Ligation of intersphincteric fistula tract: What is the evidence in a review?

Table 1 Summary of the published articles

Ref.	Year	Study design	n	Age (yr)	Gender	Fistula classification	Preperative evaluation	Healing rate	Failure or recurrence rate	Morbidity	Incontinence	Follow-up	Comments
Rojanasakul[8]	2009	Retro	18	NA	NA	13 LTS5 HS	NA	94%	R 5.6%	NA	NA	NA	Healing time 4 wk
Bleier et al[4]	2010	Retro/pros	39	49	51.3% male	28 TS, 7 HS1 SP, 2 RV	NA	57%	43%	2: Anal fissure and pain	0 (NAO)	20 wk (0-58)	PS mean 3 (0-9)74% PS R time 10w (2-38)
Shanwani et al[9]	2010	Pros	45	41.5 (27-56)	71.1% male	33 TS	44% colonoscopy48.80% anal USG	82.20%	R 17.7%	0	0 (NAO)	9 mo(2-16)	11.1% PSMOT 67.5 min (35-100)LOS 2.5 d (2-5)Healing time 7 wk (4-10)R time 3-8 mo
Ellis[11]	2010	Pros	31	48 (30-68)	22 male	31 TS	NA	94%	R 2 (6%)	NA	NA	15 mo(12-30)	Bio-LIFTInclude: CD, CS, DM patients.100% previous seton18 PS (PLUG)Satisfaction 100%
Ooi et al[12]	2011	Retro	25	40 (21-67)	17 male	6 IS, 18 TS, 1 SP	MRI 72%	68%	R 28% (all IS)	0	Basal WS 2PostOp Global WS 4Heal WS 0	22 wk(3-43)	PS 40%MOT 39 min (17-100)Healing time 6 wk (3-17)R time 13.5 wk (7-20)Satisfaction 72%
Aboulian et al[6]	2011	Retro	25	39	68% male	NA	NA	68%	Fa 32%	2 Vaginal Candidiasis	NA	27 wk(8-158)	Previous seton 65%PS 27%EC: CD.Previous seton 100%
Sileri et al[13]	2011	Pros	18	39 (4-62)	10 male	15 TS1HS2 RV	100% MRI or anal USGManometry	83%	R 3 (17%; 1 IS, 2 TS)	1 Thrombosed external hemorrhoid	NA	6 mo(4-10)
Tan et al[14]	2011	Retro	93	40 (14-71)	82.8% male	89.2% TS (39 LTS, 44 HTS)4 IS, 22 HS 6 SP	Anal USG 100%	86%	R 6.4%Fa 7.5%(4 IS, 3 sinus)	NA	NA	23 wk(1-85)	PS 28%Previous seton 17.2%Healing time 4 wk (1-12)R time 22 wk (15-24)Describes types of failures.
Wallin et al[5]	2012	Retro / Pros	93	43 (21-76)	61% male	16 HS77 TS	NA	40%Secondary 57%	Fa 34%R 26%	NA	WS 1 0%-10%Solid incontinence none (NAO)	19 mo (44-55)	EC: less 3 mo FU, RV, CD, IAR, LI, PL.32% PS92% Previous setonR time 7 mo (0.8-27)
Abcarian et al[15]	2012	Retro	40	43	NA	TS	NA	74%1st 90%2nd 75%3rd 65%	26%RFUVA: obesity, CS, PS	NA	0 (NAO)	18 wk(2-64)	Include: HIV, CD, Obesity, CS, DM.EC: acute abscessPS: 2 (0-12).
Tan et al[16]	2012	Retro	31ERAF24 LIFT	ERAF 49 (19-74); LIFT 41 (16-75)	ERAF 87.1% male; LIFT 87.50% male	High fistulas	100% anal USG	ERAF 93.5%; LIFT 62.5%.P = 0.006	ERAF Fa 6.5%; LIFT Fa 37.5%.P = 0.006	NA	NA	ERAF 6 mo (2-26); LIFT 13 mo (4-67)	Previous Seton 100%EC: VIH, CD. ERAF PS: 58.8%; LIFT PS: 25%
Mushaya et al [17]	2012	RCT	39LIFT 25ERAF 14	47.8	LIFT 17 malesERAF 10 males	HTS	100% Anal USG or MRI.	At 1 moERAF 85% vs LIFT 68%Finally 93% vs 92%	R ERAF 7% vs LIFT 8%, P = NS	LIFT 4% bleeding, 8% dehiscence IS wound.ERAF7% dehiscence apex	NAOReport equal functional outcomes	20 mo	Comorbidities: DM, RA, Ca, IHD (33%)EC: CDMOT LIFT 10 minMOT ERAF 42.5 minPain less with LIFTSatisfaction LIFT 9.8 vs ERAF 8.1, P < 0.001. RNA favored LIFT (P = 0.016)
Han et al[18]	2012	Retro	21	38 (25-56)	19 male	NA	100% Anal USG	95%.	NA	0	Mean WS 0 (5% WS 1).	14 mo(12-15)	LIFT-PLUGPS 0EC: CD, FI, MT, acute abscess, HIV, Tb. MOT 20 min (15-40)Healing time faster
van Onkelen et al[21]	2012	Retro	22	45 (17-59)	13 male	All LTS	100% MRI	82% Secondary 100%	0	NA	0 (Rockwood)	19.5 mo (3-35)	PS 10 patientsEC: CD, RVFemale all healed with first LIFT
van Onkelen et al[22]	2012	Retro	41	42 (20-69)	32 male	TS	NA	51% Secondary 71%	Fa 20 (8 IS alone)	NA	Rockwood PreOp 10 PostOp 7	15 mo (7-21)	ERAF + LIFTPS 48%3 previous ERAFEC: RV, CD
Liu et al[7]	2013	Retro	38	42	74% male	38 TS	NA	61%	Fa 1512 early type3 late type	NA	0 (NAO)	26 mo (3-44)	68% more 12 mo FU.18% PS.Previous seton 76%.Length of fistula tract correlates with healing rate.Healing time 8 wk (4-36).F time 4 mo
Lehmann et al[20]	2013	Retro	17	49 (30-76)	9 male	All recurrent fistulas. 15 TS (3 LTS, 12 HTS) 2 RV	NA	Complete 47%	40% R 13% Fa	1 Local Hematoma1 Subcutaneous infection	0 (NAO)	13.5 mo(8-26)	Previous Seton 4 MOT 35 minLOS 1.4 d
Sirikurnpiboon et al[23]	2013	Pros	4120 LIFT21LIFT plus	40.7	31 male	36 TS (3 LTS, 33 HTS), 4 HS, 1 SP	NA	83%LIFT 83% vs LIFT-plus 85% P = 0.059.	Fa 7LIFT 4LIFT-plus 3	LIFT-plus1 Anal fissure, 1 local hemorrhageLIFT1 Anal fissure	0 (NAO)	19 wk	Healing time 4 wk R time 12 wk

Ca: Cancer; CD: Crohn’s disease; CS: Cigarette smoking; DM: Diabetes; EC: Exclusion criteria; Fa: Failure; HIV: Human immunodeficiency syndrome; HS: Horseshoe fistula; HTS: High trans-sphincteric; IAR: Ileo anal reservoir; IHD: Ischemic heart disease; IS: Intersphincteric fistula; LI: Loop ileostomy; LOS: Length of stay; LTS: Low trans-sphincteric fistula; MOT: Mean operative time; NAO: Not assessed objectively; NA: Not available; PL: Patients lost; PostOp: Post-operative; Pros: Prospective; PS: Previous surgeries; R: Recurrence; RA: Rheumatoid arthritis; RCT: Randomized controlled trial; RNA: Resumption normal activities; Retro: Retrospective; RFUVA: Risk factor in univariate analysis; RV: Rectovaginal fistula; SP: Supra-sphincteric fistula; Tb: Tuberculosis; TS: Trans-sphincteric fistula; WS: Wexner score.