“LIFT”: A New approach to anal
fistula Ligation of Intersphincteric
FistulaTract
Charles TSANG
Division of Colorectal Surgery,
National University Health System
drcharlestsang@gmail.com
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
Submucosal
Glands
Intramuscular
Glands
Do abscesses become
fistula?
Year
Author
No. of Patients N
Percentage %
1986
Henrichsen, Christiansen
50
16% fistula
1984
Vasilevsky, Gordon
117
37% fistula
11% abscess
1983
Ramstead
138
18% fistula &
abscess
1984
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 harmful
loss 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
% Internal Sphincter Cut
60
50
56
40
30
20
24
10
0
Incontinent
Continent
Mann Whitney U Test, p<0.02
Results of Fistula Surgery
Author
Year
Pts.
Bennett
Hill
Lilius
Mazier
Marks/Ritchie
Vasilevsky
Sangwan
Garcia-Aguilar
1962
1967
1968
1971
1977
1985
1994
1996
108
626
150
1000
793
160
461
375
Recurrence (%) Incontinence (%)
2.0
1.0
5.5
3.9
6.3
6.5
8.0 (16*)
36.0
4.0
13.5
0.1
25.0
3.3
2.8
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
(%)
Oh
Aguilar
Wedell
Reznick
Shemesh
Kodner
Miller
NUH
1983
1985
1987
1988
1988
1993
1998
2008
15
189
27
7
8
107
26
29
87
98.5
100
86
87.5
94
77
84
Incontinence
Min (%) Maj (%)
NS
10
30
0
0
0
3
NS
0
0
0
0
0
0
Surgisis
®
Anal
Fistula
Plugs
Author
Year
Pts (N)
Follow-up
Healing
Armstrong DN 2006
et al
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 2002-2006
Law et al
n = 104
n = 793
n = 844
n = 160
n = 98
n = 457
n = 400
NUH
(2008)
Recurrence
Author
Year
No. of patients
Recurrence (%)
Mazier
1971
1000
3.9
Hanley et al.
1976
31
0
Parks et al.
1976
158
9.0
Vasilevsky and Gordon
1985
160
6.3
Fucini
1991
99
3.0
Sangwan
1994
461
6.5
Garcia-Aguilar et al.
1996
293
7.0
Mylonakis et al.
2001
100
3.0
Malouf et al.
2002
98
4.0
Westerterp et al.
2003
60
0
G. Rosa et al.
2005
844
2.1
Poon et al.
2008
135
13.3
NUH (Law et al)
2008
457
3.0 (+9.9*)
* failures
Incontinence
Author
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
33.0
Sangwan
1994
461
2.8
Garcia-Aguilar et al.
1996
293
42.0
Mylonakis et al.
2001
100
0, 6.0, 3.0 †
Malouf et al.
2002
98
10
Westerterp et al.
2003
60
50
M. Davies et al.
2008
86
4
NUH (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.
32
LIFT
28
14
15
2006
2007
2008
2009
Short-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 Data
Year
n
Success Median Follow
up
Thailand
Jan to
June 2006
18
94.4%
Max: 6
months
Singapore
April 06 –
Jan 07
17
76.5%
8 (2 to 13)
months
Malaysia
May 07 –
Sept 08
45
82.2%
9 (2 – 16)
months
USA
July 07 –
Dec 08
39
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 Tsang
Division 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 = 12, 20.0%
Male
N = 48, 80.0%
Gender
Female
24 patients (40.0%) underwent 37
prior procedures
16
11
9
1
Incision &
Drainage
Seton insertion
Fistulotomy or
Fistulectomy
Endorectal
advancement flap
Intra-operative findings
22
23
TSF: Trans-sphincteric
SSF: Supra-sphincteric
ISF: Inter-sphincteric
8
4
TSF - High
TSF - Low
TSF - Two
tracts
SSF
3
ISF - High
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)
Repeat Surgeries
5
4
3
Fistulotomy Seton technique Advancement flaps
1
1
Repeat LIFT
Drainage of post‐anal abscess
Comparing low vs. high fistulas
6
4
p = NS
17 (73.9%)
18 (81.8%)
Failure
Success
Low TSF
High TSF
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 anatomy
3 Assess sphincter function
4 Eradicate the primary tract
• LOW LIFT
fistulotomy
• HIGH LIFT
endorectal advancement flap
long-term seton
Principles of Anal fistula surgery
LIFT
Eradication
of Sepsis
Low/Simple
fistula –
Fistulotomy
Preservation
of continence
High/complex
fistula – Seton,
Flaps