extracted from critical appraisal to literature because only a few cases are available for study preventing randomized controlled trials. This study assessed the long-term success of addressing simultaneously defects in the external sphincter and complex fistulas in patients with Crohn’s disease treated with Infliximab and whose complaint was gross incontinence not related to diarrhoea. Methods:A consecutive series of seven patients with a diagnosis of sphincter defect and complex fistula were prospectively scheduled for surgical repair between June 2004 and March 2007. Patients were evaluated by physical examination, Endoanal Ultrasound and Magnetic Resonance Imaging. Patients underwent surgery after induction therapy with Infliximab at 5mg/ kg at weeks 0, 2, and 6 using a standard protocol. Subsequently, maintenance dosing every four weeks was associated with azathioprine or 6-mercaptopurine. Surgery was performed in an elective setting. All patients had complex fistula, often with any additional secondary extensions, horseshoe tracks and abscess, which were situated in the same quadrant or far from the sphincter damage. Outcomes were assessed considering continence, complications and patient’s quality of life. Results: Follow-up was 33 months (20 48). Sphincter defect ranged from 75 to 160o. Patients had undergone previous surgery for perianal fistula mean 3 (range 1 5) or abscess mean 3 (range, 1 10). Continence evolution assessed by Wexner’s score demonstrated a mean of 17 (range, 14 20) on presentation; score of 9.5 (range, 6 12) 12 months after surgery, 9.6 (range, 6 12) and 10.4 (range, 9 12) after 24 and 36 months of follow-up respectively. None of them has gross incontinence now. There was not any suture dehiscence in sphincter repair. Two fistula recurrences were detected immediately and two years later. Both patients had a low transsphincteric fistula and they remain little symptomatic with intermittent discharge of pus. After follow-up of 12 months, all patients were comfortable and asymptomatic. All patients quoted quality of life as much better than before surgery. Longterm outcome remains satisfactory without change. Conclusion: Immunomodulators have changed the surgical approach to perianal disease. Sphincter repair and fistula treatment can be simultaneously performed with good functional results and could be an alternative to proctectomy.