Ligation of Intersphincteric Fistula Tract for Fistula in Ano: Lessons Learned From a Decade of Experience

BACKGROUND: Ligation of intersphincteric fistula tract is a well-described sphincter-preserving technique for the management of fistula in ano. In 2007, we reported our early experience demonstrating a primary success rate of 94.4%. These findings have since been supported by several short-term studies, but long-term results and secondary cure rates after ligation of intersphincteric fistula tract failure remain unknown. OBJECTIVE: This study aims to report a 10-year experience of ligation of intersphincteric fistula tract with extended long-term follow-up. DESIGN: Retrospective analysis of single-center data from May 2006 to October 2010 was performed. SETTINGS: This study was conducted at a large tertiary hospital in Bangkok, Thailand. PATIENTS: All patients with primary or recurrent fistula in ano who underwent a ligation of intersphincteric fistula tract procedure were included. Patients with malignancy, incontinent patients, and patients with rectovaginal fistula were excluded. MAIN OUTCOME MEASURES: Healing as defined by the absence of symptoms with no visible external opening on clinical examination. Follow-up was continued until May 2016. RESULTS: In total, 251 patients were identified, with a primary healing rate of 87.65% at a median follow-up of 71 months. The healing rates for low transsphincteric, intersphincteric, high transsphincteric, semihorseshoe, and horseshoe fistulas were 92.1%, 85.2%, 60.0%, 89.0%, and 40.0%. Of the 42 patients who had an unhealed fistula after previous non-ligation of intersphincteric fistula tract surgery, 38 (90.48%) healed after the first attempt at ligation of intersphincteric fistula tract. There were 31 patients with unhealed fistulas after the first ligation of intersphincteric fistula tract. Of these, 3 healed spontaneously, and the rest underwent either repeat ligation of intersphincteric fistula tract, fistulotomy (if the recurrence was intersphincteric), or simple curettage (if no internal opening was found). Ultimately, only 2 of the original 251 patients remained unhealed, and there was no change in subjective continence status after surgery. LIMITATIONS: This study was limited by its retrospective design. CONCLUSION: Ligation of intersphincteric fistula tract is an effective technique for the treatment of fistula in ano, including recurrent or unhealed fistula after other procedures.