To LIFT or to flap? Which surgery to perform following seton insertion for high anal fistula?

The ideal surgery following seton insertion for high anal fistulas remains debatable.

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.

This study is a retrospective review.

This study was conducted at the Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, between April 2006 and July 2011.

After seton placement for high anal fistulas, 31 and 24 patients underwent the endorectal advancement flap and the ligation of intersphincteric fistula tract procedures.

Failure was defined as the nonhealing of the surgical wounds or persistent discharge at the external opening.

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).

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.