Complex anal fistulas: plug or flap?

Ligation of the intersphincteric fistula tract procedure and its modifications

Purpose Treatment of anal fistulae is regarded as a challenge due to the diverse nature of this disease and its countless complications. Ligation of the intersphincteric fistula tract procedure and its modifications have been popularized among many surgeons worldwide due to their simplicity and promising outcomes. The main purpose of this article was to conduct a comprehensives review of the published literature on ligation of the intersphincteric fistula tract procedure and its modifications.

Method PubMed, the Cochrane database and Ovid were searched from January 2007 to June 2017. Fully published peer-reviewed studies which applied ligation of the intersphincteric fistula tract procedure and its modifications for the treatment of anal fistulae of cryptogenic origin with follow-up of median 12 months were eligible. Uncompleted studies, case reports, reviews, abstracts, letters, short communication, comments, and studies which did not fulfill inclusion criteria were excluded. The primary outcome was to measure primary healing, overall healing, failure, and recurrence of ligation of the intersphincteric fistula tract procedure and its modifications.

Results Twenty-two studies were identified with only ten studies meeting criteria of inclusion. Original ligation of the intersphincteric fistula tract was performed in five studies with a population of 199 patients while the remaining five studies showed four different modifications of the ligation of the intersphincteric fistula tract with a total number of 147 patients. Both original LIFT and its modifications have promising as well as potentially similar outcomes; primary healing in the original ligation of the intersphincteric fistula tract (73.95%) (95% CI 60.3–85.6) performed less than the modifications (82.3%) (95% CI 64.8–94.7). Overall healing in the original ligation of the intersphincteric fistula tract (78.9%) (95% CI 58.5–93.7) performed relatively less than in the modifications (93.6%) (95% CI 81.4–99.6). Failure in the original ligation of the intersphincteric fistula tract (17.9%) (95% CI 4.9–36.5) performed almost the same as the modifications (17.7%) (95% CI 5.3–35.2). Recurrence in the original ligation of the intersphincteric fistula tract was 9.7% (95% CI 1.7–23.2). However, there was no recurrence in the modifications.

Conclusion Ligation of the intersphincteric fistula tract and its modifications are effective and simple procedures in treating simple anal fistulae, especially high transsphincteric ones. However, more trials should be performed to evaluate its effectiveness regarding complex fistulae.

LIFT and BioLIFT: a 10-Year Single-Centre Experience of Treating Complex Fistula-In-Ano With Ligation of Intersphincteric Fistula Tract Procedure With or Without Bio-prosthetic Reinforcement (BioLIFT)

PURPOSE

To assess the outcome of ligation of intersphincteric fistula tract (LIFT) and bioprosthetic graft (BioLIFT) in the management of transsphincteric perianal fistula.

METHODS

A single-institution retrospective analysis of all patients undergoing LIFT and BioLIFT from January 2009 to June 2018 was performed. Only patients who had LIFTs and BioLIFT performed as their primary sphincter-preserving procedure was included. Primary outcome measured was primary healing. Secondary outcomes measured were secondary healing, morbidity, time to recurrence, and pre- and post-operative anorectal manometry. Chi-square analysis was used to determine predictive factors.

RESULTS

A total of 116 patients were identified. One hundred five had LIFT and 11 had BioLIFT. The total primary healing rate was 60.3% (62.9% and 34.9% for LIFT and BioLIFT respectively). The overall secondary healing rate was 80.2% (80.0% and 81.9% for LIFT and BioLIFT respectively). There was no inpatient morbidity or post-procedural faecal incontinence reported. There was no significant change in the pre- and post-operative manometries in either group (P = 0.417 and P = 0.834 for LIFT and BioLIFT respectively). The only predictor for primary failure identified was anteriorly located fistula.

CONCLUSION

LIFT and BioLIFT compare favourably with other sphincter-preserving procedures. LIFT and BioLIFT can be performed safely, with minimal morbidity and with no reported loss of sphincteric function.

Anal fistula plug vs rectal advancement flap for the treatment of complex cryptoglandular anal fistulas: a systematic review and meta-analysis of studies with long-term follow-up

AIM

The aim was to compare the effectiveness of the anal fistula plug (AFP) with the rectal advancement flap (RAF) for complex cryptoglandular anal fistulas.

METHODS

We conducted a literature search to identify relevant available articles published without language restriction from Embase and PubMed databases and the Cochrane Library. Studies comparing outcomes with the AFP vs RAF for complex cryptoglandular anal fistulas were eligible for inclusion.

RESULTS

A total of 11 articles with 810 patients were included in this meta-analysis. Four RCTs and one observational clinical study provided long-term follow-up. The pooled analysis of all 11 studies indicated that there was no significant difference between the AFP and RAF in terms of healing rate, recurrence rate and incidence of fistula complications. However, the pooled results of studies with long-term follow-up revealed that the RAF group had a significantly higher healing rate (OR 0.32, 95% CI 0.13, 0.78, P = 0.01) and lower recurrence rate (OR 4.45, 95% CI 1.45, 13.65, P = 0.009) than the AFP group.

CONCLUSIONS

For the treatment of complex cryptoglandular anal fistulas, the RAF was superior to the AFP in terms of healing and recurrence rate after pooling of randomized controlled trials with long-term follow-up, even though a comparison based on the pooling of all studies showed no significant difference.

Adoption and success rates of perineal procedures for fistula-in-ano: a systematic review

AIM

Several sphincter-preserving techniques have been described with extremely encouraging initial reports. However, more recent studies have failed to confirm the positive early results. We evaluate the adoption and success rates of advancement flap procedures (AFP), fibrin glue sealant (FGS), anal collagen plug (ACP) and ligation of intersphincteric fistula tract (LIFT) procedures based on their evolution in time for the management of anal fistula.

METHOD

A PubMed search from 1992 to 2015. An assessment of adoption, duration of study and success rate was undertaken.

RESULTS

We found 133 studies (5604 patients): AFP (40 studies, 2333 patients), FGS (31 studies, 871 patients), LIFT (19 studies, 759 patients), ACP (43 studies, 1641 patients). Success rates ranged from 0% to 100%. Study duration was significantly associated with success rates in AFP (P = 0.01) and FGS (P = 0.02) but not in LIFT or ACP. The duration of use of individual procedures since first publication was associated with success rate only in AFP (P = 0.027). There were no statistically significant differences in success rates relative to the number of the patients included in each study.

CONCLUSION

Success and adoption rates tend to decrease with time. Differences in patient selection, duration of follow-up, length of availability of the individual procedure and heterogeneity of treatment protocols contribute to the diverse results in the literature. Differences in success rates over time were evident, suggesting that both international trials and global best practice consensus are desirable. Further prospective randomized controlled trials with homogeneity and clear objective parameters would be needed to substantiate these findings.