title: Ligation of the intersphincteric fistula tract: an effective new technique for complex fistulas.
abstract: BACKGROUND
  The management of complex fistulas is difficult. Maintaining continence while achieving durable fistula closure is the goal of surgical management. This study describes our experience with a novel sphincter-sparing technique called the ligation of the intersphincteric fistula tract, which involves ligation and division of the fistula tract in the intersphincteric space.
  
  
  METHODS
  All patients from July 2007 to December 2008 with trans- or suprasphincteric fistula treated with the procedure were prospectively followed. Procedures were performed by surgeons with fellowship training in a referral center. Demographic data, comorbidities, previous repair attempts, and postoperative data were collected.
  
  
  RESULTS
  A total of 39 patients underwent a ligation of the intersphincteric fistula tract during a 17-month period. Median age was 49 years. A total of 29 patients (74%) had previous attempts at repair, with a median of 2 failed repairs. Follow-up data were available in 90% (35 of 39). Median follow-up was 20 weeks. Successful fistula closure was achieved in 57% of the patients (20 of 35). Median time to failure was 10 weeks (range, 2-38 weeks). No patient reported any subjective decrease in continence after the procedure.
  
  
  CONCLUSIONS
  Ligation of the intersphincteric fistula tract is a new sphincter-sparing procedure for complex transsphincteric fistula. The success rate is comparable with other sphincter-preserving techniques. Importantly, it appeared to effectively preserve continence. Adding safe, muscle-sparing surgical options to our armamentarium for dealing with transsphincteric fistula is essential. Additionally, the procedure is easy to learn and has very low cost. Long-term follow-up and randomized, controlled trials are necessary to assess efficacy and durability.
authors.affiliation: University of Pennsylvania, Pennsylvania Hospital, Division of Colon and Rectal Surgery, Philadelphia, Pennsylvania 19106, USA. Joshua.bleier@uphs.upenn.edu
authors.forename: Joshua I S
authors.initials: JI
authors.lastname: Bleier
authors.forename: Husein
authors.initials: H
authors.lastname: Moloo
authors.forename: Stanley M
authors.initials: SM
authors.lastname: Goldberg
mesh_terms: D001003:Anal Canal; D005260:Female; D006801:Humans; D007603:Jurisprudence; D008297:Male; D008875:Middle Aged; D012003:Rectal Fistula / Q000601:surgery*; D016896:Treatment Outcome