LIFT : A New approach to anal fistula Ligation of Intersphincteric FistulaTract

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1 LIFT : A New approach to anal fistula Ligation of Intersphincteric FistulaTract Charles TSANG Division of Colorectal Surgery, National University Health System drcharlestsang@gmail.com

2 Evolution in the management of anorectal sepsis

3 Pathogenesis: Cryptoglandular theory Scent glands Marking territory Express small amounts with bowel movements Dogs > Cats Compaction Scooting, Manual expression

4 Submucosal Glands Intramuscular Glands

5 Do abscesses become fistula? Year Author No. of Patients N Percentage % 1986 Henrichsen, Christiansen 50 16% fistula 1984 Vasilevsky, Gordon % fistula 11% abscess 1983 Ramstead % fistula & abscess 1984 Ramanujam % Inadequate drainage : Origin of sepsis i.e infected gland Trapped between internal and external sphincter

6 Fundamental Principles Eradication of anorectal sepsis and removal of the fistula track FISTULOTOMY Identification of track anatomy Adequate drainage

7 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

8 Fistula Classification Parks et al. 1976

9 Clinical Assessment

10 Erroneous Assessment Seow & Phillips 1991 Initial diagnosis Final diagnosis

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12 Iatrogenic Fistulae

13 Endoanal Ultrasound

14 Primary Fistulotomy When is it safe?

15 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

16 Supra-sphincteric Trans-sphincteric

17 Internal Sphincterotomy and Continence 60 % Internal Sphincter Cut Incontinent Continent Mann Whitney U Test, p<0.02

18 Results of Fistula Surgery Author Year Pts. Recurrence (%) Incontinence (%) Bennett Hill Lilius Mazier Marks/Ritchie Vasilevsky Sangwan Garcia-Aguilar (16*) 45.0 (67*) *Previous fistula surgery

19 Fistula Surgery Patient Satisfaction Garcia-Aguilar et al Questionnaire study: 375/624 replies Cryptoglandular fistulae treated over 5 yrs 8% recurrence / 45% incontinence Dissatisfaction: 33% attributable to recurrence 84% attributable to incontinence

20 Fundamental Principles Eradication of anorectal sepsis and removal of the fistula track Adequate drainage Identification of track anatomy Preservation of continence

21 Drain for primary track Marker for primary track Stimulator of fibrosis Cutting (fistulotomy) Uses of Setons

22 Endorectal Advancement Flaps

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24 Endorectal Advancement Flaps Results Author Year Pts. Healing Incontinence (%) Min (%) Maj (%) Oh NS NS Aguilar Wedell Reznick Shemesh Kodner Miller NUH

25 Surgisis Anal Fistula Plugs Author Year Pts (N) Follow-up Healing Armstrong DN et al months 83% Ky AJ et al months 54.6% Thekkinkaltil et al weeks 44%

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27 NUH experience n = 104 n = 844 Law et al n = 793 n = 160 n = 98 n = 457 n = 400 NUH (2008)

28 Recurrence Author Year No. of patients Recurrence (%) Mazier Hanley et al Parks et al Vasilevsky and Gordon Fucini Sangwan Garcia-Aguilar et al Mylonakis et al Malouf et al Westerterp et al G. Rosa et al Poon et al NUH (Law et al) (+9.9*) * failures

29 Incontinence Author Year No. of patients Incontinence (%) Marks & Ritchie , 17, 25 * Vasilevsky and Gordon , 2.0, 3.3 * Fucini , 0.2, 0.5 * Van Tets Sangwan Garcia-Aguilar et al Mylonakis et al , 6.0, 3.0 Malouf et al Westerterp et al M. Davies et al NUH (Law et al) , 1.1, 1.4 * * solid, liquid, flatus solid, soiling, gas

30 LIFT *Rojanasakul A. LIFT procedure: a simplified technique for fistula-in-ano. Tech Coloproctol Sep; 13(3): 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 Mar; 90(3):

31 *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 Mar; 90(3):

32 LIFT 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

33 LIFT

34 Ligation of Intersphincteric Fistula Tract (LIFT)

35 Ligation of Intersphincteric Fistula Tract (LIFT)

36 Ligation of Intersphincteric Fistula Tract (LIFT)

37 Ligation of Intersphincteric Fistula Tract (LIFT)

38 Current Data Year n Success Median Follow up Thailand Jan to June % Max: 6 months Singapore April 06 Jan 07 Malaysia May 07 Sept 08 USA July 07 Dec % 8 (2 to 13) months % 9 (2 16) months 39 57% 2.5 (0.5 9) months

39 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

40 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

41 60 patients Results Median age (years): 40 (range, 16 71) Median follow up (months): 24 (12 46) N = 12, 20.0% N = 48, 80.0% Male Female Gender

42 24 patients (40.0%) underwent 37 prior procedures Incision & Drainage Seton insertion Fistulotomy or Fistulectomy Endorectal advancement flap

43 Intra-operative findings TSF: Trans-sphincteric SSF: Supra-sphincteric ISF: Inter-sphincteric TSF -High TSF -Low TSF -Two tracts SSF ISF - High

44 Outcome

45 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)

46 Repeat Surgeries Fistulotomy Seton technique Advancement flaps Repeat LIFT Drainage of post anal abscess

47 Comparing low vs. high fistulas 6 4 p = NS 17 (73.9%) 18 (81.8%) Failure Success Low TSF High TSF

48 Impact of previous surgeries p = NS

49 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

50 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

51 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

52 Principles of Anal fistula surgery LIFT Eradication of Sepsis Preservation of continence Low/Simple fistula Fistulotomy High/complex fistula Seton, Flaps

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