“lift”: a new approach to anal fistula ligation of intersphincteric

“LIFT”: A New approach to anal fistula Ligation

of Intersphincteric

FistulaTractCharles TSANGDivision of Colorectal Surgery,National University Health Systemdrcharlestsang@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

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<0.02

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 Seton technique Advancement flaps

Repeat LIFT Drainage of post‐anal abscess

Repeat Surgeries

17 (73.9%) 18 (81.8%)

6 4

Low TSF High TSF

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

Preservation of continence

Low/Simple fistula –

Fistulotomy

High/complex fistula –

Seton,

Flaps

Principles of Anal fistula surgery

LIFT