Short-term anti-TNF therapy with surgical closure versus anti-TNF therapy alone for Crohn's perianal fistulas (PISA-II): long-term outcomes of an international, multicentre patient preference, randomised controlled trial.

Background: The PISA-II trial showed that short-term anti-tumour necrosis factor (anti-TNF) therapy followed by surgical closure induces radiological healing of perianal fistulas in patients with Crohn's disease more frequently than anti-TNF therapy alone after 18 months. This study aimed to compare long-term outcomes of both treatment arms. Methods: Follow-up data were collected from patients who participated in the PISA-II trial, an international patient preference randomised controlled trial. This multicentre trial was performed in nine hospitals in the Netherlands and one hospital in Italy. Patients with Crohn's disease above the age of 18 years with an active high perianal fistula and a single internal opening were asked to participate. Patients were allocated to anti-TNF therapy (intravenous infliximab, or subcutaneous adalimumab, at the discretion of the gastroenterologist) for one year, or surgical closure combined with 4-months anti-TNF therapy. Patients without a treatment preference were randomised (1:1) using random block randomisation (block sizes of six without stratification), and patients with a treatment preference were treated according to their preferred treatment arm. For the current follow-up study, data were collected until May 2022. Primary outcome was radiological healing on magnetic resonance imaging (MRI), including all participants with a MRI made less than 6 months ago at the time of data collection. Analysis was based on observed data. Findings: Between September 14, 2013, and December 7, 2019, 94 patients were enrolled in the trial. Long-term follow-up data were available in 91 patients (36/38 (95%) anti-TNF + surgical closure, 55/56 (98%) anti-TNF). A total of 14/36 (39%) patients in the surgical closure arm were randomly assigned, which was not significantly different in the anti-TNF treatment arm (16/55 (29%) randomly assigned). Median follow-up was 5.7 years (interquartile range (IQR) 5-7). Radiological healing occurred significantly more often after anti-TNF + surgical closure (15/36 = 42% versus 10/55 = 18%; P = 0.014). Clinical closure was comparable (26/36 = 72% versus 34/55 = 62%; P = 0.18) in both groups. However, clinical closure in the surgical group was achieved with less re-interventions 4/26 (= 15%) versus 18/34 (= 53%), including (redo-)surgical closure procedures. Recurrences occurred in 0/25 (0%) patients with radiological healing versus 27/76 (36%) patients with clinical closure, sometime during follow-up. Anti-TNF trough levels were higher in patients with long-term clinical closure in both groups (P = 0.031 and P = 0.014). In 6/11 (55%) patients in the anti-TNF group with available trough levels, recurrences were diagnosed within three months of a drop under 3.5ug/ml. 36 patients stopped anti-TNF, after which 0/14 (0%) patients with radiological healing developed a recurrence and 9/22 (41%) with clinical closure. Self-rated (in)continence was comparable between groups, and 79% (60/76) of patients indicated comparable/improved continence after treatment. Decision-regret analysis showed that all (30/30) anti-TNF + surgical closure patients agreed or strongly agreed that surgery was the right decision versus 78% (36/46) in the anti-TNF arm. All surgical closure patients would go for the same treatment again, whereas this was 89% (41/46) in the anti-TNF arm. Interpretation: This study confirmed that surgical closure should be considered in amenable patients with perianal fistulas and Crohn's disease as long-term outcomes were favourable, and that radiological healing should be the aim of treatment as recurrences only occurred in patients without radiological healing. In patients with complete MRI closure, anti-TNF could be safely stopped. Funding: None.

Comparison of the modified ligation of intersphincteric fistula tract (LIFT) with Incision thread drawing method on serum IgA and IL-10 levels in high simple anal fistula.

OBJECTIVE: To compare the effect of different techniques on serum immunoglobulin A and interleukin-10 in patients with high simple anal fistula. METHODS: .The cross-sectional study was conducted at Dongyang People's Hospital, Weishan, China, from January 2019 to April 2021, and comprised patients with high simple anal fistula who were randomly and equally divided into Group A getting treatment with modified ligation of intersphincteric fistula tract, and Group B getting treatment with incision-thread-drawing method. Serum immunoglobulin A and interleukin-10 as well as the Wexner score were compared between the groups. Data was analysed using SPSS 25. RESULTS: Of the 140 patients, there were 70(50%) in each of the two groups. There were 125(89.2%) male subjects overall. The mean age in Group A was 38.91±8.91 years, while in Group B it was 38.20±8.51. Mean hospital stay in Group A was shorter than that in Group B (p<0.001). Mean serum immunoglobulin A and interleukin-10 values were not significantly different at baseline, but on day 7 post-surgery, the difference was significant between the groups (p<0.05). Likewise, Wexner score was significantly different at 3 months post-surgery (p<0.05). There was no significant difference in the incidence of postoperative complications between the groups (p=0.730). CONCLUSIONS: The modified ligation of intersphincteric fistula tract method was found to be a better option in the management of patients with high simple anal fistula.

The efficacy of Ksharsutra, Fistulectomy and Ligation of Intersphincteric Fistula Tract (LIFT) procedure in management of Fistula in ano a prospective observational study.

BACKGROUND: Fistula in ano is always a troublesome condition for the clinician and the patients owing to its complexity, recurrences, and high morbidity since ancient times. There is no gold standard treatment modality to date documented in the literature for complex fistula in ano. MATERIAL AND METHODS: We enrolled 60 consecutive adult patients attending the surgical outpatient department of a tertiary care centre in India, diagnosed with complex fistula in ano. Among them, 20 each in the Ligation of intersphincteric fistula tract (LIFT), Fistulectomy andKsharsutra(Special medicated seton) group were respectively recruited randomly. A prospective observational study was conducted. The primary outcomes were postoperative recurrence and morbidity. Post-operative morbidity is measured in terms of postoperative pain, postoperative bleeding, pus discharge and post-operative incontinence. The result of the study were analysed after 6 months of follow-up by clinical examination at outpatient department and at 18 months follow up done telephonically. RESULTS: At 6 months of follow-up, 2 patients (10%) had a recurrence in the Ligation of intersphincteric fistula tract procedure group, 3 patients (15%) in the fistulectomy group and 6 patients (30%) in Ksharsutra group, however 3(15%), 4(20%) and 9(45%) patients developed recurrence in Ligation of Intersphincteric fistula tract, Fistulectomy and Ksharsutra group respectively at 18 month of follow-up. The differences in the recurrence were not statistically significant.The mean Visual analogue score for postoperative pain after 24 h as well as after 48 h were statistically significant in Ligation of intersphincteric fistula tract versus Ksharsutra group (p < 0.05). The Visual analogue score for post-operative pain was also significant in the Ligation of the intersphincteric fistula tract versus the Fistulectomy group (p < 0.05). The patients treated via Fistulectomy and Ksharsutra had a higher proportion of bleeding (15%) as compared to the Ligation of intersphincteric fistula tract procedure. Postoperative morbidity was statistically significant between the Ligation of intersphincteric fistula tract versus the Ksharsutra and the Ligation of intersphincteric fistula tract versus Fistulectomy. CONCLUSION: Ligation of intersphincteric fistula tract had less postoperative morbidity compared to Fistulectomy and Ksharsutra procedure; although recurrence was less compared to other methods it was statistically not significant.

Ligation of intersphincteric fistula tract (LIFT) for the treatment of anal fistula: a prospective observational study

Background: The ligation of intersphincteric fistula fract (LIFT) technique avoids postoperative anal continence disturbances and preserves quality of life. Methods: A total of 70 patients with anal fistula (AF) were treated in the Day Surgery Unit. The LIFT technique was the primary treatment in 63 patients. The other had previously undergone placement of a loose seton (two-step approach). The mean follow-up was 66.8 months. Statistical analysis was performed using contingency tables, the chi-square test, and the Student T-test. Results: The use of LIFT was successful in 40 patients (57.1%). However, 6 patients (8.6%) presented persistence of postoperative intersphincteric fistula, being successfully treated by fistulotomy. There were no differences in this technique's success rate between high and low AF (p = 0.45). The success rate of one-step LIFT, however, was significantly higher (p = 0.03). No disturbances of continence were observed. Conclusions: The LIFT technique has a role in the treatment of AF, is suitable for ambulatory surgery, and has a low complications rate. A two-step approach is not always needed. (AU)

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

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

Comparative study between intersphinecteric ligation of perianal fistula versus conventional fistulotomy with or without seton in the treatment of perianal fistula: A prospective randomized controlled trial.

BACKGROUND: Fistula-in-ano is one of the most common benign anal conditions in daily surgical practice.The goals in the treatment of an anal fistula are to eradicate sepsis and to eliminate the primary fistula opening, any associated tracts, and any secondary openings without a change in continence. Conventional fistulotomy (lay open of the fistula tract) is a commonly used procedure and is still relied on by the majority of surgeons as the gold standard for the treatment of perianal fistula. Ligation of the Intersphincteric Fistula Tract (LIFT) is a new sphincter-preserving technique for the treatment of anal fistula. OBJECTIVE: To compare the efficacy of open fistulotomy and ligation of intersphincteric fistula tract (LIFT) procedure based on its post-operative outcomes. PATIENTS AND METHODS: The Present study is A prospective randomized controlled trial which included 30 patients presented with low transsphincteric perianal fistula 27 (90%) males and 3 (10%) females divided into two groups each group consisted of 15 patients. Group, I subjected to inter sphincteric ligation of perianal fistula (LIFT) procedure. Group II patients subjected to conventional fistulotomy. The study lasts 2 years from May 2017 to May 2019 with Follow up for 6 months duration. Operative time in our study was significantly higher in group (I) Managed by LIFT with a mean of 32.53 min than group (II) managed by fistulotomy with a mean of 20.87mins. Wound healing was faster in a group (I) managed by LIFT than group (II) managed by fistulotomy, as the mean time for complete wound healing was (4.53) weeks after LIFT and (5.67) weeks after fistulotomy. RESULTS: There was no case of incontinence after performing the LIFT technique in all our patients in group I. there were 2 cases of incontinence to gases only after fistulotomy in group II. The healing rate after LIFT was 80% (12/15 patients). The healing rate after fistulotomy was 93.3% (14/15 patients). CONCLUSION: LIFT procedure is an effective and preferred sphincter-saving technique for fistula-in-ano with shorter healing time and lower incidence of postoperative anal incontinence, as compared to open fistulotomy.

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.

Long-term outcomes of (Gore) fistula plug versus ligation of intersphincteric fistula tract for anal fistula / Desfechos de longo prazo do tampão de fístula (Gore) versus ligadura do trato da fístula interesfincteriana (LIFT) para fístula anal

ABSTRACT Background: The surgical treatment of anal fistula is complex due to the possibility of fecal incontinence. Fistulotomy and cutting Setons have the same incidence of fecal incontinence depending on the complexity of the fistula. Sphincter-preserving procedures such as anal fistula plug and ligation of intersphincteric fistula tract procedure may result in more recurrence requiring repeated operations. The aim of this study was to evaluate and compare the outcomes of treating fistula in Ano utilizing two methods: Fistula plug (Gore Bio-A) and ligation of intersphincteric tract (LIFT). Methods: Fifty four patients (33 males; 21 female, median ages 42 [range 32-47] years) with high anal inter-transphenteric fistula were treated with LIFT and fistula plug procedures from September 2011 until August 2016 by a single surgeon and were retrospectively evaluated. All were followed for a median of 23.9 (range 4-54) months with clinical examination. Twenty one patients underwent fistula plug and 33 patients underwent LIFT procedure (4 patients of the LIFT group underwent LIFT and rectal mucosa advancement flap). The healing rate and complications were evaluated clinically and through telephone calls. Results: The mean operative time for the Plug was 25 ± 17 min and for the LIFT was 40 ± 20 min (p = 0.017) and the mean hospital stay was 2.4 ± 1.1 and 1.9 ± 0.3 (p = 0.01) respectively. The early complications of the plug and LIFT procedures included; anal pain (33.3%, 66.6%, p = 0.13), perianal discharge (77.8%, 91%, p = 0.62), anal pruritus (38.9%, 50.0%, p = 0.71) and bleeding per rectum (16.7%, 33.3%, p = 0.39) respectively. The overall mean follow-up was 20.9 ± 16.8 months, p = 0.68. There was no statistically significant difference between the two groups (21.9 ± 7.5 months, 19.9 ± 16.1 months, p = 0.682). The healing rate was 76.2% (16/21 patients) in the fistula plug group and 81.1% (27/33 patients) in the LIFT group (p = 0.73). Patients who had LIFT procedure and a mucosal advancement flap had 100% healing rate (4 out of 4 patients). No incontinence of stool or feces and no fistula plug expulsion were seen in our patients. The healing time ranged from 1 to 6 months after surgery. There was no post-operative perianal abscess, cellulitis or pain. Conclusions: LIFT and anal plug are safe procedures for patients with primary and recurrent anal fistula. Both techniques showed excellent results in terms of healing and complication rate. None of our patients had incontinence after 5 years follow-up. The best success rate in our patients was seen after LIFT procedure with mucosal advancement flap. Larger and controlled randomized trials are needed for better assessment of treatment options.

RESUMO Introdução: O tratamento cirúrgico da fístula anal é complexo devido à possibilidade de incontinência fecal. A fistulotomia e o seton de corte têm a mesma incidência da incontinência fecal, dependendo da complexidade da fístula. Procedimentos de preservação do esfíncter, como o tampão da fístula anal e o procedimento LIFT (ligadura do trato da fístula interesfincteriana), podem resultar em mais recorrência, exigindo cirurgias repetidas. O objetivo deste estudo foi avaliar e comparar os desfechos do tratamento da fístula anal utilizando dois métodos: Tampão de fístula (Gore Bio-A) e Ligadura do Trato Interesfincteriano (LIFT). Métodos: Cinquenta e quatro pacientes (33 homens; 21 mulheres, com mediana de idade de 42 [variação 32-47] anos) foram tratados com LIFT e procedimentos com tampão de fístula de setembro de 2011 até agosto de 2016 por um único cirurgião e foram avaliados retrospectivamente. Todos foram acompanhados por uma mediana de 23,9 (variação de 4 a 54) meses com exame clínico. Vinte e um pacientes foram submetidos a tampão de fístula e 33 pacientes foram submetidos ao procedimento LIFT (4 pacientes do grupo LIFT foram submetidos a LIFT e retalho de avanço da mucosa retal). A taxa de cicatrização e as complicações foram avaliadas clinicamente e por meio de ligações telefônicas. Resultados: O tempo cirúrgico médio para o Tampão foi de 25 ± 17 minutos e para o LIFT foi de 40 ± 20 minutos (p = 0,017) e o tempo médio de internação foi de 2,4 ± 1,1 e 1,9 ± 0,3 (p = 0,01), respectivamente. As primeiras complicações dos procedimentos de tampão e LIFT incluíram: dor anal (33,3%, 66,6%, p = 0,13), secreção perianal (77,8%, 91%, p = 0,62), prurido anal (38,9%, 50,0%, p = 0,71) e sangramento pelo reto (16,7%, 33,3 %, p = 0,39) respectivamente. A média geral de acompanhamento foi de 20,9 ± 16,8 meses, p = 0,68. Não houve diferença estatisticamente significativa entre os dois grupos (21,9 ± 7,5 meses, 19,9 ± 16,1 meses, p = 0,682). A taxa de cicatrização foi de 76,2% (16/21 pacientes) no grupo com tampão de fístula e 81,1% (27/33 pacientes) no grupo LIFT (p = 0,73). Pacientes submetidos ao procedimento LIFT e um retalho de avanço da mucosa tiveram 100% de taxa de cura (4 de 4 pacientes). Nenhuma incontinência fecal e nenhuma expulsão do tampão da fístula foram observadas em nossos pacientes. O tempo de cicatrização variou de 1 a 6 meses após a cirurgia. Não houve abscesso perianal, celulite ou dor no pós-operatório. Conclusões: LIFT e tampão anal são procedimentos seguros para pacientes com fístula anal primária e recorrente. Ambas as técnicas apresentaram excelentes resultados em termos de cicatrização e taxa de complicações. Nenhum de nossos pacientes teve incontinência após 5 anos de acompanhamento. A melhor taxa de sucesso em nossos pacientes foi observada após o procedimento LIFT com retalho de avanço da mucosa. Ensaios clínicos randomizados de maior porte e controlados são necessários para melhor avaliação das opções de tratamento.

Ligation of the intersphincteric fistula tract procedure and its modifications / Procedimento de ligadura de trato de fístula interesfincteriana e suas modificações

ABSTRACT 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.

RESUMO Objetivo: O tratamento de fístulas anais é considerado um desafio devido à natureza diversa dessa doença e suas incontáveis complicações. O procedimento de ligadura do trato da fístula interesfincteriana e suas modificações foi popularizado entre cirurgiões em todo o mundo devido a sua simplicidade e desfechos promissores. O principal objetivo deste artigo foi conduzir uma revisão abrangente da literatura publicada sobre o procedimento de ligadura do trato da fístula interesfincteriana e suas modificações. Método: as bases de dados PubMed, Cochrane e Ovid foram pesquisadas de janeiro de 2007 a junho de 2017. Estudos publicados com revisão por pares que aplicaram o procedimento de ligadura do trato da fístula interesfincteriana e suas modificações para o tratamento de fístulas anais de origem criptogênica com acompanhamento de mediana de 12 meses foram elegíveis. Estudos incompletos, relatos de casos, revisões, resumos, cartas, comunicação breve, comentários e estudos que não preenchiam os critérios de inclusão foram excluídos. O desfecho primário foi medir a cicatrização primária, a cicatrização geral, falhas e recorrência do procedimento de ligadura do trato da fístula interesfincteriana e suas modificações. Resultados: Vinte e dois estudos foram identificados com apenas dez estudos atendendo aos critérios de inclusão. A ligadura original do trato da fístula interesfincteriana foi realizada em cinco estudos com uma população de 199 pacientes, enquanto os cinco estudos restantes apresentaram quatro modificações diferentes da ligadura do trato da fístula interesfincteriana com um total de 147 pacientes. Tanto o LIFT original quanto suas modificações têm resultados promissores e desfechos potencialmente semelhantes; cicatrização primária na ligadura original do trato da fístula interesfincteriana de 73,95% (IC 95% 60,3-85,6) menos realizada que as modificações de 82,3% (IC 95% 64,8-94,7). Cicatrização geral na ligadura original do trato da fístula interesfincteriana de 78,9% (IC 95% 58,5-93,7) realizada relativamente menos do que as modificações (93,6%, IC 95% 81,4-99,6). A falha na ligadura original do trato da fístula interesfincteriana (17,9%; IC 95% 4,9-36,5) realizada quase tanto quanto as modificações (17,7%; IC 95% 5,3-35,2). Recidiva na ligadura original do trato da fístula interesfincteriana em 9,7% (IC 95% 1,7-23,2). No entanto, não houve recorrência nas modificações. Conclusão: A ligadura do trato da fístula interesfincteriana e suas modificações são procedimentos eficazes e simples no tratamento de fístulas anais simples, especialmente as transesfincterianas altas. No entanto, mais estudos devem ser realizados para avaliar sua eficácia em relação às fístulas complexas.

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

BACKGROUND: Ligation of the intersphincteric fistula tract (LIFT) is a sphincter-preserving operation for anal fistulas. Although it has advantages in preserving continence after surgery, it is difficult to perform owing to the narrow field of view. We performed a modified surgical procedure based on the LIFT to overcome these drawbacks. MATERIALS AND METHODS: Twenty-eight patients who were scheduled to undergo high ligation of the anal fistula tract by the lateral approach for the treatment of transsphincteric anal fistulas were prospectively studied. Instead of making a new stab incision on the intersphincteric groove, we dissected along the fistula tract from the external opening until the intersphincteric space appeared. The fistula tract was then ligated close to the internal anal sphincter with absorbable sutures, and the distal part of the ligation was cut off. A cored-out wound was left open for drainage. RESULTS: The median follow-up was 16 months (range, 8-27 months). Of the 28 patients, 19 (68%) had simple transsphincteric fistulas and 9 (32%) had complex transsphincteric fistulas. Successful fistula closure was achieved in 21 patients (75%), with a median healing time of 4 weeks (range, 3-7 weeks). None of the patients complained of any incontinence symptoms after the procedure. Of the seven patients (25%) who failed to heal successfully, two (7%) did not heal up to 2 months after surgery and five (18%) experienced recurrence after complete healing. CONCLUSION: High ligation of the anal fistula tract by lateral approach may be a useful sphincter-sparing procedure for transsphincteric anal fistulas.

Effective and long-term outcome following ligation of the intersphincteric fistula tract (LIFT) for transsphincteric fistula.

OBJECTIVE: The purpose of this study was to evaluate the efficacy and long-term outcome of the ligation of the intersphincteric fistula tract (LIFT) procedure for transsphincteric fistula-in-ano. METHODS: A total of 43 patients that were treated with LIFT procedure and had a follow-up time of more than 1 year were included. RESULTS: The median age was 37.18 years, and 32 (74.4%) of the patients were male. The median follow-up time was 26.2 months (range 13-63 months). There were 29 (67.4%) uncomplicated transsphincteric fistulas, 10 (23.3%) horseshoe transsphincteric fistulas, and 4 (9.3%) multiple fistulas. Eight (18.5%) patients presented with dehiscence or infection at the intersphincteric wound and were successfully treated with either laying open (n = 5) or local application of silver nitrate (n = 3). The success rate, as determined from the last follow-up time point, was 83.7% (36/43). The mean time to complete failure was 8.6 weeks (range 1-28) in 7 patients. With the exception of these 7 patients, 32/36 (88.9%) patients had a Cleveland Clinic Florida Faecal incontinence score of 0, 3 patients had a score of 1, and 1 had a score of 2. No significant association was found between laying open and incontinence in these partial failure patients. CONCLUSION: The LIFT procedure can be considered an effective sphincter-sparing procedure in the management of transsphincteric fistula with an acceptable long-term outcome.

Ligation of intersphincteric fistula tract versus incision-thread-drawing procedure for complicated anal fistula: A Meta-analysis / 国际外科学杂志

Objective To systematically investigate the clinical efficiency and safety of ligation of inter sphincteric fistula tract versus incision-thread-drawing procedure for complicated anal fistula.Methods Searched PubMed,The Cochrane Library,CNKI,WanFang Data,and VIP from inception to May 2016,to collect randomized controlled trials of ligation of inter sphincteric fistula tract versus incision-thread-drawing procedure for complicated anal fistula.Search term included ligation of inter sphincteric fistula tract,fistula,incision-thread-drawing procedure,randomized controlled trial.The literatures were screened according to inclusive criteria,data were extracted and the quality of included studies was evaluated,and then meta-analysis was performed using RevMan 5.2 soft ware.A total of 5 randomized controlled trials including 305 patients were included.Results The results of meta-analysis showed that compared with incision-thread-drawing procedure,ligation of inter sphincteric fistula tract had a significant difference in amount of bleeding during surgery (MD =-18.30,95％ CI:-19.91 ～-16.69,P ＜ 0.000 01),the duration of pain (MD =-4.38,95％ CI:-4.69 ～-4.08,P ＜ 0.000 01),healing time (MD =-10.28,95％ CI:-15.71 ～-4.86,P =0.0002),hospital stay (MD =-7.44,95％CI:-10.87～-4.02,P＜0.000 1),recurrence rate (OR=0.31,95％CI:0.10～0.91,P=0.03).There was no significant difference in Operation time (MD =-5.83,95 ％ CI:-7.64 ～-4.02,P ＜ 0.000 01),effective percentage (OR =4.35,95％ CI:0.89 ～ 21.32,P =0.07) between both groups.Conclusion Compared with incision-thread-drawing procedure,ligation of inter sphincteric fistula tract shows significant advantage in cure rate,postoperative healing time,reducing post-operation pain,anal function protection and recurrence rate.

Management of Fistula-In-Ano with Special Reference to Ligation of Intersphincteric Fistula Tract.

CONTEXT: The surgical management of fistula-in-ano is still debatable and no clear recommendations have been made available until now. The present study analyses the results of ligation of intersphincteric fistula tract (LIFT) technique in treating fistula-in-ano in particular with recurrence, healing time, and continence status. AIMS: LIFT in the management of patients of fistula-in-ano of cryptoglandular origin. SETTINGS AND DESIGN: Prospective study. MATERIALS AND METHODS: This is a prospective study of 52 patients admitted from September 2012 to August 2014. Patients were managed with LIFT technique and results of LIFT technique were compared with other studies in terms of recurrence rate, incontinence rate, and other postoperative complications. RESULTS: A total of 52 patients were studied. Median follow-up was 24 weeks. Primary healing was achieved in 32 (71.11%) patients. Thirteen patients (28.88%) had a recurrence. No patient reported any subjective decrease incontinence after the procedure. CONCLUSIONS: LIFT technique is simple and easy to learn. With this method fistula-in-ano could be easily treated even at primary health care level. LIFT technique is a simple and novel modified approach for the treatment of fistula-in-ano with rapid healing rate and without any resultant incontinence.

Ligation of the intersphincteric fistula tract for the treatment of fistula-in-ano: experience of a tertiary care centre in South India.

AIM: Ligation of the intersphincteric fistula tract (LIFT) is a new sphincter-sparing surgical technique increasingly used to treat fistulae-in-ano yielding good results. The aim of this study was to evaluate its effectiveness in the treatment of complex fistulae-in-ano and to determine factors associated with recurrence and its subsequent management. METHOD: A prospective observational study was performed of 167 patients with complex fistula-in-ano treated by LIFT from June 2013 to January 2014. In all patients a LIFT with partial core-out of the fistula tract was performed. RESULTS: There were 167 patients of mean age 43.6 ± 12.8 years. Thirty-three fistulae were recurrent. 150 were trans-sphincteric, 16 were intersphincteric and one was a suprasphincteric fistula. The median postoperative stay was 2 (range: 1-14) days (mean = 2.4 days). At follow up there was no change in continence. The median healing time was 4 (range: 1-8) weeks. Two patients developed an intersphincteric abscess needing surgical drainage healing uneventfully. The mean follow up was 12.8 [median = 12 (range: 4-22)] months. The healing rate was 94.1%. Ten (5.9%) patients developed a recurrent fistula that was managed by a second LIFT procedure in seven, a sinus tract excision with curettage in two and seton placement in one. Recurrence was significantly associated with diabetes mellitus and perianal collections and showed an increased incidence with tract abscesses and multiple tracts. CONCLUSION: LIFT has a high success rate in complex fistulae-in-ano. Recurrence is related to diabetes mellitus, perianal collections, tract abscesses and multiple tracts and a second LIFT procedure may be feasible and efficient.

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.

Surgical treatment of anorectal crohn disease.

Crohn disease involves the perineum and rectum in approximately one-third of patients. Symptoms can range from mild, including skin tags and hemorrhoids, to unremitting and severe, requiring a proctectomy in a small, but significant, portion. Fistula-in-ano and perineal sepsis are the most frequent manifestation seen on presentation. Careful diagnosis, including magnetic resonance imaging or endorectal ultrasound with examination under anesthesia and aggressive medical management, usually with a tumor necrosis factor-alpha, is critical to success. Several options for definitive surgical repair are discussed, including fistulotomy, fibrin glue, anal fistula plug, endorectal advancement flap, and ligation of intersphincteric fistula tract procedure. All suffer from decreased efficacy in patients with Crohn disease. In the presence of active proctitis or perineal disease, no surgical therapy other than drainage of abscesses and loose seton placement is recommended, as iatrogenic injury and poor wound healing are common in that scenario.

Clinical efficacy of ligation of intersphincteric fistula tract for the treatment of high anal fistula / 中华消化外科杂志

Objective To investigate the clinical efficacy of ligation of intersphincteric fistula tract (LIFT) for the treatment of high anal fistula.Methods The clinical data of 77 patients with high anal fistula who were admitted to the Puren Hospital and Chaoyang Hospital from January 2011 to June 2012 were retrospectively analyzed.All the patients were treated using the LIFT method (LIFT group,37 patients) or fistulectomy + threaddrawing therapy (thread-drawing group,40 patients).The operation time,healing time,time and severity of postoperative pain,recurrence and anal sphincter dysfunction were compared between the 2 groups.The measurement data,the count data and the rank data were analyzed using the t test,chi-square test,and the rank sum test,respectively.Results The operation time of the LIFT group and the thread-drawing group were (21.4 ± 2.0) minutes and (20.6 ± 1.9) minutes,with no significant difference between the 2 groups (t =1.911,P ＞ 0.05).In the LIFT group,17 patients felt low-grade pain,no patient felt medium-grade or severe pain.In the thread-drawing group,7 patients felt low-grade pain,14 patients felt medium-grade pain,19 patients felt severe pain.The duration of postoperative pain in the LIFT group and the thread-drawing group were (3.0 ± 1.3) days and (14.1 ± 1.5)days,respectively.The severity and duration of postoperative pain of the LIFT group were significant lower and shorter than those of the thread-drawing group (u =-7.189,t =34.534,P ＜ 0.05).The healing time,anal scar area and anal sphincter function score were (26.0 ± 1.9) days,(1.24 ± 0.20) cm2 and 1 in the LIFT group,and (40.7 ± 2.8) days,(2.64 ± 0.25) cm2 and 4 in the thread-drawing group,with no significant difference between the 2 groups (t =26.574,26.868,Z =-7.513,P ＜ 0.05).The effective rate of the 2 treatment methods were 100％.The cure rate and recurrence rate were 51.4％ (19/37) and 5.4％ (2/37) in the LIFT group,and 42.5％ (17/40) and 2.5％ (1/40) in the thread-drawing group.There were no significant differences in the cure rate and recurrence rate between the 2 groups (x2=0.605,0.433,P ＞ 0.05).Conclusion LIFF method has higher cure rate for high anal fistula with short time of postoperative pain and healing,good anal sphincter function and low recurrence rate.

Why do we have so much trouble treating anal fistula?

Anal fistula is among the most common illnesses affecting man. Medical literature dating back to 400 BC has discussed this problem. Various causative factors have been proposed throughout the centuries, but it appears that the majority of fistulas unrelated to specific causes (e.g. Tuberculosis, Crohn's disease) result from infection (abscess) in anal glands extending from the intersphincteric plane to various anorectal spaces. The tubular structure of an anal fistula easily yields itself to division or unroofing (fistulotomy) or excision (fistulectomy) in most cases. The problem with this single, yet effective, treatment plan is that depending on the thickness of sphincter muscle the fistula transgresses, the patient will have varying degrees of fecal incontinence from minor to total. In an attempt to preserve continence, various procedures have been proposed to deal with the fistulas. These include: (1) simple drainage (Seton); (2) closure of fistula tract using fibrin sealant or anal fistula plug; (3) closure of primary opening using endorectal or dermal flaps, and more recently; and (4) ligation of intersphincteric fistula tract (LIFT). In most complex cases (i.e. Crohn's disease), a proximal fecal diversion offers a measure of symptomatic relief. The fact remains that an "ideal" procedure for anal fistula remains elusive. The failure of each sphincter-preserving procedure (30%-50% recurrence) often results in multiple operations. In essence, the price of preservation of continence at all cost is multiple and often different operations, prolonged disability and disappointment for the patient and the surgeon. Nevertheless, the surgeon treating anal fistulas on an occasional basis should never hesitate in referring the patient to a specialist. Conversely, an expert colorectal surgeon must be familiar with many different operations in order to selectively tailor an operation to the individual patient.