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Objectives of surgical treatment for transsphincteric and complex anorectal fistulas are the successful elimination of current/recurrent disease and the preservation of sphincter function. The concept of endorectal advancement flaps is to preserve the sphincter by closing off the primary opening by means of a mobilized flap. We performed a systematic review of the literature to assess the role of this technique.A literature search on transanal rectal advancement flaps to treat cryptoglandular or Crohn fistula-in-ano was performed for the 30-year period between 1978 and 2008. Rectovaginal/rectourinary or cancer-related fistulas were excluded. Each study was examined for length of follow-up and the 2 major end points: success rate and incontinence rate.From 35 studies with 2065 patients, we identified 1654 patients undergoing endorectal advancement flaps for cryptoglandular or Crohn disease. Four hundred eleven subjects were excluded (319 rectovaginal/rectourinary fistulas; 92 other causes). The quality of the reports was limited (low-level evidence) with numerous structural and design flaws. Weighted success and incontinence rates were 80.8%/13.2% for cryptoglandular and 64%/9.4% for Crohn fistulas.Endorectal advancement flap is one tool, although not a perfect one, to treat complex anorectal fistulas of cryptoglandular or Crohn origin. Higher level evidence would be needed for comparison with other surgical techniques.