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Campbell 2013 R 20 80 3
Han 2013 P 21 95 14
Tsunoda 2013 P 20 95 18
Abcarian 2012 P 39 74 4.6
Ooi 2012 P 25 68 5.5
Tan 2012 R 55 62.5 13
Lo 2012 R 25 89 9.8
Mushaya 2012 RCT 39 68 19.2
vanOnkelen 2012 P 41 51 15
Sileri 2011 P 18 83 6
Tan 2011 R 93 83 5
Shanwani 2010 P 45 82.2 9
Bleier 2010 R 35 57 5
Ellis 2010 R 31 94 15
Rojanasakul 2007 P 18 94.4 6.5
P,prospective;R,retrospective;RCT,randomizedcontrolledtrial.
ThreestudiesaddresstheresultsoftheBioLIFT.Theinitialpublication byEllisnoteda94%successratein31patientswitha1-yearfollow-up. SubsequentreportsbyTanandChewnotedasuccessrateof69–63%, respectively,withapproximately5–6monthsoffollow-up.
ArandomizedcontrolledtrialbyHanin2016investigatedtheresults oftheLIFT-Plugtechnique.Theauthorsrandomized235patientstoa LIFTprocedureortoaLIFT-Plugtechnique.Allpatientshada6-month follow-up.Theauthorsobservedaprimaryhealingrateof94%inthe LIFT-Pluggroupascomparedwith84%intheexclusivelyLIFTgroup. Neithergroupexperiencedasignificantchangeincontinencefromthe baselineasmeasuredbytheWexnerscore.

CONCLUSIONS

TheLIFTprocedureisarelativelynewtechniquethatcanbeusedto managethedifficultiesoffistula-in-ano.Thesimpledesignofthe operationallowsittobedoneasanalternativetoanadvancementflapor insertionofafistulaplugorfibringlue,withoutprecludingthoseoptions atalaterdate,shouldtheybenecessary.Inaddition,investigatorshave addedinsertionofafistulaplugandbiologicmeshtotheLIFTwith promisinginitialresults.AlthoughpublishedsuccessratesoftheLIFT procedurehavebeenvariable,recentworkhasnotedsomepromising results.Mostimportantly,continenceispreservedwiththeoperation. LIFTisanimportantoperationamongseveralsphincter-preserving proceduresavailabletotreatdifficultcasesoffistula-in-ano.
RECOMMENDEDREFERENCESAND READINGS
BleirJI,MolooH,GoldbergSM.Ligationoftheintersphinctericfistulatract(LIFT):aneffective
newtechniqueforcomplexfistulas.DisColonRectum2010;53:43–6. EllisCN.Outcomeswiththeuseofbioprostheticgraftstoreinforcetheligationofthe
intersphinctericfistulatract(BioLIFTprocedure)forthemanagementofcomplexanalfistulas.
DisColonRectum2010;53:1361–4. HallJF,BordeianouL,HymanN,etal.Outcomesafteroperationsforanalfistula:resultsofa
prospective,multicenter,regionalstudy.DisColonRectum2014;57:1304–8. HanJG,WangZJ,ZhengY,etal.Ligationofintersphinctericfistulatractvsligationofthe
intersphinctericfistulatractplusabioprostheticanalfistulaplugprocedureinpatientswith
transsphinctericanalfistula:earlyresultsofamulticenterprospectiverandomizedtrial.Ann
Surg2016;264:917–22. KontovounisiosC,TekkisP,TanE,RasheedS,DarziA,WexnerSD.Adoptionandsuccessratesof
perinealproceduresforfistula-in-ano:asystematicreview.ColorectalDis2016;18:441–58.
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p.68
RojanasakulA,PattanaarunJ,SahakitrungruangC,TantiphlachivaK.Totalanalsphinctersaving
techniqueforfistula-in-ano;theligationofIntersphinctericfistulatract.JMedAssocThai
2007;90:581–6. SantoroGA,AbbasMA.Complexanorectalfistulas.In:SteeleSR,HullTL,Read,TE,etal.,eds.
TheASCRSTextbookofColonandRectalSurgery.Berlin,Germany:Springer,2016:245–74. SiranyAM,NygaardRM,MorkenJJ.Theligationoftheintersphinctericfistulatractprocedure
foranalfistula:amixedbagofresults.DisColonRectum2015;58:604–12. VogelJD,JohnsonEK,MorrisAM,etal.Clinicalpracticeguidelineforthemanagementof
anorectalabscess,fistula-in-ano,andrectovaginalfistula.DisColonRectum2016;59:1117–33.
Chapter10
LigationoftheIntersphincteric FistulaTract(LIFT):Without Mesh
SyedG.HusainandAlanE.Harzman

INDICATIONS/CONTRAINDICATIONS

Primaryfistulotomyisaneffectiveandatime-testedtreatmentforanal fistulaewithsuccessratesreaching90%.Thistechnique,however, involves“layingopen”ofthefistulatract,makingitlessdesirablefor high-transsphinctericfistulaeduetoattendantriskoffecalincontinence. Traditionally,patientswithfistulaeinvolvingasignificantportionofthe sphincterhavebeentreatedwithrectalmucosaladvancementflapsor fistulapluginsertions.Sinceitsfirstdescriptionin2007,ligationof intrasphinctericfistulatract(LIFT)hasgainedincreasingpopularityin colorectalpracticesacrosstheworld.Availableliteratureindicatesthat LIFTisaneffectivetreatmentforthesechallengingfistulaeandoffersan attractivealternativetomucosaladvancementflapandfistulaplug insertion.
Inouropinion,thereisnoabsolutecontraindicationtothissurgery. Relativecontraindicationsincludeongoingsuppurationwithabscess formationandactiveCrohn’sdisease.Althoughotherreportshave suggesteditseffectivenessinpatientswithCrohn’srelatedanalfistulae, wedonotroutinelyofferthistechniquetothiscategoryofpatients.We alsoconsiderpreexistingfecalincontinencearelativecontraindicationto thisprocedure.AlthoughLIFTisasphincterpreservingoperation,there remainsariskofworseningofpreexistingincontinenceaftersurgery.
PREOPERATIVEPLANNING
Young,healthypatientstypicallydonotrequireanyextensive preoperativeevaluation.However,patientswithadvancedageorsevere comorbidconditionsmayrequirecardiopulmonarytestingand optimizationasindicatedbytheseverityoftheirunderlyingmedical condition.
Theprocedureisperformedinanambulatorysetting.Patientsare askedtoreporttotheambulatorysurgerycenter2hourspriortothe procedureforIVplacementandpreoperativepreparations.Wetypically donotusepreoperativebowelpreporenemas,andperianalhairremoval isnotnecessary.
Patientsareinstructedtoabstainfromeatinganddrinking preoperativelyperlocalpolicies.Perioperativemanagementofapatient’s homemedicationsisindividuallytailoredbasedontheunderlying medicalcondition.Antihypertensivemedicationsshouldbetakenatthe usualdosewithasipofwateronthemorningofthesurgery.Theinsulin doseistypicallyhalved,andpatientsareinstructedtoholdoral hypoglycemicdrugsonthemorningofthesurgery.Nonsteroidalanti­inflammatorydrugs(NSAIDs)useisavoided,ifpossible,duringthe2 weeksprecedingthesurgery.Managementofantiplateletand anticoagulanttherapyisalsoindividuallyadjustedbasedonthe underlyingindicationandthenecessityofsuchtherapy.Ideally,these medicationsshouldbeheldbeforesurgery;however,thisdecisionshould bemadeonlyafteracloseconsultationwiththeprescribingphysician.
Antibioticprophylaxisisgenerallynotindicated.Inourpractice, antibioticprophylaxiswithintravenousciprofloxacinandmetronidazole orertapenemisreservedonlyforpatientswithprofound immunosuppression:uncontrolledHIV,chronicsteroiduse,hematologic malignancies,orpatientsreceivingchemotherapy.
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PreoperativeSetonInsertion
Althoughtheoriginaldescriptionofthistechniquedoesnotcallfor preoperativesetoninsertion,theauthorsfeelthatitisakeyelementin preoperativepreparationforLIFT.Theauthors’preferenceistousea vesselloopforthispurposethatisleftinplacefor8–10weeksbefore proceedingwithdefinitiveoperation.Theauthorsfeelthatthefibrotic reactioninducedbythepresenceofasetongreatlyaidsinthedissection
andintraoperativeidentificationofthetract.Atthetimeofseton placement,theauthorsrecommendaminimaldissectionofthefistula tract:attemptsatpartialfistulotomyordivisionoftheskinattheseton sitearediscouraged.Theauthorshavefoundthatscarringresultingfrom thesemaneuverscanleadtoobliterationoftheintersphinctericplane, makingthedissectiontechnicallychallengingandpossiblydiminishing thechancesofsuccessfulfistulaclosureafterthesurgery.

SURGERY

Positioning
Thepatientisplacedinpronejackknifepositionovergelrollsto minimizepressureoverthedependentareas.Thegelrollscanbeplaced eitheralongthelongaxisofthebodylateraltothebreastsortransversely undertheclaviclesandacrossanteriorsuperioriliacspines.Upper extremitiesareplacedcarefullyonthearmboardsinanabducted position.Handsarekeptinasupinatedpositionwithpalmsfacingthe ground.Extrapaddingistypicallyusedundertheelbowstoprotectthe ulnarnerves.Oncethepatientisinposition,thebuttocksaretapedapart toprovideexposuretotheanus.
Technique
Theperianalareaispreppedwithaniodinesolutionusingthestandard steriletechnique.Surgicaldrapesarethenplacedtocreateasterile operativefield.Althoughthemajorityofanorectalsurgerycanbe performedundersedationwithlocalanestheticinfiltration,theauthors recommendgeneralanesthesiaforthisproceduretomaximizeexposure andrelaxationofthesphinctercomplex.
Theauthorsstarttheprocedurebyperformingtheinspectionofthe perianalskinandtheanalcanaltoruleoutanycoexistentpathologyin theanalcanalthatmaynecessitatealterationofthesurgicalplan.Some degreeofseton-associateddrainageisacceptable.However,thepresence ofafrankabscessintheareashouldpromptthesurgeontodeferthe proceduretoalaterdayafterthesuppurationhasresolved.Theauthors’ preferenceistoutilizeHillFergusonretractorsforanalcanalinspection.
A2–3cmcurvilinear,circumferentiallyorientedincisionisplaced directlyovertheintersphinctericgrooveatthesiteofthefistula(Fig.10-
1).Thedissectionisthenperformedintheintersphinctericgrooveuntil
thefistulatractisreached.Intraoperativeidentificationofthefistulatract isfacilitatedbyapplyingagentletractiononthesetonorbyreplacingthe setonwithametalfistulaprobe.Thedissectioniscontinuedoneither sideofthefistulatractuntilwereachapointaboutonehalfcentimeter proximaltothetract.Atthispoint,asmallright-angledclampisusedto encirclethefistulatract(Fig.10-2).Theexposureintheintersphincteric grooveismaintainedwithhelpof“S”retractors,orofaself-retaining retractor.Oncethefistulatractiscircumferentiallyisolated,flushligation iscarriedoutwiththeinnersurfaceoftheexternalsphincterandthe outersurfaceoftheinternalsphincterusingabsorbablesutures.Thetract
isthendividedbetweentheligations(Fig.10-3).Incasethetractis inadvertentlydividedduringthedissection,suturesusingabsorbable materialinanocclusivefigureofeightareplacedonbothseveredendsof thetract.Agentlecurettageoftheinternalopening(withintheanal canal)iscarriedout.Theauthorstypicallydonotclosetheinternal opening.Theexternalopeningisenlargedandthefistulatractuptothe pointofligationiscurettedtofacilitatedrainageandsecondaryclosure.
FIGURE10-1Skinincisionmarkedoutoverlyingthe
intersphinctericgroove.Fistulaprobeexitingthroughthe internalopening.
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FIGURE10-2Fistulatract,withtheprobethroughitfor
easeofidentification,dissectedfreeintheintersphincteric space.
FIGURE10-3Proberemoved,andfistulatractligated
anddivided.
IntheinitialpartofourexperiencewithLIFT,theauthorswould routinelyclosetheintersphinctericskinincisionwithabsorbablesutures. Theauthorsfeelthatskinclosureincreasestheriskoftheinfectionand sinusformationinthearea.Thus,morerecently,theauthorshave transitionedtoleavingtheskinincisionopenfordrainage.
Attheendoftheprocedure,theareaisinfiltratedwithalong-acting localanestheticandiscoveredwithsteriledressings.
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