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Does Ligation of the Intersphincteric Fistula Tract Raise the Bar in Fistula Surgery?

Wallin, Ulrik G. M.D., Ph.D., M.S.; Mellgren, Anders F. M.D. Ph.D.; Madoff, Robert D. M.D.; Goldberg, Stanley M. M.D.

Diseases of the Colon & Rectum:
doi: 10.1097/DCR.0b013e318266edf3
Original Contributions: Anorectal Disease

BACKGROUND: The ligation of the intersphincteric fistula tract procedure has been reported to have high cure rates, with minimal impairment of continence.

OBJECTIVE: The aim of this study was to evaluate the success rates and functional outcome after the ligation of the intersphincteric fistula tract procedure.

DESIGN: This study was performed as a retrospective review.

SETTINGS: The study was conducted at the Division of Colon and Rectal Surgery, University of Minnesota and at affiliated hospitals in Minneapolis and St. Paul, Minnesota, between March 2007 and September 2011.

PATIENTS: Ninety-three patients with transsphincteric cryptoglandular anal fistula were included.

INTERVENTIONS: Ligation of the intersphincteric fistula tract procedure was performed.

MAIN OUTCOME MEASURES: Failure was defined as persistent or recurrent drainage, air leakage from a patent external opening, or intersphincteric incision or reoperation for recurrent fistula. Success was defined as healing of the external fistula opening and intersphincteric incision. Patients were followed up with a questionnaire to assess the recurrence rate and the Wexner incontinence score.

RESULTS: The median follow-up time for was 19 months (range, 4–55). Thirty patients (32%) had a history of previous surgery for their fistula. The success rate of fistula healing was 40% after the first ligation of the intersphincteric fistula tract procedure. When including patients with repeat ligation of the intersphincteric fistula tract and subsequent intersphincteric fistulotomy after ligation of the intersphincteric fistula tract repair, the success rates were 47% and 57%. Patients with successful fistula closure reported a mean Cleveland Clinic Florida Fecal Incontinence score of 1.0 (SD 2.3). No predictor for successful fistula closure was found.

LIMITATIONS: Retrospective design, limited accuracy of diagnosing fistula failure, and lack of baseline continence were limitations of this study.

CONCLUSION: The present study indicates that the ligation of the intersphincteric fistula tract procedure for transsphincteric fistulas has a significant risk for failure but good functional outcome in patients with no recurrence.

Author Information

Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota

Financial Disclosure: Dr Mellgren has received honoraria and research support from Medtronic. Other entity affiliations are as follows: American Medical Systems (research support, consultant), Q-Med Scandinavia (research support, consultant), Carbon Medical (research support), Torax Medical (research support, consultant), Tsumara USA Inc. (consultant).

Podium presentation at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, TX, June 2 to 6, 2012.

Correspondence: Ulrik G. Wallin M.D., Ph.D., Colon and Rectal Surgery Associates, 2800 Chicago Ave S, #300, Minneapolis, MN 55407. E-mail:

© The ASCRS 2012