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

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.

[Stem Cell Therapy for Complex Anal Fistula in Crohn`s Disease: Current Evidence and Future Perspectives]

Despite progress in multidisciplinary diagnostic and therapeutic strategies, complex anal fistulas associated with Crohn's disease remain a challenge for both medical and surgical management. Conventional surgical techniques such as flap procedures or LIFT are still associated with considerable persistence and recurrence rates. Based on this background, results of stem cell therapy for Crohn's anal fistula have shown promising results and are a sphincter-preserving technique. In particular, adipose-derived, allogeneic stem cell therapy (Darvadstrocel) has shown encouraging healing rates within the randomised controlled ADMIRE-CD trial, which were reproducible in "real world" data of limited clinical studies. The current evidence has led to the integration of allogeneic stem cell therapy into international guidelines. To date, the definitive status of allogeneic stem cells in the multidisciplinary treatment algorithm for complex anal fistulas associated with Crohn's disease cannot be evaluated.

Subcutaneous incision of the fistula tract and internal sphincterotomy (SIFT-IS): a novel surgical procedure for transsphincteric anal fistula

AIM

The aetiology of anal fistula has not been fully clarified. One of the causes of anal fistulas may be the markedly deep crypts that characterize the primary openings. We developed subcutaneous incision of the fistula tract and internal sphincterotomy (SIFT-IS) to eradicate these deep crypts. The aim of this study was to evaluate outcomes in patients with anal fistula treated with SIFT-IS.

METHOD

A retrospective study was performed over a 2-year period. Patients with transsphincteric anal fistula who underwent SIFT-IS were enrolled. The primary endpoint was the anal fistula healing rate at 16 weeks postoperatively. The secondary endpoints were healing time, postoperative complications and clinical continence status.

RESULTS

One hundred and fifty one patients were enrolled. Primary healing was accomplished in 129 patients (85%). There were 17 patients (11%) with a remnant fistula and five (3%) with a recurrence. The remnant fistulas healed spontaneously at more than 16 weeks postoperatively in seven patients. The median healing time was 6 (3-96) weeks. Surgical intervention was required in seven patients with a remnant fistula and four with recurrence. At the final follow-up, the wounds had healed in 148 patients (98%). No significant postoperative complications or incontinence were observed.

CONCLUSION

Subcutaneous incision of the fistula tract and internal sphincterotomy is a promising surgical option for transsphincteric anal fistulas, with a satisfactory healing rate.

Comparison between recent sphincter-sparing procedures for complex anal fistulas-ligation of intersphincteric tract vs transanal opening of intersphincteric space

Complex anal fistulas are difficult to treat. The main reasons for this are a higher recurrence rate and the risk of disrupting the continence mechanism because of sphincter involvement. Due to this, several sphincter-sparing procedures have been developed in the last two decades. Though moderately successful in simple fistulas (50%-75% healing rate), the healing rates in complex fistulas for most of these procedures has been dismal. Only two procedures, ligation of intersphincteric fistula tract and transanal opening of intersphincteric space have been shown to have good success rates in complex fistulas (60%-95%). Both of these procedures preserve continence while achieving high success rates. In this opinion review, I shall outline the history, compare the pros and cons, indications and contraindications and future application of both these procedures for the management of complex anal fistulas.

Horseshoe Fistulae in the Age of LIFT

BACKGROUND

Horseshoe fistula is a challenging benign anorectal condition to treat. The aim of this study was to assess the utilization and success of different definitive fistula repair techniques in the treatment of horseshoe fistula.

METHODS

This was a retrospective case series which included all patients who were treated for horseshoe fistula from 2006 to 2019 at a single, tertiary care center and whom had at least one follow-up visit. Patients were excluded if < 18 years of age or carried a diagnosis of Crohn's disease. Patients were assessed for fistula recurrence and incontinence.

RESULTS

Sixty-eight patients were identified. On average, they were 47 years old, 63% male, and 18% current smokers. Seventy-nine percent required seton during their treatment course. Of the 8 first attempts at fistula repair, the types of repair included flap (15%), LIFT (35%), fistulotomy (31%), plug (12%), and fistulotomy and immediate reconstruction (1%). Recurrence for these procedures was as follows: flap 30%, LIFT 21%, fistulotomy 14%, plug 88%, and fistulotomy and immediate reconstruction 0%. Twelve patients who recurred underwent 17 additional procedures to attempt to cure their fistula. Overall, of those who underwent any attempt at definitive repair, 82% of patients were cured of their fistula, 12% had a chronic seton, and 6% had a chronic fistula. Thirteen percent of those who were cured had incontinence. The mean follow-up time was 1.1 years. Patients required a median of 3 procedures (range 1-11).

CONCLUSION

Horseshoe fistula remains a complex anorectal condition. Successful repair can be performed in > 80% of patients. However, repair can often require multiple surgical procedures.

Guidelines to diagnose and treat peri-levator high-5 anal fistulas: Supralevator, suprasphincteric, extrasphincteric, high outersphincteric, and high intrarectal fistulas

Supralevator, suprasphincteric, extrasphincteric, and high intrarectal fistulas (high fistulas in muscle layers of the rectal wall) are well-known high anal fistulas which are considered the most complex and extremely challenging fistulas to manage. Magnetic resonance imaging has brought more clarity to the pathophysiology of these fistulas. Along with these fistulas, a new type of complex fistula in high outersphincteric space, a fistula at the roof of ischiorectal fossa inside the levator ani muscle (RIFIL), has been described. The diagnosis, management, and prognosis of RIFIL fistulas is reported to be even worse than supralevator and suprasphincteric fistulas. There is a lot of confusion regarding the anatomy, diagnosis, and management of these five types of fistulas. The main reason for this is the paucity of literature about these fistulas. The common feature of all these fistulas is their complete involvement of the external anal sphincter. Therefore, fistulotomy, the simplest and most commonly performed procedure, is practically ruled out in these fistulas and a sphincter-saving procedure needs to be performed. Recent advances have provided new insights into the anatomy, radiological modalities, diagnosis, and management of these five types of high fistulas. These have been discussed and guidelines formulated for the diagnosis and treatment of these fistulas for the first time in this paper.

Sphincter-Preserving Fistulectomy Is an Effective Minimally Invasive Technique for Complex Anal Fistulas

Background

The optimal treatment of complex anal fistulas remains unclear, though many different sphincter-preserving procedures have been described. A minimally invasive technique with a better outcome is desired. The purpose of this study was to present a new technique—sphincter-preserving fistulectomy (SPF) and its clinical outcomes.

Materials and Methods

A retrospective study was performed to compare the efficacy and outcomes of SPF with ligation of the intersphincteric fistula tract (LIFT) in the management of complex anal fistulas in regards to postoperative pain, complications, wound healing time, recurrence, overall success rate, fecal continence function, and quality of life. Continence function was evaluated using the Wexner incontinence scale and anal manometry. The fecal incontinence quality of life (FIQL) scale was used to assess patients' quality of life.

Results

From June 2020 to July 2021, 41 patients with 43 SPF procedures and 35 patients with 35 LIFT procedures were included. Postoperative pain was comparable between two groups. The morbidity rate and the mean wound healing time in the SPF group were lower than those in the LIFT group (2.3% vs. 48.6%, p < 0.001; 1.4 ± 0.3 vs. 1.7 ± 0.4 months, p = 0.001). At a mean follow-up duration of 11.4 ± 3.5 months in the SPF group and 10.7 ± 4.3 months in the LIFT group, SPF achieved a better overall success rate than LIFT (97.7% vs. 77.1%, p = 0.014). Three patients in the SPF group and 4 patients in the LIFT group who all underwent a simultaneous fistulotomy procedure complained new incontinence of flatus. There was no statistical difference between the two groups in regards to the Wexner scores (p = 0.790), the maximum resting anal canal pressure (p = 0.641), the maximum squeeze pressure (p = 0.289), and the FIQL scores including lifestyle (p = 0.188), coping (p = 0.188), depression (p = 0.850), and embarrassment (p = 0.910).

Conclusions

SPF is a novel, safe, and effective minimally invasive technique for the management of complex anal fistulas, with a promising success rate and negligible impairment on continence. Future prospective studies are needed to evaluate the long-term outcomes of SPF.

The Ligation of the Intersphincteric Fistula Tract (LIFT) Technique for Simple and Complex Fistula-in-ano

Background Fistula-in-ano is one of the most common clinical condition encountered in a surgical outpatient department. Many treatment modalities have been described with variable outcomes but gold standard surgical treatment is yet to be agreed upon. The aim of the present study is to evaluate the treatment outcomes of ligature of intersphincteric fistula tract (LIFT) technique in the treatment of simple and complex fistula-in-ano with the primary objective of recurrence rate and broad objective of other postoperative complications during the period of study and after long-term follow-up.

Methods It is a retrospective study of prospectively collected data from the patients who have been operated for fistula-in-ano using the LIFT technique at our institute from February 2018 to March 2020 and followed-up until September 2020.

Results A total of 56 patients with fistula-in-ano were treated with the LIFT procedure during the study period, of which 20 patients had simple fistula and 36 had complex fistula. A success rate of 83% was obtained with completely healed fistulas in 46 patients. No patient developed postoperative incontinence.

Conclusion Ligature of intersphincteric fistula tract is an effective treatment modality for fistula-in-ano with less procedure-related morbidity, but it is associated with a higher recurrence rate in simple fistula than in complex fistula.

Stem cell injection for complex anal fistula in Crohn’s disease: A single-center experience

BACKGROUND

Despite tremendous progress in medical therapy and optimization of surgical strategies, considerable failure rates after surgery for complex anal fistula in Crohn’s disease have been reported. Therefore, stem cell therapy for the treatment of complex perianal fistula can be an innovative option with potential long-term healing.

AIM

To evaluate the results of local administration of allogenic, adipose-derived mesenchymal stem cells (darvadstrocel) for complex anal Crohn’s fistula.

METHODS

All patients with complex anal fistulas associated with Crohn’s disease who were amenable for definite fistula closure within a defined observation period were potential candidates for stem cell injection (darvadstrocel) if at least one conventional or surgical attempt to close the fistula had failed. Darvadstrocel was only indicated in patients without active Crohn’s disease and without presence of anorectal abscess. Local injection of darvadstrocel was performed as a standardized procedure under general anesthesia including single-shot antibiotic prophylaxis, removal of seton drainage, fistula curettage, closure of the internal openings and local stem cell injection. Data collection focusing on healing rates, occurrence of abscess and follow-up was performed on a regular basis of quality control and patient care. Data were retrospectively analyzed.

RESULTS

Between July 2018 and January 2021, 12 patients (6 females, 6 males) with a mean age of 42.5 (range: 26-61) years underwent stem cell therapy. All patients had a minimum of one complex fistula, including patients with two complex fistulas in 58.3% (7/12). Two of the 12 patients had horse-shoe fistula and 3 had one complex fistula. According to Parks classification, the majority of fistulas were transsphincteric (76%) or suprasphincteric (14%). All patients underwent removal of seton, fistula curettage, transanal closure of internal opening by suture (11/12) or mucosal flap (1/12) and stem cell injection. At a mean follow-up of 14.3 (range: 3-30) mo, a healing rate was documented in 66.7% (8/12); mean duration to achieve healing was 12 (range: 6-30) wk. Within follow-up, 4 patients required reoperation due to perianal abscess (33.3%). Focusing on patients with a minimum follow-up of 12 mo (6/12) or 24 mo (4/12), long-term healing rates were 66.7% (4/6) and 50.0% (2/4), respectively.

CONCLUSION

Data of this single-center experience are promising but limited due to the small number of patients and the retrospective analysis.

Long-term Outcomes After Anal Fistula Surgery: Results From Two University Hospitals in Thailand

Purpose

This study aimed to evaluate long-term outcomes after anal fistula surgery from university hospitals in Thailand.

Methods

A prospectively collected database of patients with cryptoglandular anal fistula undergoing surgery from 2011 to 2017 in 2 university hospitals was reviewed. Outcomes were treatment failure (persistent or recurrent fistula), fecal continence status, and chronic postsurgical pain.

Results

This study included 247 patients; 178 (72.1%) with new anal fistula and 69 (27.9%) with recurrent fistula. One hundred twenty-one patients (49.0%) had complex fistula; 53 semi-horseshoe (21.5%), 41 high transsphincteric (16.6%), 24 horseshoe (9.7%), and 3 suprasphincteric (1.2%). Ligation of intersphincteric fistula tract (LIFT) was the most common operation performed (n = 88, 35.6%) followed by fistulotomy (n = 79, 32.0%). With a median follow-up of 23 months (interquartile range, 12–45 months), there were 18 persistent fistulas (7.3%) and 33 recurrent fistulae (13.4%)—accounting for 20.6% overall failure. All recurrence occurred within 24 months postoperatively. Complex fistula was the only significant predictor for recurrent fistula with a hazard ratio of 4.81 (95% confidence interval, 1.82–12.71). There was no significant difference in healing rates of complex fistulas among seton staged fistulotomy (85.0%), endorectal advancement flap (72.7%), and LIFT (65.9%) (P = 0.239). Four patients (1.6%) experienced chronic postsurgical pain. Seventeen patients (6.9%) reported worse fecal continence.

Conclusion

Overall failure for anal fistula surgery was 20.6%. Complex fistula was the only predictor for recurrent fistula. At least 2-year period of follow-up is suggested for detecting recurrent diseases and assessing patient-reported outcomes such as chronic pain and continence status.

Intersphincteric Exploration With Ligation of Intersphincteric Fistula Tract or Attempted Closure of Internal Opening for Acute Anorectal Abscesses

BACKGROUND

Acute anorectal abscesses of cryptoglandular origin are commonly managed by incision and drainage, which results in fistula development in up to 73% of cases, requiring subsequent definitive fistula surgery. However, given that fistula tracts may already be present at the initial presentation, primary closure of the tract as secondary prevention of fistula formation, using ligation of intersphincteric fistula tract, may be useful.

OBJECTIVE

This study aims to examine the feasibility and outcomes of performing intersphincteric exploration with ligation of intersphincteric fistula tract or attempted closure of internal opening for acute anorectal abscesses.

DESIGN

This is a retrospective study of patients with acute anorectal cryptoglandular abscesses who underwent surgery between January 2014 and December 2016.

SETTINGS

The patients were treated at a tertiary referral center in Thailand.

PATIENTS

Eighty-six patients with acute anorectal abscesses without previous surgery were included.

INTERVENTIONS

Intersphincteric dissection was performed. Further surgical intervention was dependent on the intersphincteric findings.

MAIN OUTCOME MEASURE

The main outcome measure was the 90-day healed rate.

RESULTS

Of the 86 patients, 3 had low intersphincteric abscesses, 26 had low transsphincteric abscesses, 25 had anterior high transsphincteric abscesses, 27 had posterior high transsphincteric abscesses, and 5 had high intersphincteric abscesses. Ligation of intersphincteric fistula tract was successfully performed in 66 patients with an identifiable intersphincteric tract. Intersphincteric exploration with attempted closure of the internal opening was performed in the remaining 20 patients. The success rates were 86% and 70%. Unidentified internal opening and intersphincteric pathology were risk factors for nonhealing. No patients reported fecal incontinence postoperatively.

LIMITATIONS

The limitation of this study is its retrospective nature and that all operations were performed by a single surgeon; therefore, the results may vary according to the individual surgeon's expertise.

CONCLUSIONS

Fistula tract formation was found in most cases of acute anorectal abscesses. Definitive surgery using this strategy provides promising results. See Video Abstract at http://links.lww.com/DCR/B451.

EXPLORACIN INTERESFINTRICA CON LIGADURA DEL TRAYECTO EN LA FSTULA INTERESFINTRICA O INTENTO DE CIERRE DEL ORIFICIO INTERNO EN ABSCESOS ANORRECTALES AGUDOS

ANTECEDENTES:Los abscesos anorrectales agudos de origen criptoglandular, comúnmente se manejan mediante incisión y drenaje, lo que resulta en el desarrollo de una fístula hasta en un 73% de los casos, requiriendo posteriormente cirugía definitiva de la fístula. Sin embargo, dado que los trayectos de la fístula ya pueden estar inicialmente presentes, puede ser útil el cierre primario del trayecto, como prevención secundaria en la formación de la fístula, mediante la ligadura del trayecto de la fístula interesfintérica.OBJETIVO:El estudio tiene como objetivo, examinar la viabilidad y los resultados en realizar exploración interesfintérica, con ligadura del trayecto de fístula interesfintérica o intento de cierre del orificio interno para abscesos anorrectales agudos.DISEÑO:Se trata de un estudio retrospectivo de pacientes con abscesos criptoglandulares anorrectales agudos, que fueron operados entre enero de 2014 y diciembre de 2016.AJUSTES:Los pacientes fueron tratados en un centro de referencia terciario en Tailandia.PACIENTES:Se incluyeron 86 pacientes con abscesos anorrectales agudos, sin cirugía previa.INTERVENCIONES:Se realizó disección interesfintérica. La intervención quirúrgica adicional dependió de los hallazgos interesfintéricos.PRINCIPALES MEDIDAS DE RESULTADO:La principal medida de resultado, fue la tasa de cicatrización a 90 días.RESULTADOS:De los 86 pacientes, hubo 3 abscesos interesfintéricos bajos, 26 abscesos transesfintéricos bajos, 25 abscesos transesfintéricos anteriores altos, 27 abscesos transesfintéricos posteriores altos y 5 abscesos interesfintéricos altos. La ligadura del tracto de la fístula interesfintérica, con tracto interesfintérico identificable, se realizó con éxito en 66 pacientes. Se realizó exploración interesfintérica, con intento de cierre del orificio interno en los 20 pacientes restantes. Las tasas de éxito fueron 86% y 70% respectivamente. Orificio interno no identificado y patología interesfintérica, fueron factores de riesgo para la falta de cicatrización. Ningún paciente reportó incontinencia fecal posoperatoria.LIMITACIONES:La limitación de este estudio, es su naturaleza retrospectiva y que todas las operaciones fueron realizadas por un solo cirujano, por lo tanto, los resultados pueden variar según la experiencia de cada cirujano.CONCLUSIONES:En la mayoría de los casos de abscesos anorrectales agudos, se encontró formación de trayectos fistulosos. La cirugía definitiva con esta estrategia, proporciona resultados prometedores. Consulte Video Resumen en http://links.lww.com/DCR/B451.

Efficacy and safety of ligation of intersphincteric fistula tract in the treatment of anal fistula: A protocol for systematic review and meta-analysis

BACKGROUND

Anal fistula is characterized with perianal cellulitis, anorectal pain, smelly or bloody drainage of pus, and difficulty in controlling bowel movements. Ligation of intersphincteric fistula tract (LIFT) technique is a recently developed approach against anal fistula, and it could alleviate the pain of the patient, with little postoperative trauma, which can greatly shorten the wound healing time and hospitalization stay. We conduct the meta-analysis and systematic review to systematically evaluate the clinical efficacy and safety of LIFT in the treatment of anal fistula.

METHODS

Randomized controlled trials of LIFT against anal fistula will be searched in several Chinese and English databases. Two reviewers will independently conduct the literature extraction and risk of bias assessment. Statistical analysis will be conducted in RevMan 5.3.

RESULTS AND CONCLUSIONS

The study will help to systematically evaluate the clinical efficacy and safety of LIFT in the treatment of anal fistula.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/T4FUH.

Simple fistula-in-ano: is it all simple? A systematic review

Background

Simple anal fistula is one of the most common causes of proctological surgery and fistulotomy is considered the gold standard. This procedure, however, may cause complications. The aim of this systematic review was to assess the surgical treatment of simple anal fistula with traditional and sphincter-sparing techniques.

Methods

A literature research was performed using PubMed, Cochrane, and Google Scholar to identify studies on the surgical treatment of simple anal fistulas. Observational studies and randomized clinical trials were included. We assessed the risk of bias of included studies using the Jadad scale for randomized controlled trials, and the MINORS Scale for the remaining studies.

Results

The search returned 456 records, and 66 studies were found to be eligible. The quality of the studies was generally low. A total of 4883 patients with a simple anal fistula underwent a sphincter-cutting procedure, mainly fistulotomy, with a weighted average healing rate of 93.7%, while any postoperative continence impairment was reported in 12.7% of patients. Sphincter-sparing techniques were adopted to treat 602 patients affected by simple anal fistula, reaching a weighted average success rate of 77.7%, with no study reporting a significant postoperative incontinence rate. The postoperative onset of fecal incontinence and the recurrence of the disease reduced patients’ quality of life and satisfaction.

Conclusions

Surgical treatment of simple anal fistulas with sphincter-cutting procedures provides excellent cure rates, even if postoperative fecal incontinence is not a negligible risk. A sphincter-sparing procedure could be useful in selected patients.

Long-Term Clinical Results of Use of an Anal Fistula Plug for Treatment of Low Trans-Sphincteric Anal Fistulas

BACKGROUND An anal fistula plug is a sphincter-sparing procedure that uses biological substances to close an anorectal fistula. This study aimed to evaluate the long-term therapeutic effect of an anal fistula plug procedure in patients with trans-sphincteric fistula-in-ano and to determine the risk factors affecting fistula healing. MATERIAL AND METHODS A single-center retrospective study was performed assessing long-term treatment outcomes of patients with low trans-sphincteric anal fistulas who initially underwent anal fistula plug procedures between August 2008 and September 2012. Risk factors affecting fistula healing were identified using univariate and multivariate analyses. RESULTS A total of 135 patients who had low trans-sphincteric anal fistulas and underwent anal fistula plug procedures were analysed. The overall healing rate was 56% (75/135) with a median follow-up time of 8 years (range, 72-121 months). The primary reasons for treatment failure were plug extrusion (n=12, 20%) and surgical site infection (n=9, 15%), occurring within 30 days after surgery. Multiple logistic regression analysis showed that the duration of anal fistula ≥6 months was significantly associated with treatment failure using an anal fistula plug (OR=3.187, 95% CI: 1.361-7.466, P=0.008). Of the patients who failed initial treatment with an anal fistula plug, 6 (9%) had anal fistulas that healed spontaneously after 2-3 years without additional treatment. CONCLUSIONS As a sphincter-preserving procedure, the anal fistula plug can effectively promote healing of low trans-sphincteric anal fistulas. The long-term efficacy is good and the procedure warrants wider use in clinical practice.

Video-Assisted Ligation of Intersphincteric Fistula Tract for Complex Anal Fistula: Technique and Preliminary Outcomes

BACKGROUND

Sphincter-preserving operations have been increasingly used for treating anal fistula. However, their success rates remain modest in complex anal fistulas.

OBJECTIVE

This study aimed to report outcomes of video-assisted ligation of intersphincteric fistula tract (a procedure combining video-assisted anal fistula treatment and ligation of intersphincteric fistula tract) for treating complex anal fistulas and to compare its results with conventional ligation of intersphincteric fistula tract.

DESIGN

A review of prospectively collected data from October 2014 to December 2017 was performed.

SETTINGS

The study was conducted at a large tertiary hospital in Thailand.

PATIENTS

All patients with primary or recurrent complex anal fistulas undergoing video-assisted ligation of intersphincteric fistula tract were included. Patients with anal fistula related to malignancy, Crohn's disease, tuberculosis, or acute abscess were excluded.

MAIN OUTCOME MEASURES

Healing as defined by an absence of fistula or drainage from an external opening and complete epithelialization of the external opening were measured.

RESULTS

This study included 103 patients with a median age of 47 years. The primary healing rate was 84.5% at a median follow-up of 28 months (range, 15-38 mo). Primary healing rates of anterior high transsphincteric fistula, semi-horseshoe fistula, and horseshoe fistula were 88% (44 of 50 cases), 77% (30 of 39 cases), and 93% (13 of 14 cases). Median time to healing was 4 weeks (range, 4-8 wk). Accordingly, the overall failure rate was 15.5%. None reported worse fecal incontinence postoperatively. Video-assisted ligation of intersphincteric fistula tract had a higher rate of primary healing for complex anal fistula than ligation of intersphincteric fistula tract (84.5% vs 63.4%; p < 0.001).

LIMITATIONS

This study is limited by its small sample size.

CONCLUSIONS

The outcomes of video-assisted ligation of intersphincteric fistula tract for complex anal fistulas are quite good. This technique has the potential to become another viable option of sphincter-preserving operation for complex anal fistulas. See Video Abstract at http://links.lww.com/DCR/B373. LIGADURA ASISTIDA POR VIDEO DEL TRACTO DE LA FÍSTULA INTERESFINTÉRICA PARA LA FÍSTULA ANAL COMPLEJA: TÉCNICA Y RESULTADOS PRELIMINARIES: Las operaciones de preservación del esfínter se han utilizado cada vez más para tratar la fístula anal. Sin embargo, sus tasas de éxito siguen siendo modestas en las fístulas anales complejas.Este estudio tuvo como objetivo informar los resultados de la ligadura asistida por video del tracto de la fístula interesfintérica (un procedimiento que combina el tratamiento de la fístula anal asistida por video y la ligadura del tracto de la fístula interesfintérica) para el tratamiento de las fístulas anales complejas y comparar sus resultados con la ligadura convencional de la fístula interesfintérica tracto.Se realizó una revisión de los datos recolectados prospectivamente desde Octubre de 2014 hasta Diciembre de 2017.El estudio se realizó en un gran hospital terciario en Tailandia.Se incluyeron todos los pacientes con fístulas anales complejas primarias o recurrentes sometidas a ligadura asistida por video del tracto de la fístula interesfintérica. Se excluyeron los pacientes con fístula anal relacionada con malignidad, enfermedad de Crohn, tuberculosis o absceso agudo.Curación definida por la ausencia de fístula o drenaje de la abertura externa y la epitelización completa de la abertura externa.Este estudio incluyó 103 pacientes con una mediana de edad de 47 años. La tasa de curación primaria fue del 84,5% con una mediana de seguimiento de 28 meses (rango 15-38). La tasa de curación primaria de la fístula transesfintérica alta anterior, la fístula semi-herradura y la fístula de herradura fue del 88% (44 de 50 casos), 77% (30 de 39 casos) y 93% (13 de 14 casos), respectivamente. El tiempo mediano hasta la curación fue de 4 semanas (rango 4-8). En consecuencia, la tasa de fracaso general fue del 15,5%. Ninguno informó peor incontinencia fecal después de la operación. La ligadura asistida por video del tracto de la fístula interesfintérica tuvo una mayor tasa de curación primaria para la fístula anal compleja que la ligadura del tracto de la fístula interesfintérica (84.5% vs 63.4%; p <0.001).Este estudio está limitado por su pequeño tamaño de muestra.Los resultados de la ligadura asistida por video del tracto de la fístula interesfintérica para fístulas anales complejas son bastante buenos. Esta técnica tiene el potencial de convertirse en otra opción viable de operación de preservación del esfínter para fístulas anales complejas. Consulte Video Resumen en http://links.lww.com/DCR/B373. (Traducción-Dr Yesenia Rojas-Khalil).

Sphincter-saving therapy for fistula-in-ano: long-term follow-up after FiLaC®

BACKGROUND

The treatment of anal fistula remains a challenge between maintaining continence and radical surgery to prevent recurrence. Fistula-tract Laser Closure (FiLaC^®) is a sphincter-saving technique using a radial emitting laser fibre to close the fistula tract. The aim of this study was to report long-term outcomes in patients who received FiLaC^® therapy for transsphincteric and intersphincteric anal fistula between January 2011 and December 2017.

METHODS

A retrospective study was performed on patients who were treated with FiLaC^®- for a transsphincteric and intersphincteric anal fistula at our institution between January 2011 and December 2017. In all patients, the FiLaC^® procedure was combined with a closure of the internal orifice using a simple 3-0 Z stitch. Patient characteristics, previous proctological history, healing rates, failures and postoperative continence were investigated.

RESULTS

The study included 83 patients [mean age 50.01 ± 14.59 years. 64 (77.1%) males] with a mean follow-up period of 41.99 (± 21.59) months (range 4-87 months). Thirteen patients (15.7%) had a recurrent fistula. 65 patients (78.3%) had undergone prior abscess drainage with insertion of a seton. The primary healing rate was 74.7% (62 of 83 patients) overall. Eleven (13.3%) of the 21 patients (25.3%) who failed FiLaC^®-therapy underwent a second operation. In eight cases, Re-FiLaC^® and in three cases, fistulectomy with closure of the internal orifice was performed. Afterwards 6 (54.5%) of these 11 patients could be considered cured: 3 who had fistulectomy and three who had Re-FiLaC^® treatment. The overall healing rate after second FiLaC^® was 78.3% (65 of 83 patients) while the overall healing rate for FiLaC^® therapy combined with any second procedure was 81.9% (68 of 83 patients). The follow-up period in this group of 11 patients who received re-operation was 38 months (range 13-84 months). Changes in continence occurred in eight patients (9.6%). No patient reported major incontinence postoperatively.

CONCLUSIONS

The FiLaC^® procedure is associated with good healing rates in long-term follow-up and should be considered as a treatment option for transsphincteric and intersphincteric anal fistulae, especially due to the low complication rate and low risk of sphincter injury.

Porcine dermal collagen mesh (Permacol™) as a bioprosthesis in the ligation of intersphincteric tract (BioLIFT) procedure

BACKGROUND

Ligation of intersphincteric tract (LIFT) is a sphincter-saving technique used to treat anal fistulas. Incorporation of a bioprosthesis in LIFT (BioLIFT) aims to improve healing. The use of cross-linked porcine dermal collagen mesh Permacol™ in BioLIFT has never been investigated. The aim of this study was to compare the healing rates and outcome of LIFT and BioLIFT for complex anal fistulas using the Permacol™ biological mesh.

METHODS

A retrospective analysis of all patients having LIFT or BioLIFT for complex fistulas from January 2010 to November 2019 was performed in a tertiary referral centre. Patient data from a prospectively collected database of all patients having LIFT or BioLIFT were analyzed.

RESULTS

LIFT and BioLIFT were performed in 48 (82.8%) and 10 (17.2%) patients, respectively. All BioLIFT patients had previous interventions for their fistulas compared to 30 (62.5%) of patients who had LIFT, p = 0.023. The primary healing rate for LIFT was 87.5% (42/48) compared to 80% (8/10) in BioLIFT, (p = 0.42). Eight (13.8%) patients developed complications, 6 (12.5%) in the LIFT group vs 2 (20%) in the BioLIFT group (p = 0.62). On univariate analysis, the number of previous operations was predictive of complications (p = 0.03). BioLIFT was not associated with complication (OR = 1.75, 95% CI: 0.30-10.3, p = 0.54) or primary healing (OR = 0.57, 95% CI: 0.97-3.36, p = 0.54). There was no significant difference in recurrence (LIFT 12.5% vs BioLIFT 0%, p = 0.58). Kaplan-Meier analysis found no difference in time to recurrence between the two groups (p = 0.65).

CONCLUSION

Permacol™ mesh in BioLIFT is feasible and achieves a high primary healing rate of 80%. Prospective evidence is needed to establish the benefits of BioLIFT and determine whether Permacol™ is superior to the non-cross-linked porcine submucosal mesh.

Comparison of Ligation of the Intersphincteric Fistula Tract and BioLIFT for the Treatment of Transsphincteric Anal Fistula: A Retrospective Analysis

BACKGROUND

Ligation of the intersphincteric fistula tract is a sphincter-preserving technique for the treatment of anal fistulas. The BioLIFT modification involves the placement of a biologic mesh in the intersphincteric plane. Advocates of this modification state improved healing rates, however evidence for this is lacking, and this approach costs significantly more.

OBJECTIVE

The purpose of this study was to compare the healing rates of the ligation of the intersphincteric fistula tract with the BioLIFT.

DESIGN

This was a retrospective cohort study.

SETTINGS

The study was conducted at a tertiary care hospital from April 2008 to April 2018.

PATIENTS

All adult patients with transsphincteric anal fistulas were included. Patients were excluded if they had IBD, more than 1 fistula tract operated on simultaneously, or a previous attempt at repair.

MAIN OUTCOME MEASURES

The primary outcome was primary healing of the fistula tract, and secondary outcomes included overall success, complications, and time to recurrence.

RESULTS

There were 119 cases (75 ligation of the intersphincteric fistula tract and 44 BioLIFTs). One surgeon performed 84% of the BioLIFT cases. The primary healing rate was 75.0% versus 58.7% (p = 0.08), and the complication rate was 22.7% versus 17.3% (p = 0.48; BioLIFT vs ligation of intersphincteric fistula tract). After multivariate logistic regression, the BioLIFT had a significantly better healing rate (OR = 2.38 (95% CI, 1.01-5.62); p = 0.048). Median follow-up was 9 versus 29 weeks (BioLIFT vs ligation of intersphincteric fistula tract). Kaplan-Meier analysis demonstrated no difference in the time to recurrence (p = 0.48).

LIMITATIONS

This study was limited by the retrospective nature, different lengths of follow-up, and varying case numbers between the surgeons.

CONCLUSIONS

The BioLIFT modification is safe and effective for the treatment of anal fistulas but has a higher cost. This modification warrants additional prospective studies to establish its benefits over the ligation of the intersphincteric fistula tract procedure. See Video Abstract at http://links.lww.com/DCR/B139. COMPARACIÓN DE LIFT VERSUS BIOLIFT PARA EL TRATAMIENTO DE LA FÍSTULA ANAL TRANSFINTERÉRICA: UN ANÁLISIS RETROSPECTIVO: Ligadura del tracto de la fístula interesfintérica es una técnica para preservación del esfínter en el tratamiento de las fístulas anales. La modificación BioLIFT implica la colocación de una malla biológica en el plano interesfintérico. Protagonistas de la modificación mejoraron las tasas de curación, sin embargo, carecen evidencias definitivas y la técnica eleva costos significativamente.Comparar las tasas de curación de ligadura del tracto de la fístula interesfintérica con el BioLIFT.Estudio de cohorte retrospectivo.Hospital de atención de tercer nivel desde abril de 2008 hasta abril de 2018.Se incluyeron todos los pacientes adultos con fístulas anales transfinteréricas. Los pacientes fueron excluidos si tenían enfermedad inflamatoria intestinal, más de un tracto fistuloso operado simultáneamente o con un intento previo de reparación.El resultado principal fue la curación primaria del tracto fistuloso y los resultados secundarios incluyeron el éxito en general, las complicaciones y tiempo hasta recurrencia.Se registraron 119 casos (75 ligaduras del tracto de la fístula interesfintérica y 44 BioLIFT). Un cirujano realizó el 84% de los casos de BioLIFT. La tasa de curación primaria fue del 75.0% vs 58.7%, p = 0.08, y la tasa de complicaciones fue del 22.7% vs 17.3%, p = 0.48 comparando BioLIFT vs ligadura del tracto de la fístula interesfintérica. Después de la regresión logística multivariada, el BioLIFT tuvo una tasa de curación significativamente mejor (OR 2.38 [IC 95% 1.01-5.62], p = 0.048). La mediana de seguimiento fue de 9 vs 29 semanas (BioLIFT vs ligadura del tracto de la fístula interesfintérica). El análisis de Kaplan-Meier no demostró diferencias en el tiempo hasta la recurrencia (p = 0,48).Este estudio estuvo limitado por ser retrospectivo, las diferentes duraciones de seguimiento y el número variable de casos entre los cirujanos.La modificación BioLIFT es segura y efectiva para el tratamiento de las fístulas anales pero tiene un costo más alto. Esta modificación amerita más estudios prospectivos para establecer los beneficios sobre ligadura del tracto de la fístula interesfintérica. Consulte Video Resumen en hhttp://links.lww.com/DCR/B139.

Evaluation and management of perianal abscess and anal fistula: SICCR position statement

Perianal sepsis is a common condition ranging from acute abscess to chronic anal fistula. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. Surgery is the main treatment and several procedures have been developed, but the risks of recurrence and of impairment of continence still seem to be an unresolved issue. This statement reviews the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.

Clinical Effect of Tunnel-Like Fistulectomy Plus Draining Seton Combined with Incision of Internal Opening of Anal Fistula (TFSIA) in the Treatment of High Trans-Sphincteric Anal Fistula

Background

The aim of this study was to investigate the clinical effect of tunnel-like fistulectomy plus draining seton combined with incision of internal opening of anal fistula (TFSIA) in the treatment of high transsphincteric anal fistula.

Material/Methods

There were 80 patients with high transsphincteric anal fistula randomly divided into TFSIA group and control group, 40 cases in each group. The control group was treated with cutting seton, and the seton was tightened weekly after discharge from the hospital until the seton dropped off. In the TFSIA group, the anal fistula was dissected and resected in tunnel-like form through the external opening to the intersphinceteric space, drained with seton through the tunnel, and cut open the internal opening of the anal fistula and the intersphincteric space and expanded the drainage. The operative time, blood loss, postoperative uroschesis, anal wound pain score, healing time, Wexner anal incontinence score, keyhole-like deformity, and recurrence rate were compared between the 2 groups.

Results

The differences of the blood loss, operative time, anal wound pain score at 6 hours after operation, postoperative uroschesis and the recurrence rate after operation were not statistically significant (P>0.05), but the TFSIA were better than the control group in the anal wound pain score at 1 week after operation, healing time, Wexner anal incontinence score, and anal keyhole-like deformity rate (P<0.05).

Conclusions

TFSIA is effective in treating high transsphincteric anal fistula, and it can reduce adverse complications after operation.

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.

Effects of preoperative endoanal ultrasound on functional outcome after anal fistula surgery

Objective

Endoanal ultrasound (EAUS) is a recommended preoperative investigation for fistula-in-ano (FiA) which aims to provide the best chance of healing and preservation of continence function. This study aims are (1) to assess effect of EAUS on functional outcome and (2) to determine factors associated with clinical outcomes after FiA surgery.

Design

Retrospective analysis of subjects with cryptogenic FiA between January 2011 and December 2016, in a tertiary hospital, was performed by comparing EAUS and no-EAUS groups. Postoperative change in St. Mark’s faecal incontinence severity score (cFISS=FISS at 6 months after surgery–FISS before surgery) were compared. General linear model was used to determine factors associated with cFISS. Binary logistic regression was used to assess factors related to clinical outcomes. A p-value of <0.05 is considered significant.

Results

We enrolled 339 subjects; 109 (M:F 91:18, mean age 41.7±13.6 years) of 115 in EAUS group and 230 in no-EAUS group (M:F 195:35, mean age 42.6±13.0 years). There were higher proportions of recurrent cases (24.8% vs 13.9%, p=0.014) and complex FiA (80.7% vs 50.4%, p=0.001) in EAUS group. Postoperative FISS (mean±SE) were increased in both groups; preoperative versus postoperative FISS were 0.36±0.20 versus 0.59±0.25 in EAUS group (p=0.056) and 0.31±0.12 versus 0.76±0.17 in no-EAUS group (p<0.001). EAUS had significant effects on cFISS in both univariate analysis, F(1,261)=4.053, p=0.045; and multivariate analysis, F(3,322)=3.147, p=0.025, Wilk’s Lambda 0.972. Other associated factors included recurrent fistula (F(3,322)=0.777, p=0.007, Wilk’s Lambda 0.993) and fistula classification (F(3,322)=16.978, p<0.001, Wilk’s Lambda 0.863). After a mean follow-up of 33.6±28.6 weeks, success rate was 63.3%(EAUS) and 60% (no-EAUS), p=0.822. Factors associated with clinical outcomes were fistula complexity, number of tracts, recurrence, number of previous surgery and type of operations. Accuracy of EAUS was 90.8% and not related to clinical outcomes (p=0.522).

Conclusion

EAUS had favourable effects on functional outcome after FiA surgery while multiple factors were associated with clinical outcomes. EAUS is useful, accurate, inexpensive and can be the first tool for planning of complex and recurrent FiA.

[Quality indicators in the treatment of anal fistulas]

Anal fistulas are a common anorectal disease and are frequently associated with a perianal abscess. The etiology is based on a cryptoglandular infection in the intersphincteric space. Surgery remains the only definitive therapy. The primary goal of definitive fistula surgery is healing; however, success of fistula surgery is influenced by a variety of factors including the surgeon's experience, type of fistula, involvement of sphincter muscles, type of surgical procedure and patient-related factors. For the surgical treatment of a complex anal fistula, a variety of operative procedures have been described including fistulectomy with sphincterotomy, different flap procedures (e.g. mucosal flap and advancement flap) and finally so-called sphincter-preserving techniques, such as LIFT (ligation of intersphincteric fistula tract), VAAFT (video-assisted anal fistula treatment), the use of plugs of collagen or fibrin glue sealants as well as laser procedures or the clip. In the search for suitable quality indicators in anal fistula surgery there is a conflict between healing and preservation of continence. If potential quality indicators are identified the principles of anal fistula surgery must be adhered to and the appropriate selection of patients and procedures is of crucial importance to achieve high healing rates without compromising continence or inducing surgical revision due to abscesses or recurrence. Based on the available literature and guidelines, in the assessment of quality indicators considerable differences exist with respect to patient selection, etiology of anal fistulas and length of follow-up. Heterogeneity of treatment protocols lead to difficulties in a definitive assessment of which surgical treatment is the best option for complex anal fistulas.

Long-term outcomes and quality of life following ligation of the intersphincteric fistula tract for high transsphincteric fistulas

AIM

Published outcomes following ligation of the intersphincteric fistula tract (LIFT) for high transsphincteric fistulas (HTFs) are equivocal probably because most trials are small and comprise mixed patient populations. The aim of this study was to highlight the long-term efficacy of LIFT for HTFs in a large homogeneous sample and to determine the risk factors that contribute to non-healing resulting in failure and recurrence.

METHOD

A retrospective study was performed which assessed patients with HTFs treated by LIFT without prior loose setons from September 2012 to December 2017. Continence function was evaluated by the Wexner incontinence scale and anal manometry. Quality of life was assessed by using the faecal incontinence quality of life (FIQL) scale with four domains: lifestyle, coping, depression and embarrassment.

RESULTS

Seventy patients with HTFs underwent 71 LIFT procedures. The primary healing rate was 81.7% with a median follow-up duration of 16.5 (range 4.5-68) months. The healing rates of mature and immature fistulas were 83.7% and 77.3%, respectively. Two patients suffered failure with an unhealed intersphincteric wound. Recurrence occurred in 11 patients. Incontinence of flatus, present in four patients before surgery, improved postoperatively. Two patients undergoing LIFT combined with fistulotomy complained of flatus incontinence after surgery. No significant differences between preoperative and postoperative Wexner score, maximum resting pressure and maximum squeeze pressure were detected. The FIQL was improved in lifestyle, coping and depression. No risk factor for non-healing was found.

CONCLUSION

LIFT has a promising long-term outcome for HTFs, with negligible impairment on continence and improved quality of life.

LONG-TERM OUTCOMES OF LIGATION OF INTERSPHINCTERIC FISTULA TRACT FOR COMPLEX FISTULA-IN-ANO: MODIFIED OPERATIVE PROCEDURE EXPERIENCE

Background:

It is important but difficult to treat complex fistula-in-ano due to the high recurrent rate and following incontinence. Ligation of the intersphincteric fistula tract (LIFT), a novel surgical procedure with the advantage of avoiding anal incontinence, has a variable success rate of 57-94.4 %.

Aim:

To evaluate the long-term outcomes of modified LIFT operative procedure - ligation of intersphincteric fistula tract - to treat complex fistula-in-ano.

Methods:

Retrospective analysis of 62 cases of complex fistula-in-ano. The group was treated with the modified approach of LIFT (curved incision was made in the anal canal skin; purse-string suture was performed around the fistula; the residual fistulas were removed in a tunnel-based way) and had a follow-up time of more than one year. Patient´s preoperative general condition, postoperative efficacy and their anal function were compared.

Results:

The median age of the participants was 34, and 43 (69.4%) cases were male. Forty-one (66.1%) cases were of high transsphincteric fistula, four (6.5%) cases of high intrasphincter fistula, and 17 (27.4%) cases of anterior anal fistula in female. The median follow-up duration was 24.5 (range, 12-51) months. The success rate in the end of follow-up was 83.9% (52/62). The anorectal pressure and Cleveland Clinic Florida Fecal Incontinence (CCF-FI) evaluated three months before and after the operation did not find apparent changes.

Conclusions:

Compared with LIFT, the modified LIFT remarkably reduces postoperative failure and the recurrence rate of complex fistula with acceptable long-term outcomes.