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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1056_Библиотеки_им_академика_М_И_Перельмана.pdf
366 I. E. Gecim
weaker muscles, fistulotomy should be avoided to prevent anal incontinence (AI) to
some degree.
Fistulotomy is probably the most effective treatment of low-cryptoglandular
fistulas. Fistulotomy followed by laying open has been reported to end with complete healing in more than 98% of cases. Although there are some complications, the
rates are pretty low like 0.3% bleeding or 2–3% minor septic problems (Atkin et al.
2011).
One study compared fistulotomy with mucosal flap closure of the internal fistula
orifice, 41 patients with mucosal flap(MF) compared to 62 patients fistulotomy. In
12, 48, and 72 months checkpoints, the recurrence rates were 9 (22%), 26 (63%),
and 26 (63%) patients of the MF group, compared to 4 (7%), 16 (26%), and
24 (39%) fistulotomy group. In 4 cases, 15% of the recurrences in the MF group
and 13 (54%) of the recurrences in the fistulotomy group were presented in different
localizations ( p ¼ 0.007). As a conclusion of this comparison, the success rate of
both groups decreased by time. Recurrence appears to be caused more by failure of
treatment in MF and more by recurrent disease in another site in the fistulotomy
group (van der Hagen et al. 2006).
On the other hand, fistulotomy might be somehow more problematic for the
patients specially in regard to long-term anal function. A study from Holland gave us
a clear idea why to avoid damaging the sphincter by any means that there are some
degrees of incontinence in 34% of patients who had a fistulotomy and related
morbidity which can be observed as higher scores in AI (Ana l Incontinence) scoring
systems and lower QoL (Quality of Life) scores. In this study, median follow-up was
7.8 years, and the risk factors for this 34% of some degrees of AI were the following:
– Previous multiple abscess drainages
– High trans-sphincteric fistuli
– Suprasphincteric fistula tract
Eventually, an innocent and otherwise successful fistulotomy in general may be
an important reason for patient dissatisfaction and inevitably medicolegal problems
(Visscher et al. 2015).
Since many years, surgeons looked for some methods to choose the fistula
without fistulotomy. An original paper reporting a new approach without sacrificing
the sphincter came out of St Mark’s Hospital. An intersphincteric approach has been
developed that allows complete sphincter preservation in some patients with high
fistulas. This operation in 13 patients (8 trans-sphincteric, 5 suprasphincteric tracks)
has resulted in complete success in 7, partial success (ultimate sacrifice of the
internal anal sphincter) in 2, and failure in 4 cases. When the operation is successful,
continence is better than after failed procedures (Matos et al. 1993).
In fact, the overall success rate might be somehow less than reported. In later
studies, we learned that the recurrence after this new approach increases especially
after the first year or at least 9 months of follow-up (Figs . 1, 2,
3, and 4).
The study which made this new approach popular came from Thailand. The fistuli
included in this new cohort of patients were the ones with high-lying trans-
23 (LIFT) Ligation of Intersphincteric Fistula Tract 367
Fig. 1 Durability of LIFT over time (Liu et al. 2013)
sphincteric and complex fistulas where the treatment can become challenging
proportional to the amount of the sphincter muscle involved. This new paper also
made the name LIFT popular. LIFT has gained a high popularity immediately after
the paper was published, mainly due to the initial high success rates for a relatively
simple procedure. Fistuli of 17 patients healed primarily (94.4%). There was only
one nonhealing case (5.6%). The mean healing time was 4 weeks. The most
important point was no sphicter cut and no disturbances in clinical AI. This technique became a potentially viable option for fistula-in-ano surgery. Results
warranted larger studies with long-term evaluation (Rojanasakul et al. 2007).
Seeing the results of the LIFT technique, the success rate with the original paper
was the highest (94%). This paper was criticized for having relatively small number
of patients (18 patients) and shorter follow-up (Rojanasakul et al. 2007).
The basic advantage of the technique was supposed to be no incontinence after
LIFT surgery; however, there are at least 2 studies that reported some gas incontinence and soiling after LIFT procedure. However, there are literally no serious AI
observed after LIFT technique (Koh and Tsang 2014).
One of the largest retrospective reviews about the LIFT technique was reported
from Singapore (Tan et al. 2011). Ninety-three patients who underwent the ligation
of intersphincteric tract procedure for anal fistulas were evaluated. Median follow-up
was 23 (range, 1–85) weeks. There were 7 failures and 6 recurrences. The diseasefree interval at 1 year following the LIFT procedure was 78%. All 7 failures had
discharge at the intersphincteric wound. Four had an unhealed internal opening, and
three had isolated failures at the intersphincteric wound(Tan et al. 2011).
My personal experience, the recurrence or failure after the procedure, must be
described in two different ways. In the majority of failure or recurrence cases, the
external part of the fistula which lays within the external sphincter heals, and the part
which lays within the internal sphincter including the internal opening persists. This
type of failure may be treated with internal sphincter fistulotomy in most cases. In
fact, a modified technique of the LIFT procedure was reported.
368 I. E. Gecim
a
b
Fig. 2 LIFT technique (Koh and Tsang 2014)
While the failures occur mostly in the intersphincteric woun d, a modification to
LIFT as unroofing the fistula from internal opening to intersphincteric groove,
ligating the fistula tract, but preserving the external sphincter, was proposed. Total
23 (LIFT) Ligation of Intersphincteric Fistula Tract 369
a
b
cd
Fig. 3 (a) A loose seton in the fistula tract; (b) inter-sphincteric dissection of the tract; (c)
identification and ligation of the tract; and (d) approximation of the wound (Pommaret et al.
2016) (Table 1)
Fig. 4 Original photograph from personal archive. http://www.kolonoskopi.com.tr
370 I. E. Gecim
66 modified LIFT procedures were performed on 56 patients; after median
20.98 weeks follow-up, overall cure rate was 71.42%, with a recurrence rate of
5.35% and failure of treatment rate of 16.07%. There was no persistent fecal
incontinence. By this way, the intersphincteric space was eliminated and the cure
rates were equal to or better than the original LIFT (Bastawrous et al. 2015).
Coming back to recurrence with the persistence of the part which lays within the
external sphincter, all 6 recurrences had a demonstrable tract from the previous
internal opening to an external opening with healing of the intersphincteric wound.
The median time to recurrence was 22 (range, 15–33) weeks from the ligation of the
intersphincteric tract procedure (Tan et al. 2011).
In a recent meta-analysis, sphincter-preserving surgery types as the ligation of the
intersphincteric fistula tract (LIFT) procedure and endorectal advancement flap (AF)
in high perianal fistulas were reviewed. The aim of this study was to evaluate
outcomes of these procedures not only in patients with cryptoglandular but also in
Crohn’s perianal fistulas (Stellingwer f et al. 2019).
Total 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 rates were 74.6 versus 69.1%,
respectively, while recurrence rates were 25.6 versus 21.9%. For Crohn’s perianal
fistula (64 patients), no significant differences were observed between AF and LIFT
for overall success rate 61 versus 53%, respectively, but data on recurrence were
limited. Incontinence rates were significantly higher after AF compared with LIFT
7.8 versus 1.6%. In conclusion, overall success and recurrence rates were not
significantly different between the AF and LIFT procedure, but continence was
better preserved after LIFT.
Finally, the problem with understanding LIFT technique is the large variance
between different reports (Fig. 5).
As seen from the distribution, the success rates vary between 40% to 97%. In my
experience, patients with lower BMI and less perianal fat seem to show higher
success rates. So, the patients’ BMI and anatomy may influence the outcome.
Although there is no data to evaluate, the LIFT technique can be considered more
promising to offer high success rates and a relatively easy procedure in leaner
patients. In a recent meta-analysis, (Hong et al. 2014) the Pubmed, Web of Science,
and Cochrane databases between January 2007 and March 2013, searched to retrieve
all relevant scientific original articles and scientific abstracts (Web of Science)
related to the LIFT procedure for anal fistula for systematic review. In 24 original
articles including 1,110 patients with trans-sphincteric or complex fistula, not amenable to fistulotomy and with 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. There was no association between pre-LIFT
drainage seton and success of LIFT. Ligation of the intersphincteric fistula tract
23 (LIFT) Ligation of Intersphincteric Fistula Tract 371
Fig. 5 Pooled data with 76.4% success rate (Hong et al. 2014)
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. As mentioned by the
review, further trials are mandatory to identify predictive factors for success, and true
effectiveness of the LIFT compared to other sphincter-preserving procedu res to treat
anal fistula.
372 I. E. Gecim
1
Other
morbidity
Failure or
recurrence Incontinence
R: 5.6% NA NA
43% NAO 2 Anal
fissures and
pain
R: 17.7% NA
R: 6% NA
R: 17% NA
thrombosed
R: 6.4% NA NA
Healing
rate Follow-up time
Preoperative
evaluation
Fistula
etiology and
classification
26 weeks)
5HS
18 13 LTS NA 94% 4 (up to
39 28 TS NA 57% 20 Weeks
Prospective
cohort
Retro-/
(0–58)
7HS
1SP
2RV
prospective
(2–16)
82% 9 Months
colonoscopy
US
12 complex 48.8% anal
45 33 TS 44%
Prospective
cohort
(12–30)
18 15 TS 100% MRI
Prospective
or anal US
2RV
cohort
(4–10)
1 HS 83% 6 Months
86% 23 Weeks
Retrospective 93 44 HTS 100% anal
(1–85)
US
39 LTS F: 7.5%
22 HS
6SP
4IS
Table 1 Summary of published studies
References Study design n
Rojanasakul
et al. (2007)
Bleier et al.
2010
Shanwani
et al. 2010
Ellis 2012 Retrospective 31 31 TS NA 94% 15 Months
Sileri et al.
2011
Tan et al.
2011
23 (LIFT) Ligation of Intersphincteric Fistula Tract 373
R: 33/3%
(1–16)
Temporary
gas
incontinence
(1/29)
2/10
F: 16.7%
(CD)
NA
(1/11)
candidiasis
F: 32% NA 2 vaginal
(8–52)
R: 28% WIS 0%
(3–43)
R: 26% NAO
(2–64)
1st 90%
2nd 75%
(continued)
3rd 65%
Retrospective 12 NA 66.70% 4 Months
Singh et al.
2013
Prospective 29 NA 65.00% 12–26 Months R: 3.4%
Espin et al.
6IS
1SP
2012
Prospective 40 40 TS NA 74% Mean 18 weeks
Abcarian
et al. 2012
Retrospective 25 NA NA 68% 24 Weeks
Prospective 11 NA 72.00% 3 Months NR 0
Prospective 31 NA 87.00% 1–12 Months NR
2011
Iachino et al.
2011
Franceschilli
et al. 2011
Prospective 11 NA 54.40% 1.2–9.5 Months 9.1%
Christoforid
is et al. 2008
Prospective 25 18 TS MRI 72% 68% 22 Weeks
Ooi et al.
Aboulian
et al. 2011
374 I. E. Gecim
Other
morbidity
soiling
incontinence
Failure or
recurrence Incontinence
R: 26% OCF F1 2/32
F: 34% Flatus
F: 37.5% NA NA
F: 6.5%
Healing
rate Follow-up time
Preoperative
evaluation
Fistula
etiology and
classification
(44–55)
Retrospective 93 77 TS NA 40% 19 Months
57%
16 HS Secondary
4 partial
sphincterotomy,
1 mucosal flap, and
13 Months
(4–67)
6 Months
LIFT
62.5%
100% anal
US
fistulae
5 bioprostheses
31 ERAF ERAF
Retrospective 24 LIFT 55 High
(2–26)
93.5%
Table 1 (continued)
References Study design n
Wallin et al.
2012
Tan et al.
2012
23 (LIFT) Ligation of Intersphincteric Fistula Tract 375
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