LIFT: A New approach to anal fistula Ligation
of Intersphincteric
FistulaTractCharles TSANGDivision of Colorectal Surgery,National University Health [email protected]
Evolution in the management of anorectal
sepsis
Pathogenesis: Cryptoglandular
theory
Scent glands
Marking territory
Express small amounts with bowel movements
Dogs > Cats
Compaction
Scooting, Manual expression
SubmucosalGlands
Intramuscular Glands
Do abscesses become fistula?
Year Author No. of Patients N Percentage %1986 Henrichsen, Christiansen 50 16% fistula1984 Vasilevsky, Gordon 117 37% fistula
11% abscess1983 Ramstead 138 18% fistula &
abscess1984 Ramanujam 668 3.7%
Inadequate drainage: Origin of sepsis i.e
infected gland Trapped between internal and external sphincter
Fundamental Principles
Eradication of anorectal sepsis and removal of the fistula track
Identification of track anatomy
Adequate drainage
FISTULOTOMY
Recurrent Fistula Causes of Failure
Failure to appreciate anatomy of tract(s)
Failure to control the primary tract
Overlooked secondary sepsis / tracts
Iatrogenic tracts
Unusual pathology
Fistula Classification Parks et al. 1976
Clinical Assessment
Erroneous Assessment Seow & Phillips 1991
Initial diagnosis Final diagnosis
Iatrogenic Fistulae
Endoanal
Ultrasound
Primary Fistulotomy When is it safe?
Primary Fistulotomy
..all the anal sphincter muscles below this (anorectal)ring may be divided in any manner without harmfulloss of control.
Milligan & Morgan 1934
It is not possible to be dogmatic on how much normal sphincter muscle above the internal opening should be present, but a centimetre or so is ample.
RJ Nicholls 1996
Trans-sphincteric
Supra-sphincteric
Internal Sphincterotomy
and Continence
56
24
0
10
20
30
40
50
60
Incontinent Continent
% In
tern
al S
phin
cter
Cut
Mann Whitney U Test, p
Results of Fistula Surgery
Author
Year
Pts.
Recurrence (%) Incontinence (%)
Bennett
1962
108
2.0
36.0Hill
1967
626
1.0
4.0Lilius
1968
150
5.5
13.5Mazier
1971
1000
3.9
0.1Marks/Ritchie
1977
793
-
25.0Vasilevsky
1985
160
6.3
3.3Sangwan
1994
461
6.5
2.8Garcia-Aguilar
1996
375
8.0 (16*)
45.0 (67*)
*Previous fistula surgery
Fistula Surgery Patient Satisfaction
Garcia-Aguilar et al. 2000
Questionnaire
study: 375/624 replies
Cryptoglandular
fistulae treated over 5 yrs
8% recurrence / 45% incontinence
Dissatisfaction:
33% attributable to recurrence
84% attributable to incontinence
Fundamental Principles
Eradication of anorectal
sepsis and removal of the fistula track
Adequate drainage
Identification of track anatomy
Preservation of continence
Uses of Setons
Drain for primary track
Marker for primary track
Stimulator of fibrosis
Cutting (fistulotomy)
Endorectal
Advancement Flaps
Endorectal
Advancement Flaps Results
Author Year
Pts. Healing
Incontinence(%)
Min (%) Maj
(%)
Oh
1983
15
87
NS
NSAguilar 1985
189
98.5
10
0Wedell
1987
27
100
30
0Reznick
1988
7
86
0 0Shemesh
1988
8
87.5
0
0Kodner
1993
107
94Miller
1998
26 77
0 0NUH
2008
29
84 3 0
Surgisis
Anal Fistula Plugs
Author Year Pts (N) Follow-up HealingArmstrong DN et al
2006 46 12 months 83%
Ky
AJ et al 2008 44 6.5 months 54.6%Thekkinkaltil
et al
2008 43 47 weeks 44%
NUH experience 2002-2006N
UH
( 2008)
n = 400
n = 104
n = 457
n = 844
n = 98n = 160n = 793
Law et al
RecurrenceAuthor Year No. of patients Recurrence (%)
Mazier 1971 1000 3.9Hanley et al. 1976 31 0Parks et al. 1976 158 9.0Vasilevsky
and Gordon 1985 160 6.3Fucini 1991 99 3.0Sangwan 1994 461 6.5Garcia-Aguilar et al. 1996 293 7.0Mylonakis
et al. 2001 100 3.0Malouf
et al. 2002 98 4.0Westerterp
et al. 2003 60 0G. Rosa et al. 2005 844 2.1Poon
et al. 2008 135 13.3NUH (Law et al) 2008 457 3.0 (+9.9*)
* failures
IncontinenceAuthor Year No. of patients Incontinence (%)
Marks & Ritchie 1977 793 3, 17, 25 *Vasilevsky
and Gordon 1985 160 0.7, 2.0, 3.3 *Fucini 1991 99 0, 0.2, 0.5 *Van Tets 1994 19 33.0Sangwan 1994 461 2.8Garcia-Aguilar et al. 1996 293 42.0Mylonakis
et al. 2001 100 0, 6.0, 3.0
Malouf
et al. 2002 98 10Westerterp
et al. 2003 60 50M. Davies et al. 2008 86 4NUH (Law et al) 2008 457 0, 1.1, 1.4 *
* solid, liquid, flatus
solid, soiling, gas
LIFT
*Rojanasakul
A. LIFT procedure: a simplified technique for fistula-in-ano. Tech Coloproctol. 2009 Sep; 13(3): 237-40.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 Mar; 90(3): 581-6.
*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 Mar; 90(3): 581-6.
LIFT
14 15
28
32
2006 2007 2008 2009Short-term outcomes of the Ligation of Inter-Sphincteric
Fistula Tract procedure for treatment of fistula-in-ano: a single institution experience in Singapore, ASCRS 2008 Annual Meeting
LIFT
Ligation of Intersphincteric Fistula Tract (LIFT)
Ligation of Intersphincteric Fistula Tract (LIFT)
Ligation of Intersphincteric Fistula Tract (LIFT)
Ligation of Intersphincteric Fistula Tract (LIFT)
Current DataYear n Success Median Follow
up
Thailand Jan to June 2006
18 94.4% Max: 6 months
Singapore April 06 Jan 0717 76.5% 8 (2 to 13)
months
Malaysia May 07 Sept 0845 82.2% 9 (2
16)
months
USA July 07 Dec 0839 57% 2.5 (0.5
9)
months
Long-term results of ligation of intersphinteric
fistula
tract (LIFT) technique in the management of anal fistula.
KK Tan, Ian JW Tan, J Lu, Dean Koh, Charles TsangDivision of Colorectal Surgery, University Surgical Cluster, National University Health System, SINGAPORE
Definition
Success: complete healing of surgical wound and closure of external fistula opening
Failure: non healing of surgical wound and/or external opening with persistent discharge
Confirmed using either endoanal
ultrasound or at the subsequent surgeries
Results
60 patients
Median age (years): 40 (range, 16
71)
Median follow up (months): 24 (12
46)
N=48,80.0%
N=12,20.0%
Gender
MaleFemale
24 patients (40.0%) underwent 37 prior procedures
16
11
9
1
Incision & Drainage
Seton insertion Fistulotomy or Fistulectomy
Endorectal advancement flap
Intra-operative findings22
23
8
43
TSF - High TSF - Low TSF - Two tracts
SSF ISF - High
TSF: Trans-sphinctericSSF: Supra-sphinctericISF: Inter-sphincteric
Outcome
Outcome
Failures:
14 underwent repeated surgeries
1 refused (Deep post-anal abscess)
No patient with faecal
incontinence
Median duration from LIFT to repeat surgery: 3.5 months (2-9 months)
5
4
3
1 1
Fistulotomy Setontechnique Advancementflaps
RepeatLIFT Drainageofpostanalabscess
Repeat Surgeries
17(73.9%) 18(81.8%)
6 4
LowTSF HighTSF
Failure
Success
p
= NS
Comparing low vs. high fistulas
Impact of previous surgeries
p
= NS
Conclusions
The overall success rate of LIFT is 75% with a median follow up of 2 years (12
46 months)
The outcomes are similar between low and high transsphincteric
fistulas
The history of previous surgeries did not affect the outcome of LIFT
Summary
LIFT is a promising sphincter preserving technique, long term success of 75%
Easier to perform, wounds closed with easier post-op wound care and less pain
Easier to learn than ERAF
Anal Fistula Current Management Practice
1
Drain sepsis & control the primary tract
Loose setons
2
Delineate the anatomy3
Assess sphincter function
4
Eradicate the primary tract
LOW LIFT
fistulotomy
HIGH LIFT
endorectal advancement flaplong-term seton
Eradication of Sepsis
Preser
