pouch/fistula repair

LIFT PROCEDURE

Recent reports from Chulalongkorn University, Bangkok, Thailand, have described a novel technique called LIFT for the treatment of anal fistulae. A success rate of 94.4% was reported in the treatment of 18 patients [34, 35]. This technique prevents the entry of fecal material into the fistula tract and eliminates the formation of a septic nidus in the intersphincteric space to allow healing of the anal fistula. Detailed technical steps of the LIFT procedure are as follows (Fig. 3) [35]. The location of internal opening is identified by injection of hydrogen peroxide or water through the external opening or by gently probing the fistula tract. A 1.5 to 2.0 cm curvilinear incision is made at the intersphincteric groove overlying the fistula tract. The dissection is kept close to the external sphincter to avoid cutting through the internal sphincter and breaching the anal mucosa. After the intersphincteric tract has been identified and dissected out, the tract is ligated close to the internal sphincter. Secure ligation of the intersphincteric tract abutting the internal opening is the key to success. The tract next to the suture site is divided, and the rest of intersphincteric tract is excised. After removal of the correct fistulous tract has been confirmed, infected granulation tissues in the rest of the tract and cavity are thoroughly removed with curettage. The open defect at the external anal sphincter is sutured through the intersphincteric wound. Finally, the incision wound is closed loosely.

Fig. 3

Illustration of the ligation of intersphincteric fistula tract procedure. (A) After identification of the internal opening, the fistula tract is dissected free in the intersphincteric space. (B) The intersphincteric tract is ligated and divided.

The LIFT procedure has been used in five case series with promising early results (Table 2) [34, 36-39]. Shanwani et al. [36] reported that primary healing was achieved in 82.2% of the 45 patients. Bleier et al. [37] reported that successful fistula closure was achieved in 57% of the 35 patients. No patient reported any subjective compromise in continence after the procedure. The advantages of the LIFT procedure may include preservation of the anal sphincter, minimal tissue injury, shorter healing time, and its being a procedure that is relatively easy to perform. Additionally, even if the fistula is not healed successfully, the LIFT procedure may convert a difficult-to-treat transsphincteric fistula into an easier-to-manage intersphincteric fistula.

Table 2

Outcomes with the ligation of intersphincteric fistula tract procedure

However, a number of questions remain unanswered. First, the published results are the only case series of a heterogeneous population, and the good results may come from selection bias. Second, there were some variations in the manner in which the fistula was ligated and in the coring out or curettage of the external tract. Third, a longer and objective follow-up would be a better indicator of the durability, and no standardized questionnaires were used pre- or postoperatively with respect to fecal incontinence and quality of life [37]. Additionally, as is the anal fistula plug, the indication for the LIFT procedure seems to be limited to the transsphincteric fistula. The LIFT procedure for a high transsphincteric or suprasphincteric fistula may be technically difficult. Interestingly, another intersphincteric approach for the treatment of a complex anal fistula has been described by Matos et al. [40]. Rojanasakul [35] reported two major differences between the LIFT and the previously described technique. First, the ligation of the fistula tract is more secure than over sewing, and second, removal of infected granulation tissue by curettage is more practical and less time-consuming than total excision of the tract and primary repair. Apart from the difficulty in the LIFT procedure for a high transsphincteric or a suprasphincteric fistula, the identification of the intersphincteric tract through the intersphincteric approach seems to require more advanced technical skills than the removal of the intersphincteric tract and infected granulation tissue in a conventional technique does.

BIOLIFT PROCEDURE

Neal Ellis [41] published outcomes with the BioLIFT technique for the management of transsphincteric fistulae. He reported that the success rate was 94% of 31 patients. The BioLIFT technique is a variation of the LIFT technique in which a bioprosthetic is placed in the intersphincteric plane to reinforce the closure of the fistula tract. The bioprosthetic graft acts as a physical barrier in the intersphincteric space. Actually, the BioLIFT technique utilized a transection of the intersphincteric tract and closure of the fistula opening in the internal sphincter, which is similar to the procedure described by Matos et al. [40], instead of ligating the intersphincteric tract. When compared to the LIFT, the BioLIFT technique has two potential disadvantages. First, it requires a more extensive dissection in the intersphincteric space because the bioprosthetic must overlap the closure of the fistula tract by at least 1 to 2 cm in all directions. The second disadvantage is the relatively high cost of the bioprosthetic materials.

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