High ligation of the anal fistula tract by lateral approach: A prospective cohort study on a modification of the ligation of the intersphincteric fistula tract (LIFT) technique

A comparative study between high ligation of the inter-sphincteric fistula tract via lateral Approach Versus Fistulotomy and primary sphincteroplasty in High Trans-Sphincteric Fistula-in-Ano: a randomized clinical trial

BACKGROUND

Trans-sphincteric fistula management is very challenging and everyday new techniques are introduced to reach the safest and the most effective technique. In this study two of the most effective techniques are compared based on their post-operative outcomes.

OBJECTIVE

To compare the efficacy of high ligation of the inter-sphincteric fistula tract by lateral approach (modified LIFT) and Fistulotomy and primary sphincteroplasty (FIPS) in the management of high trans-sphincteric fistula regarding their post-operative outcomes in the form of post-operative pain, time of wound healing in weeks, wound infection, incontinence and recurrence within one year.

PATIENTS AND METHODS

The current study is single-blind, prospective, randomized, controlled, single-center trial conducted from June 2020 to June 2022 in the colorectal surgical unit of Ain Shams University Hospitals, which included 80 patients presented with high trans-sphincteric perianal fistula 55 (68.75%) males and 25 (31.25%) including a one-year follow-up postoperative.

RESULTS

There were 80 patients in our study 40 patients in each group. The mean age of group (I) is 46.65 with standard deviation 6.6. while, in group (II) the mean age is 45.85 with standard deviation 6.07 (p = 0.576). From the included 80 patients 55(68.7%) were males and 25 (31.25%) were females (p = 0.469). Regarding, postoperative wound infection occurred in 2(5%) Patients in group (I) and 7(17.5%) patients in group (II) (p = 0.154). There were no cases of incontinence in group I. However, there were 6(15%) cases of incontinence to gases only scored by Wexner score 3/20 in group II (p = 0.026) and its significant difference between the two techniques. Postoperative pain was assessed for one week duration by the visual analogue score (VAS) from 0 to 10 in which, zero is the least and 10 is the maximum. In group (I) 18(45%) patients scored their pain mild from 1 to 3, 20(50%) patients scored their pain moderate from 4 to 6 and 2(5%) patients scored severe pain from 7 to 9. While, in group (II) 14(35%) patients scored their pain mild from 1 to 3, 22(55%) patients their pain moderate from 4 to 6 and 4(10%) patients scored their pain severe from 7 to 9 (p = 0.275). Recurrence in one-year follow-up occurred in 13(32.5%) patients in group (I) about 7 patients had recurrence in the form of inter-sphincteric fistula and 6 patients in the form of trans-sphincteric fistula. While, in group II recurrence occurred in 1 (2.5%) patient in the form of subcutaneous fistula at the healing site (p = 0.001).

CONCLUSION

Fistulotomy and primary sphincteroplasty is an effective and preferred technique for the trans-sphincteric fistula repair with high statistically significant lower incidence of recurrence in one-year follow-up as compared to modified LIFT technique. Although, there is higher incidence regarding incontinence to gases only post-operative. This work recommends fistulotomy and primary sphincter reconstruction procedure in high trans-sphincteric perianal fistulas to be more popular, to be implemented as a corner stone procedure along various and classic operations for such cases as it's easy, feasible.

Surgical laser therapy for cryptoglandular anal fistula: Protocol of a systematic review and meta-analysis

INTRODUCTION

Anal fistula is the natural evolution of perianal abscess and one of the most common perianal diseases for adults. For complex fistula, it is still very challenging for anorectal surgeons to manage. With the introduction of laser technique in surgery, it is becoming more and more widely used for the treatment of cryptoglandular anal fistula. During the past decade, numerous studies have reported the clinical effectiveness and postoperative outcomes of different forms of laser treatment for anal fistula. However, as these studies were varied in terms of baseline characteristics, the evidence for the true clinical effectiveness of laser treatment for anal fistula need further critical appraisal. Therefore, the purpose of this study is to evaluate the outcomes of surgical laser therapy for cryptoglandular anal fistula stratified by laser type and Parks' classification through a synthesis of quantitative and qualitative evidence.

METHODS AND ANALYSIS

This study will be carried out with adherence to the Cochrane Handbook. We will search PubMed, Cochrane Library, and Embase until June, 2022 to identify all relevant interventional and observational studies examining the effects of laser therapy on the clinical outcomes for cryptoglandular anal fistula. Data extraction from eligible studies will be performed independently by two unblinded authors using standardized extraction forms. Risk of bias assessment for each study will be conducted using Cochrane tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa scale (NOS) tool for observational studies. The DerSimonian-Laird random-effects model will be used to calculate the pooled estimates. Heterogeneity will be examined by subgroup analysis stratified by laser type and Parks' classification and other study characteristics. Potential publication bias will be assessed by funnel plot symmetrical and Egger's regression tests.

CONCLUSIONS

The synthesis of quantitative and qualitative evidence of this systemic review will yield updated and comprehensive evidence of laser treatment on specific outcomes, which can provide anorectal surgeons with high level evidence-based recommendations to improve patient care and clinical outcomes. OSF registration number: DOI 10.17605/OSF.IO/36ADW.

Comprehensive literature review of the applications of surgical laser in benign anal conditions

Surgery for benign anal conditions is a common practice and is usually followed by a good outcome. The present review aimed to summarize the emergence and evolution of different laser techniques used for the treatment of benign anal conditions and report their current outcome. PubMed and Scopus were searched for studies that assessed the use of laser in benign anal conditions. Anal conditions reviewed were hemorrhoids, anal fistula, anal warts, anal stenosis, and anal fissure. The full text of the studies retrieved was summarized in a narrative and tabular form. Laser techniques used for the treatment of hemorrhoidal disease were laser open hemorrhoidectomy, laser hemorrhoidoplasty, and Doppler-guided hemorrhoidal laser dearterialization. Resolution of hemorrhoidal symptoms was reported in 72-100% of patients after laser treatment. YAG laser, fistula laser closure, and photodynamic therapy have been used for the treatment of anal fistula with success rates ranging from 20 to 92.6%. Anal warts can be treated with photodynamic therapy with or without YAG or CO² laser with a success rate up to 88%. A few studies reported the use of laser in the treatment of chronic anal fissure and anal stenosis. The use of laser in the treatment of benign anal conditions is associated with promising outcomes. Laser was most assessed in hemorrhoidal disease and anal fistula and showed more consistent success rates with hemorrhoidal disease than with anal fistula. Preliminary reports assessed the outcome of laser treatment in other conditions as anal fissure and warts with acceptable outcomes.

LIFT: a feasible option for primary and recurrent fistulas

BACKGROUND

The development of a surgical solution for anal fistulas with minimal recurrence and morbidity remains a challenge. Ligation of the intersphincteric fistula tract (LIFT), however, is a sphincter sparing technique that provides complete resolution of the transsphincteric fistula as well as minimizing recurrence and fecal incontinence. Our goal is to evaluate the efficacy of fistula tract ligation for primary and recurrent fistulas.

METHODS

A retrospective single-center case study was conducted from data between 2015 and 2019 in a large district hospital in Antwerp, Belgium. Patients who underwent LIFT were included. Demographic patient data as well as primary outcome during the follow-up period were collected. A systematic literature review and analysis was conducted with terms [ANAL FISTULA] [TREATMENT] [LIFT] [LIGATION OF INTERSPHINCTERIC FISTULA]. Primary healing and recurrence associated with surgical modifications were investigated.

RESULTS

4 out of 25 patients presented with early failure (84% primary success rate) after a median follow-up period of 7 months. The median time until recurrence was 105 days. The success rate after a redo ligation was 100%. Twenty-eight studies were included for review and divided into three groups depending on the technical variation of the used technique. The success rate was 74.2% for the LIFT group, 72.9% in the LIFT + group, and 77.5% in the mLIFT group p = .92.

CONCLUSION

LIFT is a feasible treatment option for primary and recurrent fistulas, with excellent success rates where fistula characteristics rather than chosen technique dictate the surgical outcome.

External sphincter-sparing anal fistulotomy (ESSAF): a simplified technique for the treatment of fistula-in-ano

BACKGROUND

Fistula-in-ano due to cryptoglandular disease is a common condition. While a simple anal fistula can be treated successfully by a fistulotomy, the risk of potential damage to the anal sphincters and subsequent poor functional outcomes persist in a large portion of patients with complex fistulae. Several sphincter-preserving treatment procedures have been described for complex fistulae over the past 3 decades, with variable results and complication rates, and no procedure is proven to be superior to the others. We developed external sphincter-sparing anal fistulotomy (ESSAF), a reproducible simple modification of the ligation of intersphincteric fistula tract (LIFT) technique for the treatment of complex fistula-in-ano.. The aim of the present study was to describe the technique and our outcomes.

METHODS

This was a retrospective review of all patients who underwent ESSAF for a complex anal fistula at our institution from January 2014 to December 2019. The primary outcome measure of this study was the primary fistula healing rate. Secondary outcome measures included fecal and/or gas incontinence and postoperative complications. During the ESSAF procedure, the mucosa and skin overlying the fistula tract are incised to allow complete exposure of the sphincter complex. Then the internal sphincter muscle fibers overlying the tract are divided and the tract is meticulously curetted and debrided. Next, the internal opening of the tract traversing the external sphincter muscle is suture-ligated with absorbable sutures. Then, a minimal amount of mucosa is advanced and the incision is partially closed with absorbable sutures, while its external portion is left open for drainage.

RESULTS

Fifty-nine patients [43 males, median age was 50 years (range 36-63 years)] underwent ESSAF for complex anal fistula during the study period. Mean follow-up was 12 ± 14.7 months. Of the 59 patients, 42 (71.2%) experienced fistula closure, with a median healing time of 8 weeks (IQR 4-16 weeks). None of the patients developed significant anal incontinence following the procedure. One patient (1.7%) suffered from soiling and another patient (1.7%) developed postoperative bleeding. There were no infectious complications. Of the 17 patients (28.8%) who failed to heal successfully, 9 (15.2%) did not heal primarily and 8 (16%) experienced recurrence after complete healing. Thirteen (76%) of these patients underwent reoperation with complete recovery after ESSAF (n = 4), fistulotomy (n = 8) or endorectal advancement flap (ERAF) (n = 1). Overall ESSAF initiated recovery in 93.2% of the patients.

CONCLUSIONS

ESSAF is a feasible, safe, reproducible and effective sphincter-sparing procedure for the treatment of complex anal fistulae.

Advances in the Treatment of Anal Fistula: A Mini-Review of Recent Five-Year Clinical Studies

Anal fistula, with its complicated pathogenesis, has been considered as a clinical challenge for centuries. The risk of frequent recurrence and incontinence constitutes a considerable threat in the long-term treatment of anal fistula. In this work, we narratively reviewed the scientific literature of new techniques that have been used for anal fistula treatment over the recent 5 years, objectively evaluated the pros and cons of each technique on the basis of clinical outcomes, and tried to disclose the effective strategies for anal fistula treatment. Up to date, surgery is the main method used for treating anal fistula, but there is no simple technique that can completely heal complex anal fistula. In the course of surgery treatment, the healing outcome, and the protection of anal function should be weighed comprehensively. Among the innovative techniques that have emerged in recent years, combined techniques based on drainage Seton and LIFT-plug seem to be the relatively effective therapies, but their effectiveness requires more multi-center prospective randomized controlled trials with large sample size and long-term follow-up to be validated.

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

BACKGROUND

Ligation 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.

METHODS

A 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.

RESULTS

Twenty-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.

CONCLUSION

The 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 the Intersphincteric Fistula Tract for High Transsphincteric Fistula Yields Moderate Results at Best: Is the Tide Turning?

BACKGROUND

Ligation of the intersphincteric fistula tract is a well-accepted and often used surgical procedure for perianal fistulas.

OBJECTIVE

This study aims to confirm results of the ligation of the intersphincteric fistula tract in a specialized colorectal center.

DESIGN

This is a retrospective cohort study.

SETTING

This study took place in a large colorectal surgical department with a tertiary referral center for perianal fistulas.

PATIENTS

Consecutive patients were operated on with ligation of the intersphincteric fistula tract for a transsphincteric perianal fistula between 2012 and December 2018.

INTERVENTIONS

Patients underwent ligation of the intersphincteric fistula tract.

MAIN OUTCOME MEASURES

The primary outcome measured was the healing rate. The secondary outcomes measured were conversion into an intersphincteric perianal fistula, risk of recurrence, complications, and postoperative continence status.

RESULTS

Forty-six patients were treated with a ligation of intersphincteric fistula tract procedure. All patients (100%) had preoperative imaging in their workup. Forty patients (87%) had a high transsphincteric fistula. The primary healing rate was a disappointing 17 of 46 patients (37%). The median time until failure was 4.2 months (interquartile range, 3.5-6.5). Of the failures, 16 converted to an intersphincteric fistula (55% of failures and 35% of all patients). The mean duration of follow-up in patients without a recurrence was 9.5 months (SD 11.9). Four patients (9%) were lost to follow-up. The mean Fecal Incontinence Severity Index postoperatively was only 2.35 (SD 5.7; range, 0-30). This resulted in 9 patients (20%) having a newly impaired continence status postoperatively. Continence impairment was mild in all these patients. The risk of developing a recurrence 1 year after surgery is 64.2% (95% CI, 49%-80%).

LIMITATIONS

This study was limited by its retrospective design and the small numbers with possible selection bias.

CONCLUSIONS

Results with the ligation of intersphincteric fistula tract procedure were not as good as hoped. The effect on fecal continence, however, was minimal. The procedure might be more suitable for low transsphincteric fistulas. See Video Abstract at http://links.lww.com/DCR/A992. LA LIGADURA DEL TRACTO DE LA FÍSTULA INTERESFINTÉRICA PARA UNA FÍSTULA TRANSESFINTÉRICA ALTA, PRODUCE RESULTADOS MODERADOS EN EL MEJOR DE LOS CASOS: ¿ESTÁ CAMBIANDO LA MAREA?: La ligadura del tracto de la fístula interesfintérica es un procedimiento quirúrgico bien aceptado y de uso frecuente para las fístulas perianales.

OBJETIVO

Confirmar los resultados de la ligadura del tracto de la fístula interesfintérica en un centro colorrectal especializado. DISEÑO:: Estudio de cohorte retrospectivo.

AJUSTE

Gran departamento de cirugía colorrectal y con centro de referencia terciaria para fístulas perianales.

PACIENTES

Pacientes consecutivos operados con ligadura del tracto de la fístula interesfintérica para una fístula perianal transesfintérica, entre 2012 y diciembre de 2018.

INTERVENCIONES

Ligadura del tracto de fístula interesfintérica.

PRINCIPALES MEDIDAS DE RESULTADO

Tasa de cicatrización, resultados secundarios: conversión a una fístula perianal interesfintérica, riesgo de recurrencia, complicaciones y estado de continencia postoperatoria.

RESULTADOS

Cuarenta y seis pacientes fueron tratados con una ligadura del tracto de la fístula interesfintérica. Todos los pacientes (100 por ciento) tenían imagenología en su preparación preoperatoria. Cuarenta pacientes (87 por ciento) tenían una fístula transesfintérica alta. La tasa de cicatrización primaria fue decepcionante en 17 de 46 pacientes (37 por ciento). El tiempo medio hasta el fracaso fue de 4.2 meses (rango intercuartil 3.5-6.5). De los fracasos, 16 se convirtieron en una fístula interesfintérica (55 por ciento de los fracasos y 35 por ciento de todos los pacientes). La duración media del seguimiento en pacientes sin recurrencia fue de 9.5 meses (desviación estándar de 11.9). Se perdieron durante el seguimiento a cuatro pacientes (9 por ciento). Después de la operación, el promedio del índice de severidad de incontinencia fecal fue de solo 2.35 (desviación estándar de 5.7, rango 0-30). Esto resultó en que 9 pacientes (20 por ciento) tuvieran una continencia deteriorada postoperatoria. El deterioro de la continencia fue leve en todos estos pacientes. El riesgo de desarrollar una recurrencia a un año después de la cirugía es del 64.2 por ciento (intervalo de confianza del 95 por ciento: 49-80 por ciento).

LIMITACIONES

Diseño retrospectivo, números pequeños con posible sesgo de selección.

CONCLUSIONES

Los resultados del procedimiento con la ligadura del tracto de fístula interesfintérica no fueron tan buenos como se esperaba. El efecto sobre la continencia fecal, sin embargo, fue mínimo. El procedimiento podría ser más adecuado para las fístulas transesfintéricas bajas. Vea el Resumen del video en http://links.lww.com/DCR/A992.