European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula

Mid- and long-term functional outcomes of advancement flap for cryptoglandular perianal fistulas

BACKGROUND

Surgical treatment for perianal fistulas requires balancing fistula closure with the risk of complications such as incontinence. The advancement flap (AF) is a widely used sphincter-sparing technique, yet it appears to offer only marginally better outcomes compared to alternative techniques, with a notable incontinence rate. This study aimed to evaluate the success rate and long-term functional outcomes of AF at our tertiary referral center.

METHODS

This retrospective cohort study analyzed prospectively collected data from electronic medical records and questionnaires distributed in December 2023. Patients aged 18 or older with primary or recurrent perianal fistulas treated with AF between 2013 and 2023 were included. Fistulas of non-cryptoglandular origin and rectovaginal fistulas were excluded. The primary outcome was fecal incontinence. Secondary outcomes included disease burden, fistula closure, and risk factors for recurrence.

RESULTS

Eighty-one patients were included; 37 (46%) were women, mean age was 45 years, and 93% had a complex fistula. The median follow-up was 27 months (IQR 15.5-64). Before AF, 36% reported some degree of incontinence, increasing to 80% at long-term follow-up after AF. Specifically, 20 out of 26 (77%) preoperative fully continent patients reported incontinence issues at long-term follow-up. Fistula disease impact on daily life was higher for those who failed AF repair. Primary fistula closure was achieved in 35 patients (43%). No risk factors for AF failure could be identified.

CONCLUSIONS

Advancement flap repair of perianal fistulas is challenging and can lead to fecal incontinence, so thorough preoperative counseling, consistent long-term follow-up, and further research comparing alternative sphincter-sparing techniques are warranted.

Ligation of the intersphincteric fistula fract (LIFT) in complex anorectal fistulas: retrospective analysis of the outcomes in a tertiary hospital

Anal fistula treatment remains a surgical challenge. This study focuses on the efficiency and safety of the Ligation of Intersphincteric Fistula Tract (LIFT) procedure for high intersphincteric anorectal fistulas, aiming to identify prognostic factors for success and complications. A retrospective chart review was conducted on all patients who underwent LIFT procedure at a tertiary referral hospital between January 2013 and January 2021. The primary endpoint was the success rate of fistula closure, confirmed with clinical investigation. Secondary endpoints included postoperative complications, reintervention and self-reported incontinence. Logistic regression analyses were performed for assessing prognostic factors for fistula closure and postoperative complications. Ninety-two patients were included in the study; after a median follow-up of 19.3 months, fistula closure was achieved in 71% (n = 65) and in 89% (n = 82) after reinterventions. 46% (n = 42) reported persistent symptoms, although 83% of which (n = 32/42) had succesful fistula tract closure by clinical evaluation. One patient developed incontinency for gas. Smoking emerged as a significant risk factor for fistula closure failure, OR = 6.75, 95% CI = [1.65, 27.69], p = 0.030. Wound dehiscence was the most common complication, occuring in 25% (n = 23). Prolonged oral antibiotics demonstrated a significant protective effect against wound dehiscence, OR = 0.31, 95% CI = [0.10, 0.96], p = 0.036. The LIFT procedure is an efficient and safe treatment for complex perianal fistula. Patient satisfaction emerged as a crucial treatment goal, as patients can remain symptomatic after fistula closure. Emphasizing smoking cessation is integral to the treatment approach. The findings suggest prolonged antibiotic treatment as a potential preventive measure for wound dehiscence.

Isolated perianal Crohn's disease: a systematic review and expert consensus proposing novel diagnostic criteria and management advice

Perianal fistulae can present a diagnostic challenge when distinguishing perianal Crohn's disease from idiopathic perianal fistulae. This distinction is key, as perianal Crohn's disease requires inflammatory bowel disease (IBD) therapy, whereas idiopathic perianal fistulae are primarily managed surgically. When luminal inflammation is absent, but Crohn's disease is suspected, the term isolated perianal Crohn's disease is sometimes applied. However, no formal guidance exists for diagnosing or managing isolated perianal Crohn's disease. Furthermore, whereas fistula granuloma might provide specific evidence of Crohn's disease, they are rarely detected in perianal fistulae, so are unlikely to sensitively delineate aetiology. This project aimed to develop an opinion-based framework for isolated perianal Crohn's disease. A systematic review evaluated clinical features suggestive of isolated perianal Crohn's disease and evidence for IBD therapies in patients with perianal fistulae without luminal IBD. The findings of this systematic review informed a multidisciplinary consensus process with IBD specialists, resulting in the formulation of diagnostic criteria and management recommendations for isolated perianal Crohn's disease. We then tested this diagnostic approach in a prospective cohort of 50 patients treated as having idiopathic perianal fistulae at a proctology referral centre, identifying six (12%) individuals as meeting the diagnostic criteria. Our findings underscore the scarcity of evidence guiding isolated perianal Crohn's disease diagnosis and the need for a composite risk-based assessment. The proposed framework provides a tool for clinical practice and research but requires validation and refinement. Clear communication with patients is essential, given the diagnostic and therapeutic uncertainties. Future studies should refine these criteria, explore biological markers for isolated perianal Crohn's disease, and establish evidence-based methods to differentiate isolated perianal Crohn's disease within the perianal fistulae spectrum.

Current practice and innovations in diagnosing perianal fistulizing Crohn's disease (pfCD): a narrative review

Perianal fistulizing Crohn's disease (pfCD) represents a severe manifestation of Crohn's disease (CD) that often leads to significant morbidity. Clinical examination alone of perianal fistulae is unlikely to be sufficient in the context of complex pfCD, as patients are likely to have complex disease and are more likely to experience complications, treatment failure, and recurrent disease. Furthermore, the relapsing-remitting nature of Crohn's disease and our limited understanding of the pathogenesis of this potentially destructive disease necessitate regular examination and radiological assessment, often in the form of magnetic resonance imaging (MRI). Recent advancements in diagnostic techniques have enhanced the accuracy and timeliness of pfCD diagnosis, facilitating better patient outcomes. A growing appreciation of isolated perianal Crohn's disease has prompted a recent attempt to develop consensus recommendations on diagnosing and treating this group of patients who would previously not have been offered CD medications. This narrative review aims to summarize current practice and the latest developments in the diagnosis of pfCD, highlighting: 1. Clinical examination and assessment tools 2. Current imaging practices 3. Innovations in imaging and biomarkers 4. The diagnosis of isolated perianal Crohn's disease.

Understanding the anatomical basis of anorectal fistulas and their surgical management: exploring different types for enhanced precision and safety

Anorectal fistulas remain one of the most challenging conditions in colorectal surgery and require precise anatomical knowledge for successful management. This comprehensive review synthesizes the current evidence on the anatomical foundations of fistula development and treatment, particularly focusing on the cryptoglandular hypothesis and its clinical implications. A systematic analysis of the recent literature has examined the relationship between anatomical structures and fistula formation, classification systems, diagnostic modalities, and therapeutic approaches. The review revealed that anatomical considerations fundamentally influence treatment outcomes, with modern imaging techniques achieving up to 98% accuracy in delineating fistula anatomy. Key findings demonstrate that surgical success rates vary significantly based on anatomical complexity: 92-97% for simple fistulas versus 40-95% for complex cases using sphincter-sparing techniques. Emerging minimally invasive approaches and regenerative therapies, including mesenchymal stem cells, show promising results with 50-60% healing rates in complex cases. Special considerations are needed for complex cases such as Crohn's disease-related and rectovaginal fistulas. This review provides surgeons with an evidence-based framework for selecting optimal treatment strategies based on anatomical considerations, emphasizing the importance of preserving the anal sphincter function while achieving complete fistula eradication. Integrating advanced imaging, surgical techniques, and emerging therapies offers new possibilities for improving patient outcomes. This review aimed to bridge the gap between anatomical knowledge and practical surgical application, enhance clinical decision-making, and improve patient outcomes in anorectal fistula management.

Differential Diagnosis Value of Neutrophil Gelatinase Associated Lipocalin as a Noninvasive Biomarker in Perianal Fistulizing Crohn's Disease

Background

Diagnosing perianal fistulizing Crohn's disease (pfCD) typically depends on costly and time-intensive endoscopic and radiographic procedures. Compelling evidence indicates that neutrophil gelatinase-associated lipocalin (NGAL) plays a role in the pathophysiology of Crohn's disease (CD) and may serve as a noninvasive biomarker for its diagnosis. This study aimed to evaluate NGAL's potential as a noninvasive diagnostic biomarker between pfCD and cryptoglandular (CG) perianal fistula, and its correlation with disease severity in pfCD.

Methods

Serum, fecal, and fistula tissue samples were collected from 96 patients with pfCD and 97 patients with CG perianal fistula as controls. Serum NGAL levels were quantified through ELISA and fistula tissue NGAL levels were quantified through immunohistochemical staining, while pfCD disease severity was evaluated using the Crohn's Disease Activity Index (CDAI) and Perianal Disease Activity Index (PDAI). Additional laboratory parameters, including NGAL, fecal calprotectin (FC), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR), were analyzed, and their correlations were assessed. Receiver operating characteristic (ROC) analysis was conducted to evaluate NGAL's diagnostic potential for pfCD.

Results

Levels of serum NGAL, FC, CRP, and ESR in patients with pfCD were significantly elevated compared to the control group (p < 0.001); Spearman correlation analysis indicated a positive correlation between serum NGAL and FC, CRP, ESR, CDAI, and PDAI scores. The area under the ROC curve (AUC) for serum NGAL in diagnosing pfCD was 0.927 (95% CI: 0.890-0.964). The AUC for FC in diagnosing pfCD were 0.887 (95% CI: 0.839-0.935). Additionally, serum and fistula tissue NGAL levels were positively correlated with disease complexity in pfCD according to the Montreal classification.

Conclusion

These findings suggest that serum NGAL is associated with pfCD severity and may offer a promising noninvasive biomarker for diagnosing and assessing pfCD.

Mucosal advancement flap versus ligation of the inter-sphincteric fistula tract for management of trans-sphincteric perianal fistulas in the elderly: a retrospective study

PURPOSE

There is no consensus on the standard approach for trans-sphincteric perianal fistulas (TPAF) in the elderly population. The most commonly used sphincter-saving procedures are ligation of the inter-sphincteric fistula tract (LIFT) and mucosal advancement flap (MAF). We aimed to evaluate the incidence and risk factors for recurrence and incontinence in elderly patients with TPAF using both approaches.

METHODS

This retrospective study included 257 patients who underwent LIFT (136 patients) or MAF (121 patients) for de novo and cryptoglandular TPAF between July 2018 and July 2021. Recurrent fistulas were clinically and radiologically detected using MRI. Postoperative incontinence was evaluated using the Wexner score and anorectal manometry. Logistic regression analysis was used to detect the risks of recurrence and incontinence.

RESULTS

The median ages of the patients were 68 (64, 74) and 68 (65, 74) years in the LIFT and MAF groups, respectively. Higher recurrence rates were observed after LIFT (17 (12.5%)) than after MAF (13 (10.7%)), but the difference was not statistically significant (P = 0.662). Postoperative incontinence was observed in 18 patients (13.2%) and seven patients (5.8%) in the LIFT and MAF groups, respectively (P = 0.044). The predictors for fistula recurrence were smoking (OR, 75.52; 95% CI, 1.02 to 5611.35; P = 0.049), length of tract (OR, 17.3; 95% CI, 1.49 to 201.13; P = 0.023), and CD classification (OR, 7.08; 95% CI, 1.51 to 33.14; P = 0.013). A low Charlson comorbidity index score (≤ 5) (OR, 0.68; 95% CI, 0.47 to 0.99; P = 0.046) and high postoperative mean squeeze anal pressure (OR, 0.97; 95% CI, 0.95 to 0.99; P = 0.001) were significant factors associated with reduced risk of incontinence. In particular, LIFT was associated with a significantly higher risk of incontinence than MAF (OR, 2.089; 95% CI, 1.006 to 4.33; P = 0.04).

CONCLUSIONS

The healing rates of MAF and LIFT procedures did not differ significantly; however, continence was significantly better after MAF. MAF should be added to the guidelines as a good option for the treatment of TPAF in elderly patients.

TRIAL REGISTRATION

The study was registered as a clinical trial www.

CLINICALTRIALS

gov (NCT06616662).

Deep Postanal Abscess With Sacrococcygeal Osteomyelitis: A Case Report

Deep postanal abscesses (DPAs) are uncommon but clinically significant conditions that, if left untreated, can result in severe septic complications. This case report presents a rare instance of sacrococcygeal osteomyelitis as a complication of a long-standing DPA. The patient underwent surgical drainage and seton placement, leading to complete resolution of both the abscess and the osteomyelitis. This case underscores the importance of prompt surgical intervention in the management of DPAs and highlights the potential for rare but serious complications such as osteomyelitis.

A technical note of flex video-assisted anal fistula treatment procedure: Utilizing modified flexible fistuloscope in video-assisted approach for anal fistula laser treatment

This study explores an innovative approach for managing complex anal fistulas, known as the flexible video-assisted anal fistula treatment (flex-VAAFT). This technique uses a modified flexible fistuloscope and a laser diode for precise laser ablation. The flexible fistuloscope offers a wider field of view compared to the traditional VAAFT fistuloscope, allowing for better visualization and accurate assessment of the fistula tract's internal anatomy, enabling meticulous debridement and irrigation. We applied the flex-VAAFT approach in seven male patients aged 36 to 66, documenting the external and internal openings, etiology, and fistula type. Seton placement was used in one case, with follow-up periods ranging from 6 to 12 months. Most patients experienced successful healing, with only one recurrence observed. There were no cases of anal incontinence, and the average hospital stay was brief, lasting between 1 and 2 days. The findings suggest that flex-VAAFT is a promising, minimally invasive method for treating anal fistulas, enhancing surgical precision while preserving anal continence.

Clinical application of the intersphincteric approach with internal incision combined with counter- drainage for deep perianal abscess

PURPOSE

This retrospective study evaluates the clinical efficacy of the Intersphincteric Approach with Internal Incision combined with Counter-Drainage (IAICD) for Deep Perianal Abscess (DPA), thereby providing a foundation for selecting optimal surgical treatment methods in clinical practice.

METHODS

Using a retrospective cohort study design, we analyzed the clinical data of 120 patients who underwent inpatient surgical treatment for DPA at our hospital from January 2022 to June 2023. Of these, 57 patients underwent the IAICD (treatment group), while 63 patients received incision-drainage (control group). Clinical data from both groups were collected for statistical analysis. The primary outcomes measured were clinical efficacy, anal function scores and appearance scores. Secondary outcomes included postoperative pain, operation time, wound healing time and length of hospital stay.

RESULTS

The treatment group had 52 cured cases, with a cure rate of 52/57 (91.2%), whereas the control group had 48 cured cases, with a cure rate of 48/63 (76.2%). The treatment group's clinical efficacy was significantly better than the control group (P = 0.03). The operation time was longer in the treatment group compared to the control group (P < 0.01). There were no significant differences between the two groups in terms of anal function scores, appearance scores, postoperative pain, wound healing time and length of hospital stay (P > 0.05). Multivariate logistic regression analysis revealed that IAICD was a protective factor for the clinical efficacy of DPA patients (P = 0.01), While wound healing time and a history of perianal surgery were identified as independent risk factors associated with poor prognosis in patients with DPA (P = 0.039, P = 0.032).

CONCLUSION

For patients with DPA who have high expectations for minimizing postoperative recurrence, a comprehensive preoperative evaluation-including a history of prior perianal surgery-precise intraoperative localization of the internal opening, and meticulous postoperative wound care can collectively optimize clinical outcomes. The IAICD procedure not only preserves anal sphincter function but also effectively reduces the recurrence rate of postoperative abscesses or fistula formation.

Faecal calprotectin as a non-invasive marker of Crohn's disease in anal fistulas

AIM

Faecal calprotectin (FC) is a noninvasive marker that reflects intestinal inflammation with good sensitivity. A prior study indicated that FC values above 150 μg/g could distinguish between anal fistulas (AF) of cryptoglandular or Crohn's disease (CD) origin. It is hypothesized as a useful triage test to rule out CD in newly referred AF patients, thus reducing the number of ileocolonoscopies performed and optimizing treatment regimens in AF while minimizing patient discomfort as well as healthcare costs. The aim of the study was to determine the accuracy of FC in distinguishing between anal fistulas of cryptoglandular and CD origin, as well as compare characteristics in fistulas.

METHOD

Patients referred with anal fistula who had an FC measurement and either ileocolonoscopy or colonoscopy within 12 weeks were included. Demographic and clinical characteristics were registered. Area under the curve (AUC) was calculated as well as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy.

RESULTS

A total of 63 patients were included (CD n = 31, 49%). FC was significantly higher in CD compared to cryptoglandular fistulas, even when CD was medically treated or had no luminal activity on endoscopy. FC ≥110 μg/g was significantly associated with CD (OR 12.5; 95% CI: 3.77-41.4) p < 0.0001. This was found by plotting a receiver operating characteristic (ROC) curve, with AUC 80.8 (95% CI: 0.6952-0.9217). Sensitivity and specificity were 0.76 and 0.80, respectively (PPV 76%, NPV 80% and accuracy 78%).

CONCLUSION

FC discriminates CD from cryptoglandular fistulas, even in medically treated CD with normal endoscopic findings.

The Songdo consensus: Development of minimum reporting standards for studies of intervention in idiopathic anal fistula using a modified nominal group technique

AIM

Cryptoglandular anal fistulas carry a substantial burden to quality of life. Surgery is the only effective curative treatment but requires balancing fistula healing against pain, wounds and continence impairment. Sphincter-preserving procedures do exist but demonstrate variable rates of success. A lack of consistency and precision in outcome reporting and methodological quality hinders effective evidence-based decision-making. We aimed to establish a series of minimum reporting standards for interventional studies in idiopathic anal fistula, to eradicate low-quality studies, thus providing a consistent baseline of useful evidence.

METHODS

An international group of 16 experts participated in a modified nominal group technique consensus. The nominal question was: 'What should be the minimum set of reporting standards for studies of intervention in idiopathic anal fistula?' The process was conducted between May and June 2023, culminating in a hybrid in-person/virtual meeting that took place at the Songdo International Proctology Symposium in June 2023.

RESULTS

Initial idea generation resulted in 37 statements within the first round. Themes included variable reporting of follow-up and incontinence. Participants indicated their agreement via a 9-point Likert scale. Any statement achieving >70% consensus was retained. Subsequent group discussion condensed the list to 11 statements for further voting and a final minimum set of 12 reporting standards was created.

CONCLUSION

To date, this is the first study dedicated to developing minimum reporting standards for interventional studies in idiopathic anal fistula using a modified nominal group technique. These standards will instruct researchers in producing meticulous, high-quality studies that are accurate, transparent and reproducible.

Postoperative pain following laser fistula closure versus ligation of the intersphincteric fistula tract: A prospective double-blinded randomized controlled trial

BACKGROUND

Prior studies focus primarily on surgical outcomes of anal fistula treatment, such as healing rates, rather than patient-reported outcomes, such as postoperative pain, which could influence surgical choice.

OBJECTIVE

To compare pain scores at 6 and 24 h postoperatively between laser closure and ligation of the intersphincteric tract for anal fistula.

DESIGN

Prospective, double-blinded randomized controlled trial.

SETTINGS

A quaternary hospital in Malaysia.

PATIENTS

Patients aged 18-75 years with high transsphincteric fistulas.

INTERVENTION

Fistula laser closure versus ligation of the fistula tract (LIFT) treatment.

MAIN OUTCOME MEASURES

Pain scores, continence, quality of life (QOL), operative time, and treatment failure were compared using chi-square, Fisher's exact test, student t-test, or Mann-Whitney with p < 0.05 denoting statistical significance.

RESULTS

Fifty-six patients were recruited (laser, n = 28, LIFT, n = 28). Median pain scores for laser versus LIFT at 6 h postoperatively were 1.0 versus 2.0 (Rest, p = 0.213) and 3.0 versus 4.0 (Movement, p = 0.448), respectively. At 24 h, this reduced to 2.5 in both arms at rest (p = 0.842) but increased to 4.8 versus 3.5 on movement (p = 0.383). Median operative time for laser was significantly shorter (32.5 min) than LIFT (p < 0.001). Laser treated patients trended toward quicker return to work (10.5 vs. 14.0, p = 0.181) but treatment failure was similar (54% vs. 50%, p = 0.71). No patients developed postoperative incontinence. Mean SF-36 scores increased from baseline (67.1 ± 17.0; 95% CI 63.6-82.4 vs. 71.3 ± 11.4; 95% CI 64.0-75.0) to 6 months postoperatively (77.7 ± 21.0; 95% CI 57.0-80.3 vs. 74.0 ± 14.3; 95% CI 67.6-81.4) regardless of the type of surgery (P > 0.05).

LIMITATIONS

Patients with prior fistula surgery (approximately 20%) led to heterogeneity. The total laser energy delivered varied depending on fistula anatomy.

CONCLUSION

Laser fistula closure is an alternative to LIFT, with similar postoperative pain and shorter operative time despite more complex fistula anatomy in the laser arm, with a greater improvement in QOL.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT06212739.

Validation of a 3D-printed model of cryptoglandular perianal fistulas

INTRODUCTION

Visualising the course of a complex perianal fistula on imaging can be difficult. It has been postulated that three-dimensional (3D) models of perianal fistulas improve understanding of the perianal pathology, contribute to surgical decision-making and might even improve future outcomes of surgical treatment. The aim of the current study is to investigate the accuracy of 3D-printed models of perianal fistulas compared with magnetic resonance imaging (MRI).

METHODS

MRI scans of 15 patients with transsphincteric and intersphincteric fistulas were selected and then assessed by an experienced abdominal and colorectal radiologist. A standardised method of creating a 3D-printed anatomical model of cryptoglandular perianal fistula was developed by a technical medical physicist and a surgeon in training with special interest in 3D printing. Manual segmentation of the fistula and external sphincter was performed by a trained technical medical physicist. The anatomical models were 3D printed in a 1:1 ratio and assessed by two colorectal surgeons. The 3D-printed models were then scanned with a 3D scanner. Volume of the 3D-printed model was compared with manual segmentation. Inter-rater reliability statistics were calculated for consistency between the radiologist who assessed the MRI scans and the surgeons who assessed the 3D-printed models. The assessment of the MRI was considered the 'gold standard'. Agreement between the two surgeons who assessed the 3D printed models was also determined.

RESULTS

Consistency between the radiologist and the surgeons was almost perfect for classification (κ = 0.87, κ = 0.87), substantial for complexity (κ = 0.73, κ = 0.74) and location of the internal orifice (κ = 0.73, κ = 0.73) and moderate for the percentage of involved external anal sphincter in transsphincteric fistulas (ICC 0.63, ICC 0.52). Agreement between the two surgeons was substantial for classification (κ = 0.73), complexity (κ = 0.74), location of the internal orifice (κ = 0.75) and percentage of involved external anal sphincter in transsphincteric fistulas (ICC 0.77).

CONCLUSIONS

Our 3D-printed anatomical models of perianal fistulas are an accurate reflection of the MRI. Further research is needed to determine the added value of 3D-printed anatomical models in preoperative planning and education.

Ligation of intersphincteric fistula tract (LIFT) for trans-sphincteric cryptoglandular anal fistula: long-term impact on faecal continence

BACKGROUND

The ligation of intersphincteric fistula tract is a surgical technique designed to treat trans-sphincteric anal fistulas aiming to preserve sphincter integrity. Recent studies suggest its efficacy in short-term fistula healing with limited impact on continence. However, comprehensive prospective data on long-term outcomes, including recurrence and bowel continence, are limited. The present study aims to report on the long-term functional outcomes.

METHODS

Patients who underwent the ligation of intersphincteric fistula tract procedure for trans-sphincteric cryptoglandular anal fistulas between July 2012 and October 2018 at two Dutch referral centres were retrospectively reviewed. The primary outcome of interest was the long-term bowel continence after the ligation of intersphincteric fistula tract procedure, using the faecal incontinence severity index. Short-term data (collected in 2018) and long-term data (collected in 2023) on bowel continence, healing rates and recurrences were obtained through electronic records and Rockwood questionnaires. Sankey diagrams were used to visually represent individual variations in continence status (preoperative versus follow-up).

RESULTS

Among 110 patients included (50% female, median follow-up 92 months), 101 patients (92%) were treated with previous surgeries (median 2, range 0-6) and 80% had previous seton drainage. Preligation of intersphincteric fistula tract, 16% of the patients reported incontinence (mean(s.d.) faecal incontinence severity index: 2.4(7.5), increasing to 18% after ligation of intersphincteric fistula tract at short-term follow-up, including 11% newly induced cases. Long-term follow-up collected using Rockwood questionnaires (63% response rate) in 69 patients uncovered a 74% incontinency rate (mean(s.d.) faecal incontinence severity index: 9.22(9.5). In those patients without subsequent surgery 49% (17 of 35) reported incontinence at long-term follow-up. Primary fistula healing after ligation of intersphincteric fistula tract was 28%. Preoperative seton drainage significantly improved healing rates (33% versus 9%). Notably, 43% (34 of 79) of unhealed fistulas transitioned into intersphincteric tracts; in these patients, 19 were treated with subsequent fistulotomy achieving cure in 18 cases.

CONCLUSIONS

Ligation of intersphincteric fistula tract healing rates fell below recent literature standards. Although the immediate impact on postoperative continence appears minimal, long-term incontinence rates are concerning. In recognizing the deterioration of individual continence, we advocate for a patient-centered approach and urge fellow researchers and clinicians to collect comprehensive prospective continence data.