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Long-term draining setons are thepreferred treatment for complex Crohn's anal fistulas due to the risks of unhealed wound, incontinence and diverting stoma. The aim of this study was to evaluate the long-term outcome after fistulotomy and advancement flap with intensive medical treatment.From 2002 to 2009 all consecutive patients with complex Crohn's anal fistulas with or without activeproctitis were treated with immunomodulators or anti-TNF therapy and seton drainage of associated abscess. After improvement definitive surgery was undertaken with maintenance medical therapy. The outcome of last clinic follow-up was recorded as complete remission (wound closed without drainage > 12 months), mild symptoms or recurrence.Twenty-two patients, mean age 45 years (range 24-80) were included. 16 patients withoutproctitis underwent fistulotomy (13) and advancements flap (3). After a mean follow-up of 43 months (range 12-96) complete remission was observed in 10 (63%), mild symptoms in five and recurrence in one case, all without incontinence. Six patients with activeproctitis underwentproctectomy (3), defunctioning stoma (2) and drainage seton (1).This study suggests that definitive surgery with intensive medical treatment in complex anal fistula is safe, with high rate of complete remission and without risk of faecal incontinence.