title: The anatomy of failures following the ligation of intersphincteric tract technique for anal fistula: a review of 93 patients over 4 years.
abstract: BACKGROUND
  Although the ligation of intersphincteric tract technique is a promising sphincter-preserving option in managing anal fistulas, failures are still seen.
  
  
  OBJECTIVE
  This study aimed to illustrate the patterns of failures and recurrences following the ligation of intersphincteric tract procedure for anal fistulas.
  
  
  METHODS
  This study is a retrospective review.
  
  
  METHODS
  This study was conducted at the Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, from April 2006 to September 2010.
  
  
  METHODS
  Ninety-three patients were evaluated.
  
  
  METHODS
  All patients underwent the ligation of intersphincteric tract procedure for anal fistulas.
  
  
  METHODS
  Failure was defined as nonhealing of the surgical wound or fistula. Recurrence was defined as the reappearance of the fistula after initial healing.
  
  
  RESULTS
  After a median follow-up of 23 (range, 1-85) weeks, there were 7 failures and 6 recurrences. The median time to healing was 4 (range, 1-12) weeks. The freedom from failure or recurrence at 1 year following the ligation of intersphincteric tract procedure was 78% (95% CI: 66%-90%). All 7 failures had discharge at the intersphincteric wound. Four had an unhealed internal opening, and 3 had isolated failures at the intersphincteric wound. Endoanal ultrasonography revealed a less complicated anatomy that enabled successful treatment with either local application of silver nitrate (n = 3) or fistulotomy (n = 4). All 6 recurrences had a demonstrable tract from the previous internal opening to an external opening with healing of the intersphincteric wound. The median time to recurrence was 22 (range, 15-33) weeks from the ligation of the intersphincteric tract procedure. Fistulotomy, repeat ligation of intersphincteric tract, or anocutaneous advancement flap procedure was successfully performed subsequently.
  
  
  CONCLUSIONS
  In patients with early failures, the medialization of the external opening to the intersphincteric wound simplified subsequent management. All recurrences should be reevaluated and managed accordingly.
authors: Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore.
authors: Ker-Kan
authors: KK
authors: Tan
authors: Ian J
authors: IJ
authors: Tan
authors: Frances S
authors: FS
authors: Lim
authors: Dean C
authors: DC
authors: Koh
authors: Charles B
authors: CB
authors: Tsang
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001003:Anal Canal / Q000601:surgery*; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008026:Ligation / Q000379:methods; D008297:Male; D008875:Middle Aged; D012003:Rectal Fistula / Q000209:etiology / Q000473:pathology / Q000601:surgery*; D012008:Recurrence; D012189:Retrospective Studies; D013536:Suture Techniques; D017211:Treatment Failure; D055815:Young Adult