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The optimal management of high anal fistulae remains controversial. Balancing the risks of incontinence and recurrence is a great challenge toproctologists.A retrospective case review of 84 consecutive patients undergoing lay open or loose seton insertion for idiopathic anal fistulae in a tertiary centre ispresented.Fifty patients (36 tertiary referrals) underwent lay open. 5 (10%) (two intersphincteric and three high transphincteric) who were fully continent at referral had a deterioration in their continence after surgery [three minor (flatus incontinence ± £1 teaspoon of mucus leakage in 24 hours), one significant (> 1 teaspoon in 24 hours), one urgency]. Of nine patients with impairment of continence both before and after surgery, two had a worsening of their impairment after laying open. The mean follow up was 9 months.As we havepreviously shown, around 1/4 to 1/3 (28% here) of patients undergoing any lay open of anal fistulae will develop impairment of continence. Some tertiary referral patients with high anal fistulae already have some degree of impairment of continence, often fromprevious surgery, but careful examination and laying open allows curative surgery with a low rate of further deterioration.