Ligation of intersphincteric fistula tract: early results of a pilot study

Is the ligation of the intersphincteric fistula tract (LIFT) procedure truly a sphincter preserving procedure for anal fistula? A scoping review of the literature

INTRODUCTION

The ligation of the intersphincteric fistula tract (LIFT) procedure has garnered popularity with its success rates and purported sphincter-continence preservation. However, there remains a paucity in the literature on the objective evaluation of sphincter integrity and fecal continence after the LIFT procedure.

OBJECTIVES

The present study undertakes a scoping review to systematically explore and map the published literature, to evaluate the sufficiency of data on the impact on continence in patients after the LIFT procedure.

DESIGN

A systematic search of MEDLINE, PubMed, EMBASe, CINAHL was performed from January 2007 to April 2020 and 597 publications were identified. Forty-two satisfied the inclusion and exclusion criteria. We performed a scoping review in accordance to the PRISMA-ScR guidelines.

RESULTS

Only 3 (7.1%) of publications were randomized controlled trials, of which just 1 (2.4%) measured incontinence as a primary outcome. Continence was measured both pre- and post-LIFT in 30 (71.4%), of which 19 (45.2%) had a fixed protocol for continence assessment, which was heterogeneous between the studies. Continence was assessed using subjective scoring systems in 27 (64.3%) and objective measurement was performed in just 6 (14.3%). No studies performed post-operative anatomical assessment of the anal sphincter complex.

CONCLUSIONS

Long-term continence in post-LIFT patients is not supported with adequately powered prospective longitudinal trials using rigorously protocoled pre- and post-operative assessment of continence. Future research that focuses on a combination of objective assessment using anal manometry as well as anatomical assessment of the sphincter complex on top of subjective evaluation is needed before we can be certain if LIFT is indeed a sphincter and continence preserving technique.

Ligation of the intersphincteric fistula tract (LIFT) for high transsphincteric fistulas: a double-center retrospective study with long-term follow-up

PURPOSE

This study aimed to evaluate the long-term efficacy of the ligation of the intersphincteric fistula tract (LIFT) procedure in treating high transsphincteric fistulas.

METHODS

We conducted a retrospective study to evaluate the success rate of LIFT treatment in 82 patients with high transsphincteric fistulas involving at least one-third of the external sphincter. This study was carried out across 2 centers from November 2009 to February 2023.

RESULTS

All patients underwent successful surgery with a median operative time of 48.9 minutes (range, 20-80 minutes), and no intraoperative or postoperative complications were reported. The median follow-up duration was 85.5 months (range, 4-120 months), with 5 patients (6.1%) lost to follow-up. Treatment was successful in 62 patients, whose symptoms disappeared and both the external opening and the intersphincteric incision completely healed, yielding an overall efficiency rate of 80.5%. There were 15 cases (19.5%) of treatment failure, including 6 (7.8%) that converted to intersphincteric anal fistula and 9 (11.7%) that experienced persistent or recurrent fistulas. Only 1 patient reported minor overflow during the postoperative follow-up, but no other patients reported any significant discomfort. There were no statistically significant differences between patients with surgical success and those with treatment failure in terms of fistula length, history of previous abscess or anal fistula surgery, number of external orifices or fistulas, and location of fistulas (all P>0.05).

CONCLUSIONS

LIFT is a safe and effective sphincter-preserving procedure that yields satisfactory healing outcomes and has minimal impact on anal function.

Medium- to long-term outcomes of seton placement for fistula-in-ano in children: the experience of 103 patients from a single institution

PURPOSE

The aim of this study was to evaluate the efficacy of seton placement for anal fistula in children.

METHODS

The clinical data of children with anal fistula treated by seton placement admitted from January 2017 to September 2022 were retrospectively analyzed. Our primary treatments for perianal abscess (PA) are conservative treatment and drainage. Patients with systemic and inflammatory bowel diseases were excluded.

RESULTS

The median follow-up time of these patients was 23 (6-58) months, and the median onset age was 16 (3-156) months. Among the 103 patients, 75 with a single fistula and 20 with a double fistula were treated by primary seton placement. Seven patients with multiple fistulas were treated using staged seton placement, and one case using primary seton placement. A total of 97 patients experienced good healing, four patients experienced poor healing and healed after dressing change and debridement, and two patients with multiple fistulas who experienced recurrence underwent a second seton placement. The average healing time was four (1-10) weeks.

CONCLUSION

The medium- to long-term outcome of seton placement indicates that this procedure is safe and effective in the treatment of anal fistula in children.

Use of 3D Anorectal Ultrasonography in the Preoperative Assessment of Complex Anal Fistulas and Patterns of Healing, Failure, and Recurrence After Ligation of the Intersphincteric Fistula Tract (LIFT)

OBJECTIVES

To use three-dimensional anorectal ultrasonography (3D-US) to evaluate the outcome of ligation of the intersphincteric fistula tract (LIFT) in patients with crypto-glandular transsphincteric fistula and describing the patterns of healing, failure, and recurrence rate.

METHODS

After classifying the fistula and determining the length of the sphincter muscle to be transected, the patients were submitted to LIFT. The accuracy of pre- and postoperative 3D-US with 360° endoprobe (16 MHz) with automatic scanning and clinical findings was evaluated against surgical findings. Three outcomes were considered: healing, failure (persistent anal fistula through the original external opening or intersphincteric), and recurrence (reappearance of the anal fistula).

RESULTS

Sixty-three patients of both sexes were evaluated. The 3D-US assessment revealed primary healing in 50 (79.3%) patients, although in 6 (9.5%) cases healing was delayed and the cavity was without communication with the anal canal. The procedure failed in 9 (15.9%) and fistula recurred in 4 (6.3%), all of whom underwent a second surgery based on a new 3D-US, resulting in a 92.3% (12/13) healing rate on 3D-US.

CONCLUSIONS

A 3D-US was found to be useful in the preoperative assessment of fistulas by quantifying the percentage of muscle to be transected, and in the postoperative assessment by identifying healing, types of failure, and recurrence. The 3D-US was accurate and consistent with surgical findings.

Tsay A, Abbass M. Immediate sphincter repair following fistulotomy for anal fistula: does it impact the healing rate and septic complications?

PURPOSE

Fistulotomy is considered the most effective treatment for anal fistula; however, it carries a risk of incontinence. Sphincteroplasty in the setting of fistulotomy is not standard practice due to concerns regarding healing and potential infectious complications. We aimed to compare the outcomes of patients who underwent fistulotomy with primary sphincteroplasty to those who did not undergo repair.

METHODS

This was a retrospective review of consecutive patients who underwent fistulotomy for cryptoglandular anal fistula. All operations were performed by one colorectal surgeon. Sphincteroplasty was performed for patients perceived to be at higher risk for continence disturbance. The main outcome measures were the healing rate and postoperative septic complications.

RESULTS

In total, 152 patients were analyzed. Group A (fistulotomy with sphincteroplasty) consisted of 45 patients and group B (fistulotomy alone) included 107 patients. Both groups were similar in age (P=0.16) and sex (P=0.20). Group A had higher proportions of multiple fistulas (26.7% vs. 6.5%, P<0.01) and complex fistulas (mid to high transsphincteric, 37.8% vs. 10.3%; P<0.01) than group B. The median follow-up time was 8 weeks. The overall healing rate was similar in both groups (93.3% vs. 90.6%, P=0.76). No significant difference between the 2 groups was noted in septic complications (6.7% vs. 3.7%, P=0.42).

CONCLUSION

Fistulotomy with primary sphincter repair demonstrated a comparable healing rate to fistulotomy alone, without an increased risk of postoperative septic complications. Further prospective randomized studies are needed to confirm these findings and to explore the functional outcomes of patients who undergo sphincteroplasty.

European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula

AIM

The primary aim of the European Society of Coloproctology (ESCP) Guideline Development Group (GDG) was to produce high-quality, evidence-based guidelines for the management of cryptoglandular anal fistula with input from a multidisciplinary group and using transparent, reproducible methodology.

METHODS

Previously published methodology in guideline development by the ESCP has been replicated in this project. The guideline development process followed the requirements of the AGREE-S tool kit. Six phases can be identified in the methodology. Phase one sets the scope of the guideline, which addresses the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula in adult patients presenting to secondary care. The target population for this guideline are healthcare practitioners in secondary care and patients interested in understanding the clinical evidence available for various surgical interventions for anal fistula. Phase two involved formulation of the GDG. The GDG consisted of 21 coloproctologists, three research fellows, a radiologist and a methodologist. Stakeholders were chosen for their clinical and academic involvement in the management of anal fistula as well as being representative of the geographical variation among the ESCP membership. Five patients were recruited from patient groups to review the draft guideline. These patients attended two virtual meetings to discuss the evidence and suggest amendments. In phase three, patient/population, intervention, comparison and outcomes questions were formulated by the GDG. The GDG ratified 250 questions and chose 45 for inclusion in the guideline. In phase four, critical and important outcomes were confirmed for inclusion. Important outcomes were pain and wound healing. Critical outcomes were fistula healing, fistula recurrence and incontinence. These outcomes formed part of the inclusion criteria for the literature search. In phase five, a literature search was performed of MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews by eight teams of the GDG. Data were extracted and submitted for review by the GDG in a draft guideline. The most recent systematic reviews were prioritized for inclusion. Studies published since the most recent systematic review were included in our analysis by conducting a new meta-analysis using Review manager. In phase six, recommendations were formulated, using grading of recommendations, assessment, development, and evaluations, in three virtual meetings of the GDG.

RESULTS

In seven sections covering the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula, there are 42 recommendations.

CONCLUSION

This is an up-to-date international guideline on the management of cryptoglandular anal fistula using methodology prescribed by the AGREE enterprise.

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.

Ligation of Intersphincteric Fistula Tract (LIFT) with or Without Injection of Bone Marrow Mononuclear Cells in the Treatment of Trans-sphincteric Anal Fistula: a Randomized Controlled Trial

BACKGROUND

Ligation of intersphincteric fistula tract (LIFT) is a sphincter-saving procedure used for treatment of complex anal fistula. The current study aimed to assess the outcome of local injection of bone marrow mononuclear cells (BM-MNCs) in conjunction with LIFT as compared to LIFT alone in regards to healing rate, time to healing, and ultimate success rate.

METHODS

This was a prospective randomized trial on patients with trans-sphincteric anal fistula. Patients were randomly allocated to one of two equal groups: LIFT and LIFT with BM-MNC injection. The main outcome measures were healing at 10 weeks of follow-up, recurrence after healing, and complications.

RESULTS

Seventy patients (48 male and 22 female) of a mean age of 37.9 ± 10.4 years were included. The mean time to complete healing after LIFT + BM-MNCs was significantly shorter than after LIFT alone (20.5 ± 5.2 vs 28.04 ± 5.8 days; P < 0.0001). The ultimate success rates of both groups were similar (LIFT = 60% vs LIFT with BM-MNCs = 68.6%, P = 0.62). There was no significant difference in the mean operation time or complication rate between the two groups. Secondary extension and previous anal surgery were significant independent predictors of failure of healing.

CONCLUSION

LIFT combined with BM-MNC injection was associated with a shorter time to complete healing than LIFT alone. However, BM-MNC injection did not have a significant impact on the overall healing and ultimate success rate.

A Retrospective Critique of the Various Sphincter-preserving Surgical Procedures for Ischiorectal Fistula

In the 1950s, the cause of anal fistulas was identified as an infection of the anal gland (cryptoglandular infection theory). Thereafter, treatment for this disorder began in the 1960s with the lay-open procedure, which involved incising the sphincter and the fistula tract. However, it was found that too much invasion into the sphincter could result in postoperative fecal incontinence. Thus, to reduce such risk, sphincter-preserving surgery was applied for superficial anal fistula in 1961 and for deep anal fistula (ischiorectal fistula) in 1965. Over the years, more effective sphincter-preserving procedures for ischiorectal fistula have been developed to improve the quality of life of the patient. In this review article, we aim to first introduce the basic surgical techniques for ischiorectal fistula. We will discuss the anatomy of the anus and the pathogenesis of ischiorectal fistula and will provide some diagnostic methods. Representative sphincter-preserving procedures that have been performed for ischiorectal fistula since 1965 will also be categorized and outlined chronologically. The discussion will look at the following techniques for ischiorectal fistula and outline the advantages and disadvantages of each procedure so that they can be used as a reference for ischiorectal fistula surgery in the future: the lay-open procedure (fistulotomy and fistulectomy), the Hanley procedure (first partial sphincter-preserving procedure), the muscle-filling procedure, the Moriya method and Ui method (modified partial sphincter-preserving procedure), the Takano method and the sphincter-preserving lateral procedure (complete sphincter-preserving procedure), the seton method (a cross between the lay-open procedure and sphincter-preserving procedure), and the overseas sphincter-preserving procedure.

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.

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.

Heterogeneity in outcome selection, definition and measurement in studies assessing the treatment of cryptoglandular anal fistula: findings from a systematic review

Background

Treatment for cryptoglandular anal fistula (AF) is challenging and a lack of uniform outcomes in the literature prevents direct comparison of treatments. This can be addressed by developing a core outcome set, a standardised set of outcomes reported in all interventional studies for a specific condition. The aim of this systematic review is to assess the range of outcomes, their definitions, and the measurement instruments currently utilised in interventional studies for adult patients with AF. This will inform the development of an AF core outcome set.

Methods

Medline, Embase and The Cochrane Library were searched to identify all patient- and clinician-reported outcomes in studies assessing medical, surgical or combination treatment of adult patients with AF published from January 2008 to May 2020. The resulting outcomes were categorized according to the Core Outcome Measurement in Effectiveness Trials (COMET) taxonomy to better understand their distribution.

Results

In total, 155 studies were included, 552 outcomes were extracted, with a median of three outcomes (interquartile range 2–5) per study. Only 25% of studies demonstrated high-quality outcome reporting. The outcomes were merged into 52 unique outcomes and structured into four core areas and 14 domains, with the majority in the domain of physiological or clinical (gastrointestinal) outcomes. The most commonly reported outcomes were healing (77%), incontinence (63%), and recurrence (40%), with no single outcome assessed across all studies. There was a wide variation in outcome definitions and measurement instruments used.

Conclusions

There is substantial heterogeneity in outcomes, definitions, and measurement instruments reported in interventional studies for cryptoglandular anal fistula. This emphasises the need for standardised outcome reporting and measurement.

Systematic review of efficacy of LIFT procedure in crpytoglandular fistula-in-ano

Background fistula-in-ano is a common problem. Ligation of intersphincteric fistula tract (LIFT) is a new addition to the list of operations available to deal with complex fistula-in-ano.

Objective we sought to qualitatively analyze studies describing LIFT for crpytoglandular fistula-in-ano and determine its efficacy.

Data sources MEDLINE (Pubmed, Ovid), Embase, Scopus and Cochrane Library were searched.

Study selection all clinical trials which studied LIFT or compared LIFT with other methods of treatment for anal fistulae, prospective observational studies, clinical registry data and retrospective case series which reported clinical healing of the fistula as the outcome were included. Case reports, studies reporting a combination with other technique, modified technique, abstracts, letters and comments were excluded.

Intervention the intervention was ligation of intersphincteric fistula tract in crpytoglandular fistula-in-ano.

Main outcome measure primary outcome measured was success rate (fistula healing rate) and length of follow-up.

A Novel Surgical Technique for Anal Fistula Surgery Designed to Preserve the Anal Sphincter Function and Anoderm

Objectives:

We reviewed surgical outcomes after introducing a novel surgical technique for anal fistula surgery designed to preserve anal sphincter function and the anoderm.

Methods:

We studied 200 male patients who underwent a functional preservative operative technique (FPOT group) for anal fistulas and 200 patients who underwent resection of trans-sphincteric anal fistulas (fistulectomy group) between February 2014 and September 2015. We compared complications, such as those affecting anal sphincter function, recurrence, and incontinence.

Results:

Fistulas recurred in three (1.5%) patients in the FPOT group and two (1%) patients in the fistulectomy group. This difference was not significant. Other complications included gas leakage and other forms of incontinence in 1 (0.5%) and 14 (7%) patients in the FPOT and fistulectomy groups, respectively. Anal function assessment demonstrated that the FPOT was significantly better at preserving function than fistulectomy in all patients.

Conclusions:

There were no significant differences between the FPOT and fistulectomy in terms of recurrence or complication rates. Also, because there was no decrease in postoperative anal function, we concluded that the FPOT is an effective preservative surgical technique for treating trans-sphincteric anal fistulas.

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.

Treatment of Refractory Perianal Fistulas with Ligation of the Intersphincteric Fistula Tract: Preliminary Results

Several surgical options exist for management of fistula in ano. The goal of treatment is to achieve closure of the fistula while maintaining continence. Sphincter-sparing operations to close perianal fistulas include advancement flap, anal fistula plug, fibrin glue, and fistulectomy. Variable success rates from 30 to 80 per cent have been reported. Ligation of intersphincteric fistula tract (LIFT), first described in 2007, has a reported success rate from 40 to 94 per cent. The objective of this study was to study our results of the LIFT procedure for refractory perianal fistulas. We conducted a retrospective 18-month review of consecutive patients with refractory perianal disease treated with the LIFT procedure at an academic, tertiary, colorectal practice. All patients undergoing a LIFT procedure for anal fistula from August 2010 to August 2012 were included in the study. The primary end points were success rates at 1 month and 3 months. Secondary end points were postoperative complications and maintenance of continence. Twenty patients underwent LIFT procedures of whom nine had previously failed treatments. Mean age was 45 years and included 12 male and eight female patients. Success rate at 1 month was 70 per cent (14 patients) and at 3 months was 80 per cent (16 patients). Success rates for patients with previously failed attempts were 67 per cent at 1 month and 89 per cent at 3 months. Continence was maintained in 100 per cent of patients. Our data support the use of the LIFT procedure for refractory perirectal fistulas.

Lift and VAAFT for high trans-sphincteric anal fistula: a single center retrospective analysis

PURPOSE

The management of complex anal fistulas remains a challenge, mainly due to the considerable risk of incontinence. We compared LIFT and VAAFT in the treatment of complex anal fistulas in terms of healing time, recurrence, continence, morbidity, and postoperative pain, focusing also on patients with local abscess at the time of surgery.

METHODS

We include all patients with high trans-sphincteric anal fistula even with abscess at the time of surgery. Anorectal manometry, endoanal ultrasound, Cleveland Clinic fecal incontinence score, VAS score, and number of previous fistula treatment were recorded. The clinical examination defined healing, insufficiency or recurrence of the fistula.

RESULTS

Fifty-four consecutive patients are undergoing surgery: 26 patients underwent LIFT and 28 underwent VAAFT. During the 18 months of follow-up there were no differences in terms of AM, CCFIS and VAS scores. Days of healing, failure, and recurrence rate were comparable in both groups. The subgroup of patients with local abscess undergoing LIFT showed worse results in terms of failure and recurrence rate (p < 0.05).

CONCLUSIONS

Both techniques are safe and effective and can offer long-term benefits. LIFT should not be used as a first treatment in high trans-sphincteric fistula with perianal abscess.

Perianal fistulas and the lift procedure: results, predictive factors for success, and long-term results with subsequent treatment

Background

Treatment of a perianal fistula is difficult due to the risk of fecal incontinence and recurrence. The ligation of intersphincteric tract (LIFT) procedure is a sphincter-saving procedure associated with success rates ranging from 57 to 94%. The aim of our study was to find predictors for a favorable outcome of the LIFT procedure, evaluation of postoperative fecal incontinence, quality of life, and subsequent treatment with long-term follow-up.

Methods

This study was performed in patients who underwent LIFT between 2013 and 2015 at our institution. Their medical data were retrieved from the electronic patient files. The fistula characteristics were described by physical examination, three-dimensional endoanal ultrasound, and perioperative evaluation. Recurrence rate, postoperative fecal incontinence, and quality of life were assessed with the Patient-Reported Outcome Measurement (PROM). Thirty-two months later, long-term follow-up including subsequent procedures was evaluated.

Results

Forty-five patients [17 men, mean age 40 years (range 24–67 years)] were included. In 41 (84%) patients, the fistula was classified as complex; 32 (71%) were referrals with a history of previous fistula surgery. The initial success rate was 18 (40%). Only the height of the internal fistula opening (≥ 15 mm p < 0.03) was associated with recurrence. The LIFT procedure did not affect the occurrence of fecal incontinence or soiling. Recurrence showed a trend with a lower PROM (p = 0.07). Twenty-four months later, further surgery leads to cure in 34 (75%), asymptomatic fistulas in 7 (16%), and persisting active fistulas in 4 (9%) patients.

Conclusions

Initial LIFT had a success rate of 40% and with subsequent surgical treatment 75%. Recurrence after LIFT is related to the height of the internal fistula opening and is associated with diminished quality of life. Continence was not affected by initial LIFT.

Cx601 (darvadstrocel) for the treatment of perianal fistulizing Crohn's disease

Introduction: Given the well-documented difficulty to treat perianal fistulizing Crohn's disease (pCD), with 40% of patients experiencing recurrence even after reiterative surgery and advanced medical therapy, research in this field has focused on the role of mesenchymal stem cells (MSC). Areas covered: The aim of this article is to furnish an overview of the pathogenetic mechanisms, clinical applications and evidences for the use of MSC for pCD with particular focus on adipose-derived allogenic MSC including darvadstrocel. Expert Opinion: The effect of MSC on fistula healing is probably mediated by their anti-inflammatory properties more than by their ability to engraft and trans-differentiate in the healthy tissue. A holistic treatment of pCD, addressing different pathophysiological factors, may represent the key for an improvement in the healing rate. In this setting, MSC might play a role as 'augmentation' therapy in combination with more conventional treatments. Whether MSC have benefit in non-complex fistula in biological naïve patients, in complex fistula with many tracts and/or in rectovaginal fistulas, are unexplored fields that need further investigation. A central registry of pCD patients undergoing treatment with MSC should be created in order to elucidate the efficacy, safety and costs of stem cells treatment on long term follow up.

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

Background

High perianal fistulas require sphincter‐preserving surgery because of the risk of faecal incontinence. The ligation of the intersphincteric fistula tract (LIFT) procedure preserves anal sphincter function and is an alternative to the endorectal advancement flap (AF). The aim of this study was to evaluate outcomes of these procedures in patients with cryptoglandular and Crohn's perianal fistulas.

Methods

A systematic literature search was performed using MEDLINE, Embase and the Cochrane Library. All RCTs, cohort studies and case series (more than 5 patients) describing one or both techniques were included. Main outcomes were overall success rate, recurrence and incontinence following either technique. A proportional meta‐analysis was performed using a random‐effects model.

Results

Some 30 studies comprising 1295 patients were included (AF, 797; LIFT, 498). For cryptoglandular fistula (1098 patients), there was no significant difference between AF and LIFT for weighted overall success (74·6 (95 per cent c.i. 65·6 to 83·7) versus 69·1 (53·9 to 84·3) per cent respectively) and recurrence (25·6 (4·7 to 46·4) versus 21·9 (14·8 to 29·0) per cent) rates. For Crohn's perianal fistula (64 patients), no significant differences were observed between AF and LIFT for overall success rate (61 (45 to 76) versus 53 per cent respectively), but data on recurrence were limited. Incontinence rates were significantly higher after AF compared with LIFT (7·8 (3·3 to 12·4) versus 1·6 (0·4 to 2·8) per cent).

Conclusion

Overall success and recurrence rates were not significantly different between the AF and LIFT procedure, but continence was better preserved after LIFT.

INTERESFINCTERIAL LIGATION OF FISTULA TRACT (LIFT) FOR PATIENTS WITH ANAL FISTULAS: A BRAZILIAN BI-INSTITUTIONAL EXPERIENCE

Background:

The best treatment for anal fistula should extirpate infection and promote healing of the tract, whilst preserving the anal sphincter complex and full continence.

Aim:

To analyze the success rate after a modified technique for ligation of the intersphincteric fistula tract (LIFT) for patients with anal fistulas.

Methods:

A prospective (observational cohort study) Brazilian bi-institutional experience with a modified (ligation of the intersphincteric fistula tract without excision) LIFT technique was undertaken. A clinical database was settled for the following variables: age, gender, BMI, comorbidities, distance between external orifice and the anus, previous fistula surgery, type of fistula, operative time, intra- and postoperative complications, duration of follow-up, and success rate.

Results:

Between November 2015 and January 2017, 38 patients with transsphincteric fistulas were operated on using the modified LIFT procedure. Seventeen (44.7%) were men. Median age was 41 (18-67) years. Median BMI was 26.4 (22-38) kg/m². Five (13.2%) had undergone previous surgery. The fistula was transsphincteric in all cases. Median follow-up was 32 (range, 14-56) weeks. Success was observed in 30 (79%) patients.

Conclusions:

The LIFT technique without excision of the fistula tract proved to be safe and effective for transsphincteric anal fistulas.

Japanese Practice Guidelines for Anal Disorders II. Anal fistula

Anal fistulas usually result from an anal gland infection in the intersphincteric space, which is caused by bacteria entering through the anal crypt (cryoptglandular infection). Reports of anal fistulas have been as high as 21 people in 100,000. Anal fistulas are 2-6 times more prevalent in males than females, with the condition occurring most frequently in patients in their 30s and 40s. Anal abscess symptoms include sudden onset of anal pain, swelling, redness, and fever. Purulent discharge or intermittent perianal swelling and pain are most often consistent with anal fistula symptoms. Methods for diagnosing anal fistulas include visual inspection, palpation, digital examination, anoscopic examination, barium enema, fistulography, as well as imaging, such as ultrasound, CT, and MRI. Parks classification is widely adapted in the West; however, Japan usually employs Sumikoshi classification. Antibiotics should be administered in cases of perianal abscess with surrounding cellulitis, or concomitant systemic disease, or those not alleviated by incision and drainage. The site and size of incision and drainage depend upon the abscess type and location. Incisions should be performed taking care not to damage the sphincter muscles and with possible future fistula surgery in mind. As spontaneous recovery is rare, except in the case of children, surgery is the principle approach to anal fistulas. Several approaches are utilized for anal fistulas. A specific procedure may be chosen depending upon curability and anal function. Postsurgical outcomes vary from study to study. Fecal incontinence may occur after fistula surgery, but reports vary.

The treatment of anal fistula: second ACPGBI Position Statement - 2018

It is over 10 years since the first ACPGBI Position Statement on the management of anal fistula was published in 2007. This second edition is the result of scrutiny of the literature published during this time; it updates the original Position Statement and reviews the published evidence surrounding treatments for anal fistula that have been developed since the original publication.

Sphincter-Sparing Anal Fistula Repair: Are We Getting Better?

BACKGROUND

Sphincter-sparing repairs are commonly used to treat anal fistulas with significant muscle involvement.

OBJECTIVE

The current study evaluates the trends and efficacy of sphincter-sparing repairs and determines risk factors for fistula recurrence.

DESIGN AND SETTINGS

A retrospective review was performed at 3 university-affiliated teaching hospitals.

PATIENTS

All 462 patients with cryptoglandular anal fistulas who underwent 573 sphincter-sparing repairs between 2005 and 2015 were included. Patients with Crohn's disease were excluded.

MAIN OUTCOME MEASURES

The primary outcome was the rate of fistula healing defined as cessation of drainage with closure of the external opening. Risk factors for nonhealing were also analyzed.

RESULTS

Five hundred three sphincter-sparing repairs were analyzed, whereas 70 were lost to follow-up. Two hundred twenty sphincter-sparing repairs (44%) resulted in healing, 283 (56%) resulted in nonhealing with a median follow-up of 9 (range, 1-125) months. The median time to fistula recurrence was 3 (range, 0-75) months with 79% and 91% of recurrences noted within 6 and 12 months. Patients treated with a dermal advancement flap, rectal advancement flap, or ligation of the intersphincteric tract procedure were less likely to have a recurrence than patients treated with a fistula plug or fibrin glue (p < 0.001). Over time, there was a significantly increased use of the ligation of the intersphincteric tract procedure (p < 0.001) and a significantly decreased use of fistula plugs and fibrin glue (p < 0.001); healing rates improved accordingly. There were no significant differences in healing rates with respect to patient demographics, comorbidities, or fistula characteristics.

LIMITATIONS

This study was limited by its retrospective design.

CONCLUSIONS

Healing rates following sphincter-sparing repairs of cryptoglandular anal fistulas are modest, but have improved over time with the use of better surgical techniques. In this study, ligation of the intersphincteric fistula tract and flaps were superior to fistula plugs and fibrin glue; the former procedures are therefore favored. See Video Abstract at http://links.lww.com/DCR/A391.

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

BACKGROUND

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.

OBJECTIVE

This study aims to report a 10-year experience of ligation of intersphincteric fistula tract with extended long-term follow-up.

DESIGN

Retrospective analysis of single-center data from May 2006 to October 2010 was performed.

SETTINGS

This study was conducted at a large tertiary hospital in Bangkok, Thailand.

PATIENTS

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.

MAIN OUTCOME MEASURES

Healing as defined by the absence of symptoms with no visible external opening on clinical examination. Follow-up was continued until May 2016.

RESULTS

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.

LIMITATIONS

This study was limited by its retrospective design.

CONCLUSION

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.

What happens after a failed LIFT for anal fistula?

BACKGROUND

Ligation of the intersphincteric fistula tract (LIFT) was developed to treat transsphincteric anal fistulas. The aftermath of a failed LIFT has not been well documented.

METHODS

Retrospective chart review of LIFT procedure for transsphincteric anal fistula between March 2012 and September 2016.

RESULTS

53 patients with LIFT procedure were identified, 20 (37.7%) had persistent fistula with median followup of 4 months. Following LIFT, recurrence of fistula was transsphincteric (75%) or intersphincteric (25%) (p = NS). Persistent transsphincteric fistulas after LIFT were treated with seton (71.4%) followed by advancement flap (20%) or fistulotomy (50%). Of the recurrent intersphincteric fistulas, 50% underwent seton placement followed by fistulotomy, or advancement flap. Of the patients who underwent surgery after failed LIFT, 50% have had resolution of the fistula; 31.7% are still undergoing treatment.

CONCLUSION

Patients who underwent surgery after failed LIFT had 50% healing with placement of seton followed by fistulotomy or rectal advancement flap.

Pathogenesis and persistence of cryptoglandular anal fistula: a systematic review

Anal fistulas continue to be a problem for patients and surgeons alike despite scientific advances. While patient and anatomical characteristics are important to surgeons who are evaluating patients with anal fistulas, their development and persistence likely involves a multifaceted interaction of histological, microbiological, and molecular factors. Histological studies have shown that anal fistulas are variably epithelialized and are surrounded by dense collagen tissue with pockets of inflammatory cells. Yet, it remains unknown if or how histological differences impact fistula healing. The presence of a perianal abscess that contains gut flora commonly leads to the development of anal fistula. This implies a microbiological component, but bacteria are infrequently found in chronic fistulas. Recent work has shown an increased expression of proinflammatory cytokines and epithelial to mesenchymal cell transition in both cryptoglandular and Crohn's perianal fistulas. This suggests that molecular mechanisms may also play a role in both fistula development and persistence. The aim of this study was to examine the histological, microbiological, molecular, and host factors that contribute to the development and persistence of anal fistulas.

Ligation of Intersphincteric Fistula Tract Is Suitable for Recurrent Anal Fistulas from Follow-Up of 16 Months

Since 2007, ligation of the intersphincteric fistula tract (LIFT) for the management of anal fistula was all introduced with initial success and excitement. It remains controversial which surgical procedure is suitable for transsphincteric fistula, especially to complex anal fistula. This retrospective study was designed to evaluate the results in patients with recurrent anal fistula by LIFT. A retrospective study of 55 complex fistula patients who underwent LIFT procedure in a single medical center was analyzed. Patients and fistula characteristics, complications, and recurrences were reviewed. All 55 patients underwent the procedure with a median follow-up of 16 months. Median operative time was 44 (range 23–88) minutes. Of the 55 patients, 33 (60%) healed completely and did not require any further surgical treatment at end of follow-up. Twenty-two (40%) recurrences and six complications were observed. Compared with patients who had undergone more than two surgical procedures, LIFT was more suitable for patients who had undergone one to two surgical procedures, and significant difference was observed in number of operations before LIFT (p = 0.002). Clinicians can consider the use of LIFT for the treatment of recurrent anal fistulas. A larger number of patients and prospective study are needed to be performed.

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.

Systematic review of evidence and consensus on perianal fistula: an analysis of national and international guidelines

AIM

Treatment of perianal fistula has evolved with the introduction of new techniques and biologicals in Crohn's disease (CD). Several guidelines are available worldwide, but many recommendations are controversial or lack high-quality evidence. The aim of this work was to provide an overview of the current available national and international guidelines for perianal fistula and to analyse areas of consensus and areas of conflicting recommendations, thereby identifying topics and questions for future research.

METHOD

MEDLINE, EMBASE and PubMed were systematically searched for guidelines on perianal fistula. Inclusion was limited to papers in English less than 10 years old. The included topics were classified as having consensus (unanimous recommendations in at least two-thirds of the guidelines) or controversy (fewer than three guidelines commenting on the topic or no consensus) between guidelines. The highest level of evidence was scored as sufficient (level 3a or higher of the Oxford Centre for Evidence-based Medicine Levels of Evidence 2009, http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/) or insufficient.

RESULTS

Twelve guidelines were included and topics with recommendations were compared. Overall, consensus was present in 15 topics, whereas six topics were rated as controversial. Evidence levels varied from strong to lack of evidence.

CONCLUSION

Evidence on the diagnosis and treatment of perianal fistulae (cryptoglandular or related to CD) ranged from nonexistent to strong, regardless of consensus. The most relevant research questions were identified and proposed as topics for future research.

Fistula tract curettage and the use of biological dermal plugs improve high transsphincteric fistula healing in an animal model

PURPOSE

The treatment of high transsphincteric fistula is a complex procedure, which may be associated with the risk of recurrence and fecal incontinence. In this study, we used an animal model to compare different types of sphincter-preserving treatments for transsphincteric fistula.

METHODS

Sixteen female New Zealand rabbits, weighing 2.8-4.8 kg underwent a surgical creation of high transsphincteric fistula. After 6 weeks, magnetic resonance imaging (MRI) was performed in order to confirm fistula formation and measure the fistula diameter. The rabbits were divided into three groups. Group 1 received no plug treatment (control). Autologous dermal graft and acellular dermal matrix were used as a plug in groups 2 and 3, respectively. Five weeks after treatment, fistula tract healing was determined by measuring the largest fistula diameter with MRI. All rabbits were euthanized and the anorectum excised en bloc for histopathological examination.

RESULTS

According to the MRI findings, all groups showed significant healing after the treatment (p < 0.05). The healing rate of fistula diameters after treatment was 40, 66, and 29% in the control, dermal graft, and acellular dermal matrix groups, respectively. In terms of negative healing parameters such as neutrophil, eosinophil, lymphocyte, and plasmocyte accumulation, dermal graft and acellular dermal matrix groups showed significantly lower results than those in the control group (p < 0.05).

CONCLUSION

According to MRI and histopathological results, fistula tract curettage and fistula orifice closure improved transsphincteric anal fistula healing. Additionally, in this study, plug treatment favoring autologous dermal graft resulted in better healing.

Ligation of Intersphincteric Fistula Tract: a Sphincter-Sparing Option for Complex Fistula-in-Ano

Fistulae-in-ano represent one of the more challenging anorectal diseases faced by surgeons, as appropriate management requires careful balance between the need for local sepsis control and patients' desire to maintain fecal continence. The ligation of intersphincteric fistula tract (LIFT) procedure, first described by Rojanasakul and colleagues in 2007, represents a sphincter-sparing technique for fistula management which has become our method of choice for transsphincteric fistulas. With this technique, patients frequently enjoy successful fistula healing., or, at worst, conversion to a less complex fistula tract. Here, we describe and illustrate our surgical approach and review success and recurrence rates presented in the published literature.

The ligation of the intersphincteric fistula tract procedure for anal fistula: a mixed bag of results

BACKGROUND

The ligation of the intersphincteric fistula tract procedure, a sphincter-preserving technique, aims to obtain complete, durable healing, while preserving fecal continence in the treatment of transsphincteric anal fistulas.

OBJECTIVE

This was a systematic review to evaluate the outcomes of the originally described (classic) ligation of the intersphincteric fistula tract procedure and the identified technical variations of the procedure.

DATA SOURCES

PubMed, Web of Science, and the archive of Diseases of the Colon & Rectum were searched with the terms "ligation of intersphincteric fistula" and "ligation of intersphincteric fistula tract."

STUDY SELECTION

Original, English-language studies reporting the primary healing rate for each technical variation of the ligation of the intersphincteric fistula tract procedure were included. Studies were excluded when the technique used was unclear or when primary healing rate was reported in a pooled manner including outcomes from multiple technical variations of the ligation of the intersphincteric fistula tract procedure.

INTERVENTION

Outcomes associated with all of the technical variations of the ligation of the intersphincteric fistula tract procedure were investigated.

MAIN OUTCOME MEASURES

The main outcome measured was primary healing rate. Secondary outcome measures included time to healing, changes in continence, and risk factors for failure.

RESULTS

In all, 26 studies met criteria for review, including 1 randomized controlled trial and 25 cohort/case series. Seven technical variations of the ligation of the intersphincteric fistula tract procedure were identified and classified according to the surgical technique. Primary healing rates ranged from 47% to 95%.

LIMITATIONS

The levels of evidence available in the published works are relatively low, as indicated by the Oxford Center for Evidence-Based Medicine evidence levels.

CONCLUSIONS

The ligation of the intersphincteric fistula tract procedure is a promising treatment option for transsphincteric fistulas, with reasonable success rates and minimal impact on continence. The true efficacy of the procedure is unknown because of the number of technical variations and the pooled results reported in the literature.

Modern management of anal fistula

Ideal surgical treatment for anal fistula should aim to eradicate sepsis and promote healing of the tract, whilst preserving the sphincters and the mechanism of continence. For the simple and most distal fistulae, conventional surgical options such as laying open of the fistula tract seem to be relatively safe and therefore, well accepted in clinical practise. However, for the more complex fistulae where a significant proportion of the anal sphincter is involved, great concern remains about damaging the sphincter and subsequent poor functional outcome, which is quite inevitable following conventional surgical treatment. For this reason, over the last two decades, many sphincter-preserving procedures for the treatment of anal fistula have been introduced with the common goal of minimising the injury to the anal sphincters and preserving optimal function. Among them, the ligation of intersphincteric fistula tract procedure appears to be safe and effective and may be routinely considered for complex anal fistula. Another technique, the anal fistula plug, derived from porcine small intestinal submucosa, is safe but modestly effective in long-term follow-up, with success rates varying from 24%-88%. The failure rate may be due to its extrusion from the fistula tract. To obviate that, a new designed plug (GORE BioA^®) was introduced, but long term data regarding its efficacy are scant. Fibrin glue showed poor and variable healing rate (14%-74%). FiLaC and video-assisted anal fistula treatment procedures, respectively using laser and electrode energy, are expensive and yet to be thoroughly assessed in clinical practise. Recently, a therapy using autologous adipose-derived stem cells has been described. Their properties of regenerating tissues and suppressing inflammatory response must be better investigated on anal fistulae, and studies remain in progress. The aim of this present article is to review the pertinent literature, describing the advantages and limitations of new sphincter-preserving techniques.

Biomaterials in the treatment of anal fistula: hope or hype?

Anal fistula (AF) presents a chronic problem for patients and colorectal surgeons alike. Surgical treatment may result in impairment of continence and long-term risk of recurrence. Treatment options for AFs vary according to their location and complexity. The ideal approach should result in low recurrence rates and minimal impact on continence. New technical approaches involving biologically derived products such as biological mesh, fibrin glue, fistula plug, and stem cells have been applied in the treatment of AF to improve outcomes and decrease recurrence rates and the risk of fecal incontinence. In this review, we will highlight the current evidence and describe our personal experience with these novel approaches.

Management of complex anorectal fistulas with seton drainage plus partial fistulotomy and subsequent ligation of intersphincteric fistula tract (LIFT)

BACKGROUND

Ligation of intersphincteric fistula tract (LIFT) is a relatively new technique in the treatment of complex anorectal fistulas. As it spares the anal sphincter, rates of post-operative incontinence may be lower when compared to conventional treatment. To date, there have not been enough reports of long-term fistula recurrence rates. We performed a long-term follow-up study of 75 patients who underwent LIFT following seton drainage and partial fistulotomy.

METHODS

Only patients with complex cryptogenic anorectal fistulas were included. After seton insertion and partial fistulotomy, the tract was reviewed at 4 months for the absence of anorectal sepsis. Patients then underwent LIFT in a day surgery setting. Operative time, complications, recurrences and incontinence were evaluated.

RESULTS

Between May 2008 and June 2013, 75 patients [51 men, mean age 49.5 years, standard error of the mean (SEM) 1.4 years] were treated with a LIFT protocol. The mean operating time for LIFT was 13.2 min (SEM 1.5 min). Complications included minor bleeding, superficial wound dehiscence and perianal pain. At a mean follow-up of 14.6 months (SEM 1.7 months), there were nine (12 %) recurrences, diagnosed at a mean 9.2 months (SEM 2.7 months). They were treated with seton insertion followed by LIFT with biomesh or anorectal advancement flap, and there were no subsequent recurrences. Review of preoperative and post-operative continence scores revealed only one (1.3 %) patient with minor incontinence following LIFT. Recurrences were significantly related to fistulas with multiple tracts (p < 0.001).

CONCLUSIONS

Our results suggest that the protocol of seton insertion and partial fistulotomy followed by LIFT is associated with a low recurrence rate comparing well with published results from studies involving other techniques and protocols for treating anal fistula.

Sphincter-sparing techniques for fistulas-in-ano

Anal fistulas require surgical treatment to cure the fistula. Fistulotomy is the treatment of choice because of its high success rate, but it also carries a risk of postoperative incontinence. Different methods have been proposed to overcome the need for dividing part or all of the sphincter, so-called "sphincter saving techniques" (SST), such as flap advancement, intrafistular injection of glue, or the insertion of a bio-prosthesis (collagen plug). However, the success rate of SSTs is lower than that of fistulotomy. Ligation of the Intersphincteric Fistula Tract (LIFT) is one of the most recent SSTs. It aims to ligate and transect the fistula by an approach through the intersphincteric space. The methodological quality of most published studies has been only average, but several studies have reported attractive success rates of 70 to 95% without postoperative incontinence. Other techniques such as endo-anal clip or injection of autologous stem cells are still anecdotal.

Ligation of intersphincteric fistula tract versus mucosal advancement flap in patients with high transsphincteric fistula-in-ano: a prospective randomized trial

PURPOSE

The aim of this study was to compare the ligation of the intersphincteric fistula track with the mucosal advancement flap in the treatment of high transsphincteric anal fistulas.

DESIGN AND SETTING

This was a prospective randomized study performed at academic medical centers.

PATIENTS

Patients with transsphincteric anal fistulas involving the upper part of anal sphincter were included.

INTERVENTION

Patients were randomly assigned to either ligation of intersphincteric fistula track or mucosal advancement flap.

MAIN OUTCOME MEASURES

The primary end points of the study were fistula closure, recurrence within 1 year, and continence by using the Wexner score. Secondary end points were morbidity, postoperative pain with the use of the visual analog scale, and quality of life with the use of the Cleveland Global Quality of Life score.

RESULTS

There were 70 patients (35 in each group). Mean age was 36.1 years in patients undergoing ligation of the intersphincteric fistula track vs 32.9 years in patients undergoing mucosal advancement flap (p = 0.33). Mean visual analog scale after 1 week was significantly higher in the mucosal advancement flap group than in the ligation of intersphincteric fistula track group (3.1 vs 4.8, p = 0.04), but no significant difference was found after 4 weeks. Primary healing was achieved in 33 patients undergoing ligation of the intersphincteric fistula track vs 32 patients undergoing mucosal advancement flap (p = 0.99). Mean healing time was 22.6 days in the ligation of intersphincteric fistula track group vs 32.1 days in mucosal advancement flap group (p = 0.01). After 1 year of follow-up, successful outcome was achieved in 26 patients (74.3%) undergoing ligation of intersphincteric fistula track and in 20 patients (65.7%) undergoing mucosal advancement flap (p = 0.58). No significant change in Wexner score occurred 4 weeks postoperatively. There was no significant difference between groups regarding Cleveland Global Quality of Life score (p = 0.5 and 0.07 after 4 and 12 weeks).

LIMITATIONS

The short-term follow-up is a probable limitation. Although the sample size was calculated to detect difference with 80% power at a significance level of 5%, the negative result within this relatively small number of patients might have resulted from type II statistical error.

CONCLUSIONS

In patients with high transsphincteric anal fistulas, both ligation of intersphincteric fistula track procedure and mucosal advancement flap have a similar long-term healing rate, recurrences, continence, and quality of life. However, ligation of the intersphincteric fistula track has the advantage of less postoperative pain.

A global consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn's disease

OBJECTIVE

To develop a consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn's disease (pCD), based on best available evidence.

METHODS

Based on a systematic literature review, statements were formed, discussed and approved in multiple rounds by the 20 working group participants. Consensus was defined as at least 80% agreement among voters. Evidence was assessed using the modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria.

RESULTS

Highest diagnostic accuracy can only be established if a combination of modalities is used. Drainage of sepsis is always first line therapy before initiating immunosuppressive treatment. Mucosal healing is the goal in the presence of proctitis. Whereas antibiotics and thiopurines have a role as adjunctive treatments in pCD, anti-tumour necrosis factor (anti-TNF) is the current gold standard. The efficacy of infliximab is best documented although adalimumab and certolizumab pegol are moderately effective. Oral tacrolimus could be used in patients failing anti-TNF therapy. Definite surgical repair is only of consideration in the absence of luminal inflammation.

CONCLUSIONS

Based on a multidisciplinary approach, items relevant for fistula management were identified and algorithms on diagnosis and treatment of pCD were developed.

Multidisciplinary and evidence-based management of fistulizing perianal Crohn's disease

Perianal symptoms are common in patients with Crohn's disease and cause considerable morbidity. The etiology of these symptoms include skin tags, ulcers, fissures, abscesses, fistulas or stenoses. Fistula is the most common perianal manifestation. Multiple treatment options exist although very few are evidence-based. The phases of treatment include: drainage of infection, assessment of Crohn's disease status and fistula tracts, medical therapy, and selective operative management. The impact of biological therapy on perianal Crohn's disease is uncertain given that outcomes are conflicting. Operative treatment to eradicate the fistula tract can be attempted once infection has resolved and Crohn's disease activity is controlled. The operative approach should be tailored according to the anatomy of the fistula tract. Definitive treatment is challenging with medical and operative treatment rarely leading to true healing with frequent complications and recurrence. Treatment success must be weighed against the risk of complications, specially anal sphincter injury. A full understanding of the etiology and all potential therapeutic options is critical for success. Multidisciplinary management of fistulizing perianal Crohn's disease is crucial to improve outcomes.

Results of collagen plug occlusion of anal fistula: a multicentre study of 126 patients

AIM

The Biodesign(®) anal fistula plug was introduced as a means of obliterating the fistula tract and promoting healing through biocompatibility. The results demonstrated unexplained variations from good to bad. This report analysed the results of a retrospective multicentre study.

METHOD

All plug procedures performed in four Stockholm hospitals between June 2006 and June 2010 were identified and studied using a common protocol. The outcome after the first plug-insertion procedure was assessed by chart review performed a minimum of 8 months after plug insertion. Cox proportional-hazards models were used to assess the associations of various factors with fistula healing.

RESULTS

One-hundred and twenty-six patients (mean age 47 years) were deemed suitable for the plug procedure. Eighty-five per cent of fistulae were cryptoglandular, 64% of patients were male and a mean of 2.9 previous fistulae procedures had been performed. All patients, except four, had an indwelling seton at the time of the plug procedure, which was performed in accordance with previously established principles of day surgery. After a median of 13 months, 30 (24%) fistulae had closed with no discomfort or secretion reported. The outcome in the four hospitals varied from 13% to 33% with similar numbers of patients in each hospital. A success rate of 12% was observed for patients with anterior fistula compared with 32% for those with posterior tracks [hazard ratio (HR) for successful healing = 2.98; 95% CI: 1.01-8.78) and 41% for those with a lateral internal opening (HR = 3.76; 95% CI: 1.03-13.75). Age, sex and number of previous procedures were not associated with healing.

CONCLUSION

Four independent patient groups showed low success rates after the first plug-insertion procedure. Anterior fistulae were much less likely to heal compared with fistulae in other locations.

Ligation of intersphincteric fistula tract (LIFT) to treat anal fistula: systematic review and meta-analysis

Sphincter-preserving approaches to treat anal fistula do not jeopardize continence; however, healing rates are suboptimal. In this context, ligation of the intersphincteric fistula tract (LIFT) can be considered promising offering high success rates and a relatively simple procedure. This review aimed to investigate the outcomes of LIFT to treat anal fistula. We conducted a systematic review of the Pubmed, Web of Science, and Cochrane databases, to retrieve all relevant scientific original articles and scientific abstracts (Web of Science) related to the LIFT procedure for anal fistula between January 2007 and March 2013. The search yielded 24 original articles including 1,110 patients; these included one randomized controlled study, three case control studies, and 20 case series. Most studies included patients with trans-sphincteric or complex fistula, not amenable to fistulotomy. During a pooled mean 10.3 months of follow-up, the mean success, incontinence, intraoperative, and postoperative complication rates were 76.4, 0, 0, and 5.5%, respectively. A sensitivity analysis showed that the impact on success in terms of follow-up duration, study size, and combining other procedures was limited. There was no association between pre-LIFT drainage seton and success of LIFT. Ligation of the intersphincteric fistula tract appears to be an effective and safe treatment for trans-sphincteric or complex anal fistula. Combining other procedures and a pre-LIFT drainage seton does not seem to confer any added benefit in terms of success. However, given the lack of prospective randomized trials, interpretation of these data must be cautious. Further trials are mandatory to identify predictive factors for success, and true effectiveness of the LIFT compared to other sphincter-preserving procedures to treat anal fistula.