Cutting of sphincter in fistulectomy with primary closure in complex fistula-in-ano: is it feasible?

Introduction: Treatment of complex fistulas such as inter- or transsphincteric, recurrent, and high fistulae have high rate of recurrence or incontinence. Fistulectomy with primary sphincter reconstruction might represent an effective and safe alternative to reduce rate of recurrence and incontinence. The aim of this study is to assess incontinence and recurrence after fistulectomy with primary sphincter reconstruction for management of complex fistulas. Material and Methods: There were 60 patients with complex fistulae involving the sphincter, with 56 male and 4 female, mean age 40.6 years, operated by fistulectomy and primary sphincter repair over a period of 7 years. Patients were followed up for 6months for any complications, recurrence, and incontinence. Results: The majority of patients (50, 83.3%) had complete wound healing in 2 weeks, while 4 (6.6%) patients had hematoma and superficial wound dehiscence, which were managed conservatively and healed in 4 weeks. There was one recurrence. All patients had good continence postoperatively, except for mild fecal incontinence (FI, score 3), seen in 6 (10%) patients. However, all these patients regained continence within 6 weeks. Conclusions: Primary reconstruction of anal sphincter with fistulectomy is a safe option for complex fistula-in-ano. (AU)

Management of complex fistula-in-ano by interception of fistula track with application of ksharasutra (IFTAK): a novel technique

Objective: Despite all the technological advances, successful management of complex fistula-in-ano is still a challenge due to recurrence and incontinence. The present study evaluates the outcomes of a novel technique, Interception of Fistula Track with Application of Ksharasutra (IFTAK) in terms of success rate and degree of incontinence. Methods: In the present prospective study, 300 patients with complex fistula-inano were treated by the IFTAK technique, whose surgical steps include: incision at the anterior or posterior midline perianal area, identification and interception of the fistulous track at the level of the external sphincter, rerouting the track (and extensions) at the site of interception, and application of a ksharasutra (medicated seton) in the proximal track (from the site of interception to the internal opening) that is laid open gradually, with the resulting wound healing with minimum scarring. The distal track is allowed to heal spontaneously. Results: There were 227 transsphincteric and 73 intersphincteric varieties of fistula with supralevator extension in 23 cases, of which 130 were recurrent fistulas, 29 had horseshoe track, while 25 had blind fistula with no cutaneous opening. The mean duration of the ksharasutra application was 8.11 ± 3.86 weeks with an overall success rate of 93.33% at the 1-year follow-up. A total of 3.67% of the cases reported with a mild impairment of continence on the Wexner incontinence scoring system. Pre- and postoperative anal manometry evaluation showed minimal reduction in median basal and squeeze pressures. Conclusion: The IFTAK technique is a minimally invasive, daycare surgical procedure for the management of complex fistula-in-ano with low recurrence and minimal sphincter damage. (AU)

Ligadura interesfinteriana del trayecto fistuloso (LIFT) como alternativa de tratamiento a una fístula perianal compleja / Ligation of intersphincteric fistula tract (LIFT) as an alternative treatment for complex perianal fistula

Resumen Introducción: Las técnicas quirúrgicas para la fístula perianal compleja han tenido altas tasas de recidiva asociado al riesgo de incontinencia fecal. La técnica de LIFT (Ligadura Interesfintérica del trayecto fistuloso) ha logrado menores tasas de recidiva con casi nulo riesgo de incontinencia según reportes inter-nacionales. Sin embargo, aún no está consolidada como técnica estándar para esta patología. Objetivo: Presentar los resultados (éxito clínico e incontinencia según escala de Wexner) de nuestros pacientes con fístula perianal compleja operados con técnica de LIFT. Materiales y Método: Estudio descriptivo de cohorte prospectiva no aleatoria, con pacientes operados por fístula perianal compleja en el Hospital del Salvador, entre los años 2015 al 2017. Resultados: Se incluyen 22 pacientes operados. En un 77% se obtiene éxito terapéutico en la primera cirugía y hasta un 90% con una segunda cirugía más simple. Ninguno de los pacientes modificó su Wexner preoperatorio. Conclusiones: En pacientes con fístula perianal compleja la técnica de LIFT es una alternativa que ofrece igual o mejores tasas de curación clínica con bajo riesgo de incontinencia fecal.

Introduction: Surgical techniques for complex perianal fistula have high recurrence and fecal incontinence rates. The technique of LIFT (ligation of the intersphincteric fistula tract) has achieved lower rates of recurrence with almost no risk of incontinence according to international reports. However, it is not yet consolidated as a standard technique for this pathology. Objective: To present the results (clinical success and incontinence according to the Wexner scale) of our patients with complex perianal fistula operated with the LIFT technique. Materials and Method: Descriptive study of a non-randomized prospective cohort, with patients operated for complex perianal fistula at the Hospital del Salvador, between 2015 and 2017. Results: 22 operated patients are included. In 77%, therapeutic success is obtained in the first surgery and up to 90% with a second surgery. None of this patients modified their preoperative Wexner. Conclusions: In patients with complex perianal fistula, the LIFT technique is an alternative that offers high cure rates with low risk of fecal incontinence.

The Ligation of Intersphincteric Fistula Tract Technique: A Preliminary Experience

PURPOSE: Surgery is the only treatment for anal fistula. Many surgical techniques have been described. The aim of this study was to communicate the authors' preliminary experience in the use of a recently proposed, simplified technique. METHODS: This was a prospective study of 28 patients admitted from January 13, 2016 through July 20, 2017. Patients were managed with the ligation of intersphincteric fistula tract (LIFT) technique and results were observed and documented, including recurrence rate, incontinence rate, and other postoperative complications. RESULTS: A total of 28 patients were studied. The mean operation time was 31 minutes (range, 23–44 minutes), and there were no intra- and postoperative complications. The overall complete healing rate was 85.7%, and the recurrence rate was 14.2%. Follow-up was conducted at 1, 3, and 6 months. CONCLUSION: Many surgical techniques have been described for the treatment of anal fistula. The correct choice of surgical technique out of available procedures is the most important factor for proper treatment and reducing the risk of recurrence or incontinence. In the authors' experience, the LIFT technique is simple and easy to learn, and is a good choice for the treatment of simple anal fistula; however, a tailored surgery remains the gold standard for this condition.

Long-term outcomes of ligation of intersphincteric fistula tract for complex fistula-in-ano: modified operative procedure experience / Resultados em longo prazo da ligadura da fístula interesfincteriana no complexo das fístulas perianais: modificação técnica de procedimento cirúrgico

ABSTRACT 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.

RESUMO Racional: É importante, mas difícil de se tratar fístula anal complexa devido à alta taxa de recorrência e de incontinência pós-operatória. A ligadura do trajeto da fístula interesfincteriana (LIFT) - um novo procedimento cirúrgico com a vantagem de evitar a incontinência anal - tem taxa de sucesso variável entre 57-94,4%. Objetivo: Avaliar os resultados em longo prazo do procedimento cirúrgico LIFT modificado - ligadura do trato interesfincteriano com fístula - para tratar fístula complexa anal. Métodos: Análise retrospectiva de 62 casos de fístula complexa no ânus tratados com abordagem modificada de LIFT (incisão curva na pele do canal anal; sutura em bolsa realizada em torno da fístula; as fístulas residuais removidas em um túnel) e teve tempo de acompanhamento de mais de um ano. A condição geral pré-operatória dos pacientes, a eficácia pós-operatória e a função anal foram comparadas. Resultados: A mediana de idade dos participantes foi de 34 anos, e 43 (69,4%) dos casos eram de homens. Quarenta e um (66,1%) casos eram de fístula transesfincteriana alta, quatro (6,5%) de fístula intra-esfincteriana alta e 17 (27,4%) de fístula anal anterior em mulheres. A mediana da duração do acompanhamento foi de 24,5 meses (12-51). A taxa de sucesso no final do acompanhamento foi de 83,9% (52/62). A pressão anorretal e a Incontinência Fecal da Cleveland Clinic Florida (CCF-FI) avaliadas três meses antes e após a operação não encontraram alterações aparentes. Conclusões: Comparado com o LIFT, o LIFT modificado reduz notavelmente a falha pós-operatória e a taxa de recorrência de fístula complexa com resultados aceitáveis em longo prazo.

Long-term results of ligation of intersphincteric fistula tract (LIFT) for management of anal fistula / Resultados em longo prazo da ligadura interesfincteriana do trato fistuloso (LIFT) para o tratamento de fístula anal

ABSTRACT Background: Ligation of intersphincteric fistula tract technique is a new sphincter saving method with good results in management of anal fistula, but few studies report long-term follow-up data. Material and methods: This study investigated the use of ligation of intersphincteric fistula tract as a sphincter saving method based on long term results. This was a retrospective review of prospectively collected data. The study was conducted at two tertiary care university medical centers. 36 patients with complex fistula from January 2010 to January 2014 treated with classic ligation of intersphincteric fistula tract were retrospectively followed. Demographic data, previous repair attempts, the type of the fistula and score of fecal continence were collected. The procedure was performed by colorectal surgeons. Primary healing rate, failures and fecal incontinence score of patients were followed for 6-48 months. Results: A total of 36 patients underwent ligation of intersphincteric fistula tract during 24 months. The mean age of the patients was 35 years and 50% had two previous attempts at surgery. A total of 25 patients (69/5%) had high transsphincteric fistula. The mean follow up was 27 months. Successful fistula closure was achieved in 63/8% of the patients (23 of 36). The mean time of recurrence was 4.5 weeks. Only one (2/77%) patient reported gas incontinence (score: 3) after the procedure. Conclusion: The recurrence rate and fecal incontinence were measured. The ligation of intersphincteric fistula is a promising sphincter-preserving procedure that is simple and safe. Our study demonstrates favorable long-term results of ligation of intersphincteric fistula tract for management of complex anal fistulas.

RESUMO Introdução: A técnica LIFT (Ligation of Intersphincteric Fistula Tract; ligadura interesfincteriana do trato fistuloso) é um novo método de preservação esfinctérica com bons resultados no tratamento da fístula anal, mas são poucos os estudos que relatam dados de seguimento em longo prazo. Material e métodos: Esse estudo investigou o uso de LIFT como método de preservação esfinctérica, com base em resultados em longo prazo. Essa foi uma revisão retrospectiva de dados prospectivamente coletados. O estudo foi realizado em dois centros médicos terciários universitários. Trinta e seis pacientes com fístula complexa tratados com LIFT cássica de janeiro de 2010 até janeiro de 2014 foram retrospectivamente seguidos. Foram coletados dados demográficos, tentativas precedentes de reparo, tipo de fístula, e escore de continência fecal. O procedimento foi realizado por cirurgiões colorretais. Percentual de cicatrização primária, insucessos, e escore de incontinência fecal dos pacientes foram monitorados durante 6 a 48 meses. Resultados: No total, 36 pacientes foram submetidos a LIFT em um período de 24 meses. A média de idade dos pacientes era de 35 anos e 50% já tinham sido previamente submetidos a duas tentativas de cirurgia. Vinte e cinco pacientes apresentavam fístula trans-esfinctérica alta. A média do seguimento foi de 27 meses. Foi obtido fechamento bem-sucedido da fístula em 63,8% dos pacientes (23 de 36). O tempo médio até a recorrência foi de 4,5 semanas. Apenas um (2,77%) paciente informou incontinência gasosa (escore = 3) após o procedimento. Conclusão: O percentual de recorrência e a incontinência fecal foram mensurados. A ligadura de fístula intersfinctérica é um procedimento promissor de preservação esfinctérica, de simples execução e seguro. Nosso estudo demonstra resultados favoráveis com o uso de LIFT em longo prazo para o tratamento de fístulas anais complexas.

A Retrospective Analysis and Clinical Review of Fistula-in-Ano

PURPOSE: The results for treatment of fistula-in-ano have much improved, along with the development of anatomical knowledge, classification, and operative techniques, during last several decades. The authors retrospectively reviewed the results for treatment of fistula-in-ano, especially complex fistulas, during the last 11 years. METHODS: A retrospective study of fistula-in-ano was performed for 229 patients who had been operated on in St. Benedict Hospital between January 1988 and December 1998. Complex fistulas (IIH, III & IV) were analyzed separately. RESULTS: The most common type was IILs (92 cases, 40.2%), and the most common horseshoe type was IIIBc (5 cases, 2.2%). The average hospital stay was 11.5 days for all fistula-in-ano types, but 15.1 days for complex fistulas. Non-specific inflammation (209 cases, 91.3%) was the most common pathologic finding. Various operative procedures were used : fistulotomy (80 cases, 34.9%), fistulectomy (74 cases, 32.3%), coring out fistulectomy (63 cases, 27.5%), seton technique (11 cases, 4.8%), and muscle-filling technique (1 case, 0.4%). There was no difference in the recurrence rate among the operative types. Various procedures were tried for complex fistulas, but the sphincter-preserving fistulectomy by Takano seemed to have a low recurrence rate and a short postoperative course. However, because of the small number of cases, this difference in recurrence rate and postoperative course was not statistically significant. The overall postoperative complication rate was 7%: anal infection (4 cases, 1.7%), anal bleeding (3 cases, 1.3%), and urinary retention (2 cases, 0.9%). CONCLUSIONS: The operations for most of the fistulae, IH, IL & IIL, were simple and uneventful. However, the operations for complex fistulae were complicated and more skill was required. We have thought Takano's operation to be a good curative procedure with less postoperative deformity and shortened postoperative course. However this research couldn't prove that with statistical significance, probably because of the insufficient number of patients. If further cases are collected and continuous follow-up is done, then a better result can be expected.