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

Malakorn, Songphol M.D.; Sammour, Tarik M.B.Ch.B., F.R.A.C.S., Ph.D.; Khomvilai, Supakij M.D.; Chowchankit, Irin M.D.; Gunarasa, Shankar M.B.B.S.; Kanjanasilp, Prapon M.D.; Thiptanakij, Charnjiroj M.D.; Rojanasakul, Arun M.D.

doi: 10.1097/DCR.0000000000000880
Original Contributions: Anorectal Disease
Denotes Associated Video Abstract
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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. See Video Abstract at

Colorectal Division, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand

Funding/Support: None

Financial Disclosures: None reported.

Podium presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, WA, June 10 to 14, 2017.

Correspondence: Songphol Malakorn, M.D., Colorectal Division, Department of Surgery, Chulalongkorn University, Bangkok, Thailand 10330. E-mail:

© 2017 The American Society of Colon and Rectal Surgeons