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Hypothesis: An increase in national utilization of bariatric surgery correlates with the dissemination of laparoscopic bariatric surgery.

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Although the majority of anorectal fistulas may be treated with fistulotomy, patients with higher-lying fistulas or women with anterior fistulas in whom simple fistulotomy may threaten continence present a management dilemma. Endorectal flap advancement repair is one potential solution. Chart review was performed of consecutive patients receiving endorectal advancement flaps during a 5-year period (1999–2003). Twenty-nine patients received endorectal advancement flap repair. In 21 (72%) patients, an etiology of the fistula could not be clearly identified, and they were considered to be cryptoglandular in origin. Eight (24%) patients had pathology presumed to be related to prior obstetrical injury. There were 18 (62%) women, and the majority (72%) had anterior fistulas and flaps. Primary success was defined as resolution of symptoms for at least a 3-month period without an additional surgical procedure. If resolution of symptoms after flap placement was achieved after an additional surgical procedure, it was considered a secondary success. Primary success was achieved in 20 (69%) patients, and a secondary success in four (44%) of the remaining nine patients, for a total success of 83 per cent. Anal advancement flaps demonstrate a reasonable success rate when utilized in this group of patients with challenging anorectal fistulas.