EVALUATION OF LIGATION OF THE INTERSPHINCTERIC FISTULAS TRACT (LIFT) TECHNIQUE IN TRANSSPHINCTERIC PERIANAL FISTULA

INTRODUCTION

A perianal fistula is a tubular structure lined with granulation tissue that connects a main entry within the anal canal or rectum to a secondary opening in the perianal skin.¹ For many years, probing the fistula tract has been the procedure of choice for identifying the anatomy of fistulas. The most commonly used treatment is to open a fistulous tract (fistulotomy). However, if a considerable portion of the sphincter muscle is damaged, this treatment may become difficult.²

The LIFT technique is a novel surgical method for treating trans-sphincteric fistula that was first described by Rojanasakul et al.³ in 2007. It has been shown to be effective in the short term with no incontinence. It is done by identifying the internal opening; making incision at the inter-sphincteric groove; dissecting the inter-sphincteric space; identifying the inter-sphincteric fistula tract; securing ligation and excision of the inter-sphincteric tract; confirming the removal of the correct fistulous tract;

opening and curing the external opening; and finally closing the inter-sphincteric wound.³

 Despite its initial feasibility and high success rates, multiple later investigations have indicated inferior healing rates and greater recurrences due to non-standardized operating practices and patients’ inclusion criteria.

The primary goal of this research is to evaluate healing, failure, recurrence, incontinence, and other key concerns associated with the LIFT technique in trans-sphincteric.

PATIENTS AND METHODS

Our study included 40 patients of trans-sphincteric anal fistula who came to our tertiary care center between December 2019 and December 2021.

Anal fistula with trans-sphincteric track is required for inclusion. All cases were clinically diagnosed and confirmed by MRI and CT. Patients having anal fistula owing to a particular illness are excluded. There are three forms of anal fistulas: low inter-sphincteric, supra-sphincteric, and extra-sphincteric.

Ethical approval: All patients who participated in this trial provided informed consent. This study was authorized by the ethical committee of Al-Azhar University's college of medicine in Damietta, Egypt.

Preoperative assessment: full medical history including age, gender, BMI, diabetes, and a history of previous anal surgeries and previous fistula surgeries. Secondly: digital rectal examination is performed to detect the position of the external opening, fistulous tract, internal opening, and anal tone. MRI and CT scans to confirm the presence of anal fistulas and define their anatomy. The following regions were thoroughly checked intraoperatively: external opening position, internal opening location, tract length, presence of external piles at the incision site, and anal muscle thickness.

Operative procedures: All patients had the LIFT surgery.⁴ The following procedures were carried out in the lithotomy position under spinal or general anesthesia: The internal hole was discovered after sensitive probing of the fistula tract. If probing failed, a hydrogen peroxide solution was injected through the exterior opening into the fistula tract. The inter-sphincteric plane was reached using a 2-3 cm incision at the medial end of the fistulous tract. By dissection with scissors and electrocautery while the probe was still in place, the inter-sphincteric space was discovered and penetrated between the internal and external sphincters. Rather than cutting, we found the inter-sphincteric tract and hooked it with a right-angled clamp before transfixing the patient. Rather than cutting, we located the inter-sphincteric tract and hooked it with a right-angled clamp; we then transfixed the inter-sphincteric fistula tract with polyglactin (Vicryl) 3/0 on both sides, one near the internal opening and the other near the external sphincter defect. The tract was split between the places of ligation. From the external aperture, the distal half of the tract was fully curetted. Vicryl 3/0 simple interrupted single layer was used to approximate the inter-sphincteric incision wound. The tract's tight suturing was verified by introducing a probe through the exterior orifice or injecting hydrogen peroxide.

Postoperative follow-up: All patients were released after 24 hours unless there was a complication. All patients were given ciprofloxacin and metronidazole orally for 7 days. For wound healing and postoperative complications, including recurrence, weekly visits for the first month, then every two months for the remaining six months. A successful outcome was defined as the surgical wound and external opening fully healing. Persistence of fistula was defined as the presence of persistent discharge with no complete wound healing of either the external opening or the inter-sphincteric wound (procedure failure). Recurrence was defined as the emergence of symptoms following complete healing of the exterior opening and the inter-sphincteric wound.

Statistical analysis: Mean values were used for quantitative variables, while absolute and relative frequencies were used for qualitative data (SD). To compare proportions between groups, Fisher's exact test was performed, whereas Student's t-test was utilized to compare mean values. The p values displayed are all two-tailed. The statistical significance limit of p 0.05 was set. The Jamovi statistical tool was used to conduct this research (version 2.0.0).⁵

RESULTS

Table 1 summarizes the demographics and clinical characteristics of the individuals enrolled. LIFT procedures were performed on 40 patients. The patients are composed of 32 men (80%) and 8 women (20%), with a median age of 44 (range: 25–64) and a median symptom duration of 20 months (range: 2–72 months). In five of the patients (12.5 percent), previous definitive fistula repairs had failed. A fistula tract's median length was 4 cm (range: 3–10 cm), with 62.5 percent of fistula tracts being longer than 3 cm. Six patients had hyperlipidemia, five had diverticulitis, three had diabetes, and three had high blood pressure (Table 1)

Table 1: Demographics and clinical characteristics of the included patients.

Fig. 1: Frequencies of Comorbidities.

Following the initial LIFT operation, 29 (72.5%) of the 40 patients recovered without the need for additional surgeries. The average follow-up time was 24 weeks (range: 3-46 weeks). Age, gender, comorbidities, and sickness duration had no statistically significant influence on healing. However, the median fistula tract length in the repaired group is shorter than in the failed group (3cm vs 7cm, p=0.014). When 3 cm was selected as an artificial cutoff limit, fistula tracts shorter than 3 cm showed significantly better primary healing (56 percent versus 44 percent, p = 0.003). Furthermore, there was no subjective incontinence or intraoperative issue. (Tables 2 and 3).

Table 2: Overall results (total number=40).

Fig. 2: Frequency of Healing rate among the studied group.

Fig. 3: Frequency of complications among the studied group.

       - Fisher’s exact test is significant (p < .05).

Table 3: Effect of fistula length on the healing rate.

There was no statistically significant difference between people with surgical difficulties and those without postoperative issues in terms of age, median symptom duration, and other comorbidities. However, there was a significant difference between the two groups in terms of recurrent fistula and piles with fistula, with P-values of 0.005 and 0.001, respectively. (Table 2 and Table 4).

*: Fisher’s exact test; •: Independent t-test

Table 4: Relation of postoperative complications with demographic and clinical characteristics of the studied patients