Systematic review and meta-analysis of endorectal advancement flap and ligation of the intersphincteric fistula tract for cryptoglandular and Crohn's high perianal fistulas.

M E Stellingwerf,W A Bemelman,E M Van Praag,C J Buskens,P J Tozer

doi:10.1002/bjs5.50129

M E Stellingwerf, W A Bemelman + Show 3 more

Open Access

https://doi.org/10.1002/bjs5.50129

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Journal: BJS Open	Publication Date: Jan 21, 2019
Citations: 117	License type: CC BY 4.0

Affiliation: Amsterdam University Medical Centers, St Mark's Hospital

Abstract

BackgroundHigh perianal fistulas require sphincter‐preserving surgery because of the risk of faecal incontinence. The ligation of the intersphincteric fistula tract (LIFT) procedure preserves anal sphincter function and is an alternative to the endorectal advancement flap (AF). The aim of this study was to evaluate outcomes of these procedures in patients with cryptoglandular and Crohn's perianal fistulas.MethodsA systematic literature search was performed using MEDLINE, Embase and the Cochrane Library. All RCTs, cohort studies and case series (more than 5 patients) describing one or both techniques were included. Main outcomes were overall success rate, recurrence and incontinence following either technique. A proportional meta‐analysis was performed using a random‐effects model.ResultsSome 30 studies comprising 1295 patients were included (AF, 797; LIFT, 498). For cryptoglandular fistula (1098 patients), there was no significant difference between AF and LIFT for weighted overall success (74·6 (95 per cent c.i. 65·6 to 83·7) versus 69·1 (53·9 to 84·3) per cent respectively) and recurrence (25·6 (4·7 to 46·4) versus 21·9 (14·8 to 29·0) per cent) rates. For Crohn's perianal fistula (64 patients), no significant differences were observed between AF and LIFT for overall success rate (61 (45 to 76) versus 53 per cent respectively), but data on recurrence were limited. Incontinence rates were significantly higher after AF compared with LIFT (7·8 (3·3 to 12·4) versus 1·6 (0·4 to 2·8) per cent).ConclusionOverall success and recurrence rates were not significantly different between the AF and LIFT procedure, but continence was better preserved after LIFT.

Highlights

Perianal fistulas are a common medical and surgical problem, resulting in an abnormal tract between the anorectal canal and the perianal skin
This study suggests that for cryptoglandular fistula overall success and recurrence rates after the advancement flap (AF) and ligation of the intersphincteric fistula tract (LIFT) procedure are comparable
Continence seems to be better preserved after the LIFT procedure for both indications, making the LIFT procedure an attractive surgical option for either disease

Summary

Introduction

Perianal fistulas are a common medical and surgical problem, resulting in an abnormal tract between the anorectal canal and the perianal skin. High perianal fistulas are more difficult to eradicate and require sphincter-preserving surgery because of a serious risk of incontinence. High perianal fistulas require sphincter-preserving surgery because of the risk of faecal incontinence. For cryptoglandular fistula (1098 patients), there was no significant difference between AF and LIFT for weighted overall success (74⋅6 (95 per cent c.i. 65⋅6 to 83⋅7) versus 69⋅1 (53⋅9 to 84⋅3) per cent respectively) and recurrence (25⋅6 (4⋅7 to 46⋅4) versus 21⋅9 (14⋅8 to 29⋅0) per cent) rates. For Crohn’s perianal fistula (64 patients), no significant differences were observed between AF and LIFT for overall success rate (61 (45 to 76) versus 53 per cent respectively), but data on recurrence were limited. Conclusion: Overall success and recurrence rates were not significantly different between the AF and LIFT procedure, but continence was better preserved after LIFT

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