Intersphincteric Fistula Tract Procedure Research Articles

Predictors of recurrence and long-term patient reported outcomes following surgical repair of anal fistula, a retrospective analysis

PurposeSurgery for anal fistulas can result in devastating complications, including reoperations and fecal incontinence. There is limited contemporary evidence comparing outcomes since the adoption of the ligation of intersphincteric fistula tract procedure into mainstream practice. The purpose of this study is to compare recurrence rates and long-term outcomes of anal fistula following repair.MethodsData was collected from the electronic medical records or patient reported outcomes from patients aged 18 or older with a primary or recurrent cryptoglandular anal fistula. Primary outcome was recurrence defined as the identification of at least one fistula os or a high clinical suspicion of anal fistula. Secondary outcomes included fecal incontinence and postoperative quality of life.ResultsA total of 171 patients underwent definitive surgical repairs for their anal fistula. So 66.5% had a simple fistula, and 33.5% had a complex fistula. Of the 171 patients, 12.5% had a recurrence. The recurrence rates were 5.9% for simple fistula and 25.4% for complex fistula. Predictors of recurrence included diabetes mellitus, history of anorectal abscess, complex fistula, and sphincter sparing surgery. LIFT or plug/biologic procedures were both associated with a 50% or greater recurrence rate. No significant differences were found in fecal incontinence or associated quality of life between sphincter sparing or non-sphincter sparing surgical resections.ConclusionThe study provides insights into the long-term outcomes of surgical repair for anal fistula. We demonstrate that sphincter sparing operations are associated with increased recurrence, meanwhile, non-sphincter sparing surgeries did not increase the risk of fecal incontinence or worsen quality of life.

Comparison of BioLIFT versus LIFT for the treatment of trans-sphincteric anal fistula: a protocol for systematic review and meta-analysis

IntroductionIdentifying the optimal treatment for anal fistula has been challenging. Since first reported in 2007, the ligation of the intersphincteric fistula tract (LIFT) procedure has reported healing rates between 40%...

Efficacy of Ligation of Inter-sphincteric Fistula Tract technique for fistula-in-ano: A prospective observational study

Background: Fistula-in-ano is one of the commonest diseases presented to the surgical outpatient department that affects the patient physically and psychologically. As the disease is known for recurrence, the ideal technique for fistula repair is still undetermined. Materials and Methods:We hereby report 85 patients diagnosed clinically and radiologically having fistula-inano who underwent the Ligation of Inter-sphincteric Fistula Tract (LIFT) procedure at a tertiary care center. Results: The median time for the LIFT procedure was 32.5 minutes (range 25-40 minutes), and the median time taken for healing of the wound was around eight weeks. The majority of patients (95.4%) had no recurrence, and only 4 (4.6%) had a recurrence on follow-up within one year. None of the patients presented with stool or flatus incontinence. Conclusion: The LIFT technique can be the preferred treatment option for fistula-in-ano that are having simple straight tract, single opening lying posteriorly, and having either trans-sphincteric or inter-sphincteric variety with lower complication rates and preserving continent anal sphincter allowing patients to return early to their routine activities normal daily activities

The efficacy of Ksharsutra, Fistulectomy and Ligation of Intersphincteric Fistula Tract (LIFT) procedure in management of Fistula in ano a prospective observational study

BackgroundFistula in ano is always a troublesome condition for the clinician and the patients owing to its complexity, recurrences, and high morbidity since ancient times. There is no gold standard treatment modality to date documented in the literature for complex fistula in ano.Material and methodsWe enrolled 60 consecutive adult patients attending the surgical outpatient department of a tertiary care centre in India, diagnosed with complex fistula in ano. Among them, 20 each in the Ligation of intersphincteric fistula tract (LIFT), Fistulectomy andKsharsutra(Special medicated seton) group were respectively recruited randomly. A prospective observational study was conducted. The primary outcomes were postoperative recurrence and morbidity. Post-operative morbidity is measured in terms of postoperative pain, postoperative bleeding, pus discharge and post-operative incontinence. The result of the study were analysed after 6 months of follow-up by clinical examination at outpatient department and at 18 months follow up done telephonically.ResultsAt 6 months of follow-up, 2 patients (10%) had a recurrence in the Ligation of intersphincteric fistula tract procedure group, 3 patients (15%) in the fistulectomy group and 6 patients (30%) in Ksharsutra group, however 3(15%), 4(20%) and 9(45%) patients developed recurrence in Ligation of Intersphincteric fistula tract, Fistulectomy and Ksharsutra group respectively at 18 month of follow-up. The differences in the recurrence were not statistically significant.The mean Visual analogue score for postoperative pain after 24 h as well as after 48 h were statistically significant in Ligation of intersphincteric fistula tract versus Ksharsutra group (p < 0.05). The Visual analogue score for post–operative pain was also significant in the Ligation of the intersphincteric fistula tract versus the Fistulectomy group (p < 0.05). The patients treated via Fistulectomy and Ksharsutra had a higher proportion of bleeding (15%) as compared to the Ligation of intersphincteric fistula tract procedure. Postoperative morbidity was statistically significant between the Ligation of intersphincteric fistula tract versus the Ksharsutra and the Ligation of intersphincteric fistula tract versus Fistulectomy.ConclusionLigation of intersphincteric fistula tract had less postoperative morbidity compared to Fistulectomy and Ksharsutra procedure; although recurrence was less compared to other methods it was statistically not significant.

Thirteen-year audit of the management of anorectal fistulae in a tertiary colorectal unit

Persistent anorectal fistulae are referred for assessment in the Durban Metropolitan area to the colorectal unit at the tertiary hospital. This audit aimed to report the assessment and management of these fistulae to benchmark the outcomes from these approaches at a South African tertiary colorectal unit. Retrospective analysis of prospectively collected data of patients with anorectal fistulae over a 13-year period at a tertiary referral centre. Data analysed included demographics, clinical presentation, comorbidity, management and outcome. Study outcomes measures were healing time and secondary outcome measures were complications of surgery. One hundred and thirty-three patients (median age 44 and M:F ratio 2.8:1) with 206 fistulae were accrued. The initial assessment and diagnostic procedures included insertion of seton (126), fistulectomy (14), and fistulotomy (65). Definitive procedures included two-stage seton fistulotomy (43), ligation of the inter-sphincteric fistula tract (LIFT) procedure (39), modified Hanley procedure (17), and mucosal advancement flap (5). One patient had no surgery and nine did not undergo a definitive procedure. Additional procedures included anal sphincter reconstruction (2) and repair of rectovaginal fistula (2). Residual anal incontinence occurred in 13.5%. The failure rate was 6% and healing occurred in 94%. The median healing time was 8 months after the initial surgery and 4 months following the definitive procedure. The fistula healing rate overall was 94% and was associated with an incontinence rate of 13.5%.

A Comparison of Different Surgical Treatments for Complex Anal Fistula: A Systematic Review.

Fistula-in-ano is a common proctological condition that primarily affects younger people and leads to chronic morbidity. An anal fistula is divided into simple and complex fistulas. A complex fistula is a challenging problem due to higher recurrence rates and incontinence associated with surgery. Many new methods have been developed for the closure of complex fistula-in-ano, but there is no single best method. The aim of this study is to identify a superior surgical technique for treating complex/high cryptoglandular perianal fistulas (HCPFs). A literature search was done using PubMed and Google Scholar for the period of 2012-2021. Articles that contain surgical treatment for complex anal fistula in the English language published in the last 10 years were included. The types of studies included were randomized controlled trials (RCTs), meta-analyses, systematic reviews, cohort studies, and traditional reviews. Articles excluded were those done more than 10 years ago, in other languages, and containing simple fistula management only. Nine studies were included in the review; a systematic review and meta-analysis concluded that no single method is effective. The ligation of the intersphincteric fistula tract (LIFT) procedure seems to be a promising and effective technique as it has a low rate of fecal incontinence as compared to other methods. Biological techniques give variable success rates so does fistula plug (FP). Mucosal advancement flap (MAF) and rerouting seton give good results according to one study. Fistula plug gives variable results and is not a preferred method.Ligation of the intersphincteric fistula tract (LIFT) seems to be a promising new technique for complex anal fistulas, but the data available is not enough to determine the best method. More randomized trials are required to compare traditional techniques and emerging new biological methods to see the best technique available.

'Bumps down under:' hemorrhoids, skin tags and all things perianal.

There continues to be a concentrated effort to improve treatment options readily available for some of the most common perianal diseases: hemorrhoids, anal fissure and anal fistula. The emphasis remains on therapies that definitively address the underlying pathology yet minimize pain and risk of incontinence, have a short recovery period, and are cost-effective. In this analysis, recent developments in the literature are reviewed. Treatment of early stage hemorrhoidal disease remains the same. For grades II-IV disease, hemorrhoidal vessel ligation/obliteration with laser or bipolar energy are reported. For more advanced diseases, modifying the technique for hemorrhoidectomy to improve postoperative complications and pain is described. For anal fissure, a stepwise method continues to be the mainstay of treatment (initiating with vasodilators, followed by botox, and ultimately sphincterotomy), which decreases the risk of incontinence with proper patient selection and technique. Management of anal fistula continues to be challenging, balancing cure vs. risk of harm. Recent developments include modifications to ligation of intersphincteric fistula tract procedure and use of laser to obliterate the tract. Advancements in managing benign anorectal disease are ongoing. Several reports are novel, whereas others involve enhancing well-established treatment options by either operative technique or patient selection.

The Use of Seton as a Bridge to Definitive Ligation of the Intersphincteric Fistula Tract Procedure for Fistula-in-ano: A Systematic Review and Meta-analysis

Abstract Background There is still controversy over the usefulness of seton placement prior to the ligation of the intersphincteric fistula tract (LIFT) surgery in the management of anal fistula. Objective To evaluate the impact of preoperative seton placement on the outcomes of LIFT surgery for the management of fistula-in-ano. Design systematic review and meta-analysis. Data Sources A search was performed on the MEDLINE (PubMed), EMBASE, Scopus, Web of Science, Cochrane Library and Google Scholar databases. Study Selection Original studies without language restriction reporting the primary healing rates with and without seton placement as a bridge to definitive LIFT surgery were included. Intervention The intervention assessed was the LIFT with and without prior seton placement. Main Outcome Measures The main outcome was defined as the primary healing rate with and without the use of seton as a bridge to definitive LIFT surgery. Results Ten studies met the criteria for systematic review, all retrospective, with a pooled study population of 772 patients. There were no significant differences in the percentages of recurrence between patients with and without seton placement (odds ratio [OR] 1.02; 95% confidence interval [CI] 0.73–1.43: p = 0.35). The I2 value was 9%, which shows the homogeneity of the results among the analyzed studies. The 10 included studies demonstrated a weighted average overall recurrence of 38% (interquartile range [IQR] 27–42.7%), recurrence with the use of seton was 40% (IQR 26.6–51.2%), and without its use, the recurrence rate was 51.3% (IQR 31.3–51.3%) Limitations The levels of evidence found in the available literature were relatively fair, as indicated after qualitative evaluation using the Newcastle-Ottawa scale and the Attitude Heading Reference System (AHRS) evidence levels. Conclusions Our meta-analysis suggests that the placement of seton as a bridge treatment prior to LIFT surgery does not significantly improve long-term anal fistula healing outcomes. Ligation of the intersphincteric fistula tract surgery can be performed safely and effectively with no previous seton placement.International prospective register of systematic reviews—PROSPERO registration number: CDR42020149173.

Transanal Opening of Intersphincteric Space for Fistula-in-Ano.

The role of the intersphincteric space in the pathogenesis of fistula-in-ano is being increasingly recognized. Submucosal and intersphincteric rectal abscesses have been surgically managed by laying open and draining the intersphincteric space as well as by the modified ligation of intersphincteric fistula tract (LIFT) procedure. In 2017, the transanal opening of intersphincteric space (TROPIS) technique was reported for the treatment of high, complex anal fistulae. We aim to investigate the advantages of performing the TROPIS procedure in patients with fistula-in-ano. This was a prospective cohort study investigating the outcomes in patients who had undergone a procedure using the TROPIS technique for the treatment of fistula-in-ano. Preoperative magnetic resonance imaging scans and electronic colonoscopies were performed on all patients. A clinical database evaluating the following variables was constructed: age, gender, body mass index (BMI), previous fistula surgery, type of fistula, postoperative complications, duration of follow-up, success rate, and incontinence scores pre- and postoperatively. The TROPIS procedure was performed on 41 patients with fistula-in-ano with a follow-up time of 6-23months. The characteristics of the patients were as follows: 36 males, 6 females, mean age 38.6±13.2years, and mean BMI 23.5±3.9kg·m-2. All patients (41) had transsphincteric fistulae, and 90.2% (37) had high fistula. Of the 41 patients, 22% (9) had recurrent fistulae, 29.27% (12) had horseshoe fistulae, 7.3% (3) had supralevator fistulae, and 14.6% (6) had an associated abscess. The fistula healed completely in 85.3% (35) of patients and failed to heal in 14.7% (6) of patients, and the healing of high fistula was 86.5% (32). Of those patients who had not healed completely, 2 were found to have contracted iatrogenic infections due to foreign residues and underwent surgery with the passing of a loose seton. The additional 4 patients who had not healed underwent a fistulotomy and healed completely thereafter. There were no significant changes in incontinence scores. The incontinence scores were .15 ± .36 preoperatively and .22 ± .47 3months postoperatively (t = -1.438, P = .16). The TROPIS technique is a novel sphincter-preserving procedure, which can be effectively used in treating fistula-in-ano.

A comparative study of ligation of intersphincteric fistula tract (LIFT) and conventional fistulotomy in treatment of fistula-in-ano

Background: A hospital randomized control study was conducted at a tertiary care Hospital, to compare outcomes between the Ligation of Intersphincteric Fistula Tract (LIFT) technique and conventional fistulotomy for the treatment of low trans-sphincteric fistula in ano, including 50 patients of low trans-sphincteric fistula in ano randomly divided into two groups. LIFT technique was used in first group while Conventional Fistulotomy was performed in another. Mean duration of operation was significantly less and mean hospital stay, post-operative pain and analgesics need was significantly less in cases operated with LIFT. Mean time for complete healing was significantly less in cases operated with LIFT technique and the difference in complication rate was statistically nonsignificant. Recurrence was reported in 3 (12%) and 1 (4%) cases operated by LIFT and fistulotomy respectively. Ligation of Intersphincteric Fistula Tract (LIFT) procedure is effective and preferred sphincter saving technique for fistula-in-ano. Despite slightly more recurrence, LIFT procedure has certain advantages over standard fistulotomy like shorter operative time, less postoperative pain, shorter hospital stay and faster wound healing and early resumption of normal duties.

Comparative study between intersphinecteric ligation of perianal fistula versus conventional fistulotomy with or without seton in the treatment of perianal fistula: A prospective randomized controlled trial

BackgroundFistula-in-ano is one of the most common benign anal conditions in daily surgical practice.The goals in the treatment of an anal fistula are to eradicate sepsis and to eliminate the primary fistula opening, any associated tracts, and any secondary openings without a change in continence. Conventional fistulotomy (lay open of the fistula tract) is a commonly used procedure and is still relied on by the majority of surgeons as the gold standard for the treatment of perianal fistula. Ligation of the Intersphincteric Fistula Tract (LIFT) is a new sphincter-preserving technique for the treatment of anal fistula. ObjectiveTo compare the efficacy of open fistulotomy and ligation of intersphincteric fistula tract (LIFT) procedure based on its post-operative outcomes. Patients and methodsThe Present study is A prospective randomized controlled trial which included 30 patients presented with low transsphincteric perianal fistula 27 (90%) males and 3 (10%) females divided into two groups each group consisted of 15 patients. Group, I subjected to inter sphincteric ligation of perianal fistula (LIFT) procedure. Group II patients subjected to conventional fistulotomy. The study lasts 2 years from May 2017 to May 2019 with Follow up for 6 months duration. Operative time in our study was significantly higher in group (I) Managed by LIFT with a mean of 32.53 min than group (II) managed by fistulotomy with a mean of 20.87mins. Wound healing was faster in a group (I) managed by LIFT than group (II) managed by fistulotomy, as the mean time for complete wound healing was (4.53) weeks after LIFT and (5.67) weeks after fistulotomy. ResultsThere was no case of incontinence after performing the LIFT technique in all our patients in group I. there were 2 cases of incontinence to gases only after fistulotomy in group II. The healing rate after LIFT was 80% (12/15 patients). The healing rate after fistulotomy was 93.3% (14/15 patients). ConclusionLIFT procedure is an effective and preferred sphincter-saving technique for fistula-in-ano with shorter healing time and lower incidence of postoperative anal incontinence, as compared to open fistulotomy.

Comparative Study between Open Fistulectomy and Ligation of Intersphincteric Fistulas Tract (LIFT) Procedure for Uncomplicated Perianal Fistula

A new sphincter-saving procedure involving the ligation of the intersphincteric fistula tract (LIFT) procedure was recently described by Rojanasakul et al from Thailand. The main concept in the LIFT is to identify the fistula tract in the intersphincteric space and the subsequent ligation and division of the tract. Some studies abroad have shown a considerably high success rate in terms of wound healing and absence of incontinence in treating fistula-in-ano by this procedure. This study aimed to compare between the earlier fistulectomy and this new innovative LIFT technique. The study was designed as a comparative type of observational study conducted at Dhaka Medical College Hospital, Dhaka and Popular Medical College Hospital from January 2014 to December 2014. Study was carried out on 40 hospital admitted patients with uncomplicated Fistula-in-ano, irrespective of age and sex. LIFT and fistulectomy was the procedure as operative treatment for their disease. Outpatient follow-up was undertaken. In our study, 30 (75%) male and 10 (25%) female patients were operated with a male to female ratio 3: 1. Mean age was 37.3 years. Vast majority of the cases i.e 23 fistula (68%) was inter-sphincteric type and the rest 17 (32%) were trans-sphincteric type. Fistulectomy took less time than LIFT. Spinal Headache was the most common complication 7.5% (3 cases). No difference was found in comparison to wound healing. (p =00.18). LIFT was found better than fistulectomy regarding post-operative incontinence (p =0.008). LIFT was found better in term of recurrence (p = 0.04) than fistulectomy but in long term there is no difference (p=0.3). In treatment of uncomplicated perianal fistula LIFT has no benefit over fistulectomy

P443 Magnetic resonance imaging after ligation of the intersphincteric fistula tract for high perianal fistulas in Crohn’s disease: a retrospective cohort study

Abstract Background Surgical closure of high perianal fistulas using the ligation of the intersphincteric fistula tract (LIFT) procedure is increasingly used in Crohn’s disease. Currently, data on MRI findings after the procedure is lacking, while this is the most important modality to assess deep fistula healing. Therefore, we aimed to evaluate pre- and postoperative fistula characteristics on MRI and the relation with clinical outcomes after LIFT procedure. Methods Consecutive Crohn’s patients treated with LIFT between 2007 and 2018 for high perianal fistulas who underwent a baseline and follow-up (FU) MRI were included in this retrospective study. MRI’s were scored by two radiologists according to a composed score based on the original and modified Van Assche scores with the addition of several items (Table 1). Findings at MRI and the relation to clinical healing were described. Results A total of 12 patients were included (4 male, median age 34 years (IQR 28–39)). The FU MRI was performed a median 5.5 months (IQR 2.5–6.0) after the LIFT procedure. At this time eight patients (67%) reached clinical healing, which increased to ten patients (83%) during follow-up. None had a recurrence. Three patients (25%) needed a re-intervention after the FU MRI due to inflammatory masses and/or persisting fistula tracts. At baseline, all patients showed a tract predominantly filled with granulation tissue, which changed to predominantly fibrotic in seven patients (58%) (Figure 1). All clinically responding patients showed a decrease in tract volume and/or hyperintensity (i.e. activity) with an absence of hyperintensity on T1 and T2 in four (33%) patients. Conclusion Clearly decreased fistula activity can be observed on MRI after LIFT surgery in Crohn’s patients. A large proportion of patients develops a fibrotic tract relatively soon after the procedure and shows no clinical recurrences, suggesting a highly effective therapy and prognostic value of MRI.

Complex Anal Fistula: Long-Term Results of Modified Ligation of Intersphincteric Fistula Tract=LIFT.

Objectives:The anal fistula is a permanent infectious tunnel formed between the anal canal and skin in the perianal region. Fistulas are treated by surgery at any stage. Many surgical methods have been reported to treat anal fistula. One of the promising surgical methods with a high success rate is ligation of the intersphincteric fistula tract, which is performed in anatomical spaces without damage to the internal and external sphincters. We evaluated the success rate of a modified ligation of the intersphincteric fistula tract procedure for complex anal fistulas in which the technical differences were minimized by the surgery being performed by the same surgical team.Methods:In this study, Data of the 56 patients were retrospectively collected. Data regarding patient history, visual and digital anal examination, Cleveland Clinic Florida Fecal Incontinence (CCF-FI) score, anal-phase pelvic magnetic resonance imaging (MRI), rectosigmoidoscopy or colonoscopy and anal manometry were recorded. The changes in data recorded during the preoperative and postoperative periods were compared in each other.Results:The mean age of the patients was 41±15.5 years. The number of patients for each fistula type compromised in this study was as follows in accordance with frequency: high transsphincteric fistula, high intersphincteric fistula, and horseshoe abscess. The fistula recurred in seven patients during postoperative follow-up and the success rate of modified LIFT was calculated as 87.5%. The change in the mean±SD preoperative and postoperative CCF-FI scores and anal pressure was not statistically significant.Conclusion:One promising advantage of the ligation of the intersphincteric fistula tract procedure is that it turns a complex fistula into a simple fistula that can be treated with minimal risk of sphincter damage.

Ligation of intersphincteric fistula tract (LIFT) in treatment of anal fistula: An updated systematic review, meta-analysis, and meta-regression of the predictors of failure

BackgroundLigation of intersphincteric fistula tract has gained increasing popularity as a sphincter-sparing technique for complex anal fistula. The present review aimed to investigate the pooled success and complication rates of ligation of intersphincteric fistula tract in the published literature and to explore the risk factors for failure after ligation of intersphincteric fistula tract. MethodsA Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant literature search was conducted. Electronic databases were searched in the period of January 2007 through April 2019 for studies that assessed the outcome of the ligation of intersphincteric fistula tract procedure. The main outcomes of the review were the pooled success and complication rates of ligation of intersphincteric fistula tract, predictors of failure after ligation of intersphincteric fistula tract, operation time, hospital stay, and how failures were managed. ResultsTwenty-six studies comprising 1,378 patients (996 male) were included in this review. The mean age of patients was 42.3 ± 4.2 years. The weighted mean rate of success was 76.5%. The median follow-up duration was 16.5 months. The weighted mean complication rate was 13.9%. The most common complication was wound dehiscence. Fecal incontinence was recorded in 1.4% of patients. Factors that were statistically significantly associated with failure after the ligation of intersphincteric fistula tract procedure were horseshoe fistulas, fistulas associated with Crohn’s disease, and those with a history of previous fistula surgery. ConclusionThe pooled success and complication rates of the ligation of intersphincteric fistula tract procedure were about 76% and 14%, respectively. Horseshoe fistulas, Crohn’s disease, and previous fistula surgery were identified as predictors for failure after ligation of intersphincteric fistula tract procedure.

Ligation of intersphincteric fistula tract technique in the management of anorectal fistula

Background and aims Anorectal fistula is one of the most common problematic anal conditions in daily surgical practice. Many treatment modalities are used. This study evaluates the ligation of intersphincteric fistula tract procedure on the basis of its postoperative outcomes. Patients and methods This study was carried out on 25 patients. Participants of either sex diagnosed with anal fistula (transsphincteric fistula, either high or low) were included in the study between April 2016 and May 2018. Patients with recurrent fistulas, Crohn’s disease, and anal or distal rectal cancers were excluded from the study. Results The mean age group of the study participants was 36.6±8.34. The sex distribution showed a higher number of men (n=17) compared with women (n=8). The mean operative time was 35.46±3.6 min and the mean healing time was 6 weeks. Anal incontinence was not observed (0%). A total of two (8%) participants developed recurrence. Conclusion The Ligation of intersphincteric fistula tract procedure is an effective and sphincter-preserving technique for fistula-in-ano with a shorter healing time and a lower incidence of recurrence.

The science, techniques, and art of anal fistula treatment

Anal fistula is a diverse disease. There is no single treatment which is effective for all types of anal fistulas. The management of simple anal fistula is straightforward, and a fistulotomy is recommended. However, in complex anal fistula if fistulotomy or fistulectomy is performed, it is combined with primary sphincter repair. Alternatively, a sphincter sparing procedure may be performed for complex anal fistula. The basic principle of sphincter preserving surgery for anal fistula involves three basic steps: disconnection of the tract from the anal canal, deepithelialization of the tract, and drainage from the external opening. The disconnection of the fistula tract from the anal canal can be achieved by direct closure of the internal opening, with endoanal advancement flap or with ligation of intersphincteric fistula tract procedure. After disconnecting the fistula from the anal canal, the remaining tract, which is now converted into a sinus is cleaned and deepithelialized. The tract is deepithelialized either mechanically by curetting or by using an energy source-like LASER or endocautery. The external opening of the tract is widened so that it does not close and continues to drain until the fistula is completely healed. The art of anal fistula treatment involves the assessment of the extent of the disease and selecting appropriate treatment strategy for a particular patient. None of the procedures are technically very demanding; however, selecting the right procedure for a particular patient is important.

Reprint of: The LIFT procedure

The Ligation of Intersphincteric Fistula Tract (LIFT) procedure is a recent sphincter-preserving procedure added to the surgical armamentarium of managing anal fistulas. It has gained popularity for its simple, easy-to-learn technique and success rate reliably exceeding 70%. Studies using validated continence scores have verified its advantage in preserving continence. The procedure is aimed at the cryptoglandular source of infection within the intersphincteric space. This is achieved through a small incision parallel to the intersphincteric groove and corresponding to the internal opening. After excision of the intersphincteric portion of the fistula tract, the openings on the internal and external sphincter are suture-ligated. Wound care is simple with minimal post-operative pain. Pre-operative imaging with endoanal ultrasonography helps to position the incision. Most failures or recurrences occur in the intersphincteric wound. This can be treated successfully with simple fistulotomy. The use of a seton before a LIFT procedure has not been proven beneficial. This technique has also been applied to Crohn׳s disease-related fistulas with similar success. Modifications to the technique using bioprosthetic inserts have also been reported to confer better results albeit at a greater cost.

Long-term outcomes of (Gore) fistula plug versus ligation of intersphincteric fistula tract for anal fistula

BackgroundThe surgical treatment of anal fistula is complex due to the possibility of fecal incontinence. Fistulotomy and cutting Setons have the same incidence of fecal incontinence depending on the complexity of the fistula. Sphincter-preserving procedures such as anal fistula plug and ligation of intersphincteric fistula tract procedure may result in more recurrence requiring repeated operations. The aim of this study was to evaluate and compare the outcomes of treating fistula in Ano utilizing two methods: Fistula plug (Gore Bio-A) and ligation of intersphincteric tract (LIFT). MethodsFifty four patients (33 males; 21 female, median ages 42 [range 32–47] years) with high anal inter-transphenteric fistula were treated with LIFT and fistula plug procedures from September 2011 until August 2016 by a single surgeon and were retrospectively evaluated. All were followed for a median of 23.9 (range 4–54) months with clinical examination. Twenty one patients underwent fistula plug and 33 patients underwent LIFT procedure (4 patients of the LIFT group underwent LIFT and rectal mucosa advancement flap). The healing rate and complications were evaluated clinically and through telephone calls. ResultsThe mean operative time for the Plug was 25 ± 17 min and for the LIFT was 40 ± 20 min (p = 0.017) and the mean hospital stay was 2.4 ± 1.1 and 1.9 ± 0.3 (p = 0.01) respectively. The early complications of the plug and LIFT procedures included; anal pain (33.3%, 66.6%, p = 0.13), perianal discharge (77.8%, 91%, p = 0.62), anal pruritus (38.9%, 50.0%, p = 0.71) and bleeding per rectum (16.7%, 33.3%, p = 0.39) respectively. The overall mean follow-up was 20.9 ± 16.8 months, p = 0.68. There was no statistically significant difference between the two groups (21.9 ± 7.5 months, 19.9 ± 16.1 months, p = 0.682). The healing rate was 76.2% (16/21 patients) in the fistula plug group and 81.1% (27/33 patients) in the LIFT group (p = 0.73). Patients who had LIFT procedure and a mucosal advancement flap had 100% healing rate (4 out of 4 patients). No incontinence of stool or feces and no fistula plug expulsion were seen in our patients. The healing time ranged from 1 to 6 months after surgery. There was no post-operative perianal abscess, cellulitis or pain. ConclusionsLIFT and anal plug are safe procedures for patients with primary and recurrent anal fistula. Both techniques showed excellent results in terms of healing and complication rate. None of our patients had incontinence after 5 years follow-up. The best success rate in our patients was seen after LIFT procedure with mucosal advancement flap. Larger and controlled randomized trials are needed for better assessment of treatment options.

Ligation of Intersphincteric Fistula Tract for Fistula in Ano: Lessons Learned From a Decade of Experience.

Ligation of intersphincteric fistula tract is a well-described sphincter-preserving technique for the management of fistula in ano. In 2007, we reported our early experience demonstrating a primary success rate of 94.4%. These findings have since been supported by several short-term studies, but long-term results and secondary cure rates after ligation of intersphincteric fistula tract failure remain unknown. This study aims to report a 10-year experience of ligation of intersphincteric fistula tract with extended long-term follow-up. Retrospective analysis of single-center data from May 2006 to October 2010 was performed. This study was conducted at a large tertiary hospital in Bangkok, Thailand. All patients with primary or recurrent fistula in ano who underwent a ligation of intersphincteric fistula tract procedure were included. Patients with malignancy, incontinent patients, and patients with rectovaginal fistula were excluded. Healing as defined by the absence of symptoms with no visible external opening on clinical examination. Follow-up was continued until May 2016. In total, 251 patients were identified, with a primary healing rate of 87.65% at a median follow-up of 71 months. The healing rates for low transsphincteric, intersphincteric, high transsphincteric, semihorseshoe, and horseshoe fistulas were 92.1%, 85.2%, 60.0%, 89.0%, and 40.0%. Of the 42 patients who had an unhealed fistula after previous non-ligation of intersphincteric fistula tract surgery, 38 (90.48%) healed after the first attempt at ligation of intersphincteric fistula tract. There were 31 patients with unhealed fistulas after the first ligation of intersphincteric fistula tract. Of these, 3 healed spontaneously, and the rest underwent either repeat ligation of intersphincteric fistula tract, fistulotomy (if the recurrence was intersphincteric), or simple curettage (if no internal opening was found). Ultimately, only 2 of the original 251 patients remained unhealed, and there was no change in subjective continence status after surgery. This study was limited by its retrospective design. Ligation of intersphincteric fistula tract is an effective technique for the treatment of fistula in ano, including recurrent or unhealed fistula after other procedures. See Video Abstract at http://links.lww.com/DCR/A387.