure was 13 (range, 4-284) weeks. Over a median follow up of 6 (range, 2-26) months, 29 (93.5%) patients had successful outcomes. There were 24 patients, median age 41 (range, 16-75) years, in the ligation of intersphincteric fistula tract group. The median interval from the seton placement to the definitive surgery was 14 (range, 8-74) weeks. Over a median follow-up of 13 (range, 4-67) months, 15 (62.5%) patients had successful outcomes. Hence when performed as the initial definitive procedure after a seton, the endorectal advancement flap technique had a significantly higher success rate in comparison with the ligation of intersphincteric fistula tract approach (93.5% vs 62.5%) (p = 0.006).
  
  
  CONCLUSIONS
  In patients who have had seton placement for high anal fistulas, the endorectal advancement flap technique is associated with better short-term outcomes in comparison with the ligation of intersphincteric fistula tract technique.
authors.affiliation: Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore.
authors.forename: Ker-Kan
authors.initials: KK
authors.lastname: Tan
authors.forename: Rayan
authors.initials: R
authors.lastname: Alsuwaigh
authors.forename: Aloysius M
authors.initials: AM
authors.lastname: Tan
authors.forename: Ian J
authors.initials: IJ
authors.lastname: Tan
authors.forename: Xuandao
authors.initials: X
authors.lastname: Liu
authors.forename: Dean C
authors.initials: DC
authors.lastname: Koh
authors.forename: Charles B
authors.initials: CB
authors.lastname: Tsang
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D013505:Digestive System Surgical Procedures / Q000295:instrumentation / Q000379:methods*; D005260:Female; D006801:Humans; D008026:Ligation / Q000379:methods; D008297:Male; D008875:Middle Aged; D012003:Rectal Fistula / Q000601:surgery*; D012189:Retrospective Studies; D013524:Surgical Flaps; D013536:Suture Techniques; D016896:Treatment Outcome