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

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.

Design: This study is a retrospective review.

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

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

Main Outcome Measures: 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).

Conclusion: 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.