The Ligation of the Intersphincteric Fistula Tract Procedure for Anal Fistula: A Mixed Bag of Results

BACKGROUND:The ligation of the intersphincteric fistula tract procedure, a sphincter-preserving technique, aims to obtain complete, durable healing, while preserving fecal continence in the treatment of transsphincteric anal fistulas. OBJECTIVE:This was a systematic review to evaluate the outcomes of the originally described (classic) ligation of the intersphincteric fistula tract procedure and the identified technical variations of the procedure. DATA SOURCES:PubMed, Web of Science, and the archive of Diseases of the Colon & Rectum were searched with the terms “ligation of intersphincteric fistula” and “ligation of intersphincteric fistula tract.” STUDY SELECTION:Original, English-language studies reporting the primary healing rate for each technical variation of the ligation of the intersphincteric fistula tract procedure were included. Studies were excluded when the technique used was unclear or when primary healing rate was reported in a pooled manner including outcomes from multiple technical variations of the ligation of the intersphincteric fistula tract procedure. INTERVENTION:Outcomes associated with all of the technical variations of the ligation of the intersphincteric fistula tract procedure were investigated. MAIN OUTCOME MEASURES:The main outcome measured was primary healing rate. Secondary outcome measures included time to healing, changes in continence, and risk factors for failure. RESULTS:In all, 26 studies met criteria for review, including 1 randomized controlled trial and 25 cohort/case series. Seven technical variations of the ligation of the intersphincteric fistula tract procedure were identified and classified according to the surgical technique. Primary healing rates ranged from 47% to 95%. LIMITATIONS:The levels of evidence available in the published works are relatively low, as indicated by the Oxford Center for Evidence-Based Medicine evidence levels. CONCLUSIONS:The ligation of the intersphincteric fistula tract procedure is a promising treatment option for transsphincteric fistulas, with reasonable success rates and minimal impact on continence. The true efficacy of the procedure is unknown because of the number of technical variations and the pooled results reported in the literature.