jcoloproctol(rioj).2016;36(4):227–230
w w w . j c o l . o r g . b r
Journal
of
Coloproctology
Original
Article
Long-term
results
of
ligation
of
intersphincteric
fistula
tract
(LIFT)
for
management
of
anal
fistula
Fakhrosadat
Anaraki
a,
Gholamreza
Bagherzade
a,
Roubik
Behboo
b,
Omid
Etemad
a,∗aColorectalDivisionofSurgicalWard,AyatollahTaleghaniHospital,ShahidBeheshtiUniversityofMedicalSciencesandHealthCare
Services,Tehran,Iran
bIranUniversityofMedicalSciencesandHealthCareServices,RasulAkramHospital,DepartmentofColorectalSurgery,Tehran,Iran
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received20March2016 Accepted20April2016 Availableonline30June2016
Keywords:
Fistulatract Intersphincteric Complexfistula
a
b
s
t
r
a
c
t
Background:Ligationofintersphinctericfistulatracttechniqueisanewsphinctersaving
methodwithgoodresultsinmanagementofanalfistula,butfewstudiesreportlong-term follow-updata.
Materialandmethods: Thisstudyinvestigatedtheuseofligationofintersphinctericfistula
tractasasphinctersavingmethodbasedonlongtermresults.Thiswasaretrospective reviewofprospectivelycollecteddata.Thestudywasconductedattwotertiarycare uni-versitymedicalcenters.36patientswithcomplexfistulafromJanuary2010toJanuary2014 treatedwithclassicligationofintersphinctericfistulatractwereretrospectivelyfollowed. Demographicdata,previousrepairattempts,thetypeofthefistulaandscoreoffecal conti-nencewerecollected.Theprocedurewasperformedbycolorectalsurgeons.Primaryhealing rate,failuresandfecalincontinencescoreofpatientswerefollowedfor6–48months.
Results:Atotalof36patientsunderwentligationofintersphinctericfistulatractduring24
months.Themeanageofthepatientswas35yearsand50%hadtwopreviousattempts atsurgery.Atotalof25patients(69/5%)hadhightranssphinctericfistula.Themeanfollow upwas27months.Successfulfistulaclosurewasachievedin63/8%ofthepatients(23of 36).Themeantimeofrecurrencewas4.5weeks.Onlyone(2/77%)patientreportedgas incontinence(score:3)aftertheprocedure.
Conclusion: Therecurrencerateandfecalincontinenceweremeasured.Theligationof
inter-sphinctericfistulaisapromisingsphincter-preservingprocedurethatissimpleandsafe.Our studydemonstratesfavorablelong-termresultsofligationofintersphinctericfistulatract formanagementofcomplexanalfistulas.
©2016SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.This isanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
∗ Correspondingauthor.
E-mail:[email protected](O.Etemad). http://dx.doi.org/10.1016/j.jcol.2016.04.012
228
jcoloproctol(rioj).2 0 1 6;36(4):227–230Resultados
em
longo
prazo
da
ligadura
interesfincteriana
do
trato
fistuloso
(LIFT)
para
o
tratamento
de
fístula
anal
Palavras-chave:
Tratofistuloso Intersfinctérico Fístulacomplexa
r
e
s
u
m
o
Introduc¸ão: AtécnicaLIFT(LigationofIntersphinctericFistulaTract;ligadurainteresfincteriana
dotratofistuloso)éumnovométododepreservac¸ãoesfinctéricacombonsresultadosno tratamentodafístulaanal,massãopoucososestudosquerelatamdadosdeseguimento emlongoprazo.
Materialemétodos:EsseestudoinvestigouousodeLIFTcomométododepreservac¸ão
esfinc-térica,combaseemresultadosemlongoprazo.Essafoiumarevisãoretrospectivadedados prospectivamentecoletados.Oestudofoirealizadoemdoiscentrosmédicosterciários uni-versitários.TrintaeseispacientescomfístulacomplexatratadoscomLIFTcássicadejaneiro de2010atéjaneirode 2014foramretrospectivamenteseguidos.Foramcoletadosdados demográficos,tentativasprecedentesdereparo,tipodefístula,eescoredecontinênciafecal. Oprocedimentofoirealizadoporcirurgiõescolorretais.Percentualdecicatrizac¸ãoprimária, insucessos,eescoredeincontinênciafecaldospacientesforammonitoradosdurante6a48 meses.
Resultados: Nototal,36pacientesforamsubmetidosaLIFTemumperíodode24meses.A
médiadeidadedospacienteserade35anose50%játinhamsidopreviamentesubmetidosa duastentativasdecirurgia.Vinteecincopacientesapresentavamfístulatrans-esfinctérica alta.Amédiadoseguimentofoide27meses.Foiobtidofechamentobem-sucedidodafístula em63,8%dospacientes(23de36).Otempomédioatéarecorrênciafoide4,5semanas. Ape-nasum(2,77%)pacienteinformouincontinênciagasosa(escore=3)apósoprocedimento.
Conclusão:Opercentualderecorrênciaeaincontinênciafecalforammensurados.Aligadura
defístulaintersfinctéricaé umprocedimentopromissordepreservac¸ãoesfinctérica, de simplesexecuc¸ãoeseguro.Nossoestudodemonstraresultadosfavoráveiscomousode LIFTemlongoprazoparaotratamentodefístulasanaiscomplexas.
©2016SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Introduction
Anal fistulacausedbyanorectalsepsis, ischaracterizedby chronicpurulentdischargeorrecurrentabscess.1These fis-tulasareoftenarisenfromcryptoglandularabscess.Basedon thelocationofanalfistulasrelativetosphinctermuscle,they characterizedinto twogroups: simpleandcomplex.Simple fistulasconsistofintersphinctericandlowtranssphincteric fistulaswhicharemanagedbysimplefistolotomywithoutany significantriskofincontinence.2Mostoffistulasaresimple andcanbetreatedsatisfactorilybylayingopentheprimary tract.1,3,4 Atleast, complexfistulahasoneofthe following characteristics:hightranssphincteric(thetractcrossesmore than30%oftheexternalsphincter),supersphincteric, extras-phinctericmultiple fistulatract,anterior fistulainwomen, recurrentfistula,fistulainpatientswithpreexisting inconti-nence,localirradiation,cancer,IBD.5–7
Ouraiminsurgical management istoeffectively eradi-catethesepticfociandanyepithelialisedtractsandpreserve theanalsphincterfunction.1Althoughcomplexfistulaisnot common,varioustreatmentoptions otherthan fistolotomy are available for less sphincter damages: fibrin glue injec-tion,endorectaladvancementflap,useofsetonandstaged fistolotomy.4,6–9Thesemethodsmayhavesomerisksof mor-bidity,forexampleinsertionofcuttingsetonhasupto67%
incontinencerate.10Endorectaladvancementflaphasupto 35%riskofincontinence.11
Fibringlueinjectiondespitenoriskofincontinencedoes nothaveanysignificantsuccessfortreatingthefistulas.12A newsphinctersavingmethodinvolvingtheligationof inter-sphincteric fistulatract (LIFT), hasbeen recently described byRojanasaskulfromThailand.12Asuccessrateof94%was reportedinthetreatmentof18patientswithoutanyissuewith incontinency.
AnothercaseofLIFT procedurewasreportedbyJashova I.S.BleiveratthemeetingoftheAmericanSocietyofColon and Rectum Surgeons, on May 2009.Thesuccessfulfistula closure was achieved in 57% of the patients without any decrease incontinence.13 Inanother study,Shanvani from Malaysiareported82.2%successrateinLIFTprocedure.14The presentstudywasaprospectiveobservationalstudydesigned toassessresultsobtainedinourColorectalDepartment.We assessedthehealingrateandalsoremovedthepitfallofthe previousstudiesbyusingJorge–Wexnerincontinencescorefor quantifyingtheincontinencerateoftheprocedure(LIFT).
Material
and
methods
jcoloproctol(rioj).2 0 1 6;36(4):227–230
229
January2010toJanuary2014.Allpatientswereinformedabout the procedure before the surgery. The study proposal was reviewedandapprovedbyresearchcenterofShahidBeheshti University.
Assessments
Patientswithfistulainanoarisenfromcryptoglandular infec-tionsareincludedinourstudyandunderwentsurgeryfrom January2010toJanuary2014.Allpatientswereinformedabout the procedure before the surgery. The study proposal was reviewedandapprovedbyresearchcenterofShahidBeheshti University.
Operativetechnique
Allpatientswereadmittedadaybeforethesurgery.Limited chemicalbowelprepattemptedwithbisacodyltabletinthe afternoonbeforethesurgery.
Afterregionalanesthesia,thepatientwasplacedin litho-tomyposition.Internalorificewasidentifiedbygentlyprobing thefistulatract,oncebothopeningwasdelineated,afansler anoscope was inserted.Via skin incision made by using a scalpel,anintersphinctericgrooveatthesiteofthetractwas entered.Carewastakennottoinjurethesphincter.
Theintersphincterictractwasidentifiedandisolatedusing asmall right-angledclamp.Bothsidesofthetractin inter-sphinctericspacewasligatedwitha3/0vicryl.Followingthat, thetractwasdividedbetweenthepointsofligation.The inter-nalopeningwassuturedusing3/0vicryl.Subsequently,the externalopeningandtheremnantofthetractwascoredout uptotheproximityofexternalsphincter. Finally,the inter-sphinctericincision wasapproximatedwithinterrupted 3/0 vicryl.Thecoredoutwoundwasleftopenedfordressing.
Postoperativemanagement
Allpatientswereprescribedonanti-inflammatoryanalgesic,a stoolsoftener,andoralciprofloxacinandmetronidazolefora week.Patientswereinstructedtoperformwashingthewound withwarmwater3timesaday.Allpatientswereexamined atweeks1,2,4,8,15 and oneyear afterthe surgery and finally werefollowedbyphonethereafter.Thefollowingparameters werenotedatthevisits:healingtime,recurrence,andscore ofincontinence.
Results
35patientsmetthestudycriteriaandtreatedwithLIFT tech-nique.Twenty(81%)weremen.Themeanage35-yrs(range: 22–50).Themeanprevioussurgerieswere twotimes(range 0–9).
Types of fistulas were as following: 25 (71%) high-transsphincteric,5(14/5%)suprasphincteric,1(2/8%) horse-shoesuprasphincteric,and4(11/4%)anteriorfistula.Scoreof fecalincontinencepriortoLIFTwaszeroinallthepatients. Inonepatientgasincontinence(score=3)wascreatedafter thesurgery. Medianfollow upperiodwas 15 months(6–24 months).Successfulclosurerateofthefistulatractwas66%
Table1–Demographicdata.
Numberofpatients 36
Male/female 21/15
Meanage/years 35
Meanprevioussurgery 2(0–9)
Table2–Typeoffistula.
Hightranssphincteric 25
Suprasphincteric 6
Horseshoe 1
Anteriorinfemale 4
ofthepatients(23of35).Themeantimeofrecurrencewas4.5 weeksin12patients.
InTable1youcanseedemographicdataandTable2shows typesoffistula.
Discussion
Resultsofthe studiesshows thatLIFT, isasafeand effec-tivetreatmentformanagementofcomplexperianalfistulas. Thesuccessrateof66% isanoticeableresultcomparedto othertreatmentoptions.Therearesomeunfavorableresults ofothersphinctersavingoptionsfortreatingcomplexfistulas. Mucosaladvancementflaphasrecurrencerateupto63%.15,16 Fibringlueinjectionisalowrisktechniquebutitsresultshave beendisappointingwithsuccessrateaslowas16%.17,18 Simi-larlytheresultsofanalplugsuccessratearebetween29%and 87%.19,20Twostrengthsofthisstudyare:firstlyitrepresents the first experienceofIranian surgeons forLIFT procedure and secondlyinthisstudy despitethethreeprevious stud-ies inThailand, Malaysiaand Canada.Wehaveobjectively measuredthescoreoffecalincontinencebeforeandafterthe procedurebyJorge–Wexnerscoringsystem.Sowecould eval-uatetheeffectofLIFTonsphincterfunctionmorecarefully.
Twooffiverecurrencesinourstudywereintersphincteric fistulaswhichwere managedbysimplefistulotomy. Itmay replaceadifficultmethodtotreathightranssphinctericfistula toaneasieronetomanageintersphinctericfistula nonethe-less.
In our study LIFT procedure is a difficult method for treatmentofsuprasphinctericfistulas,multiplefistulas,and fistulaswithextensions,butwecoulduseLIFTwithhigh suc-cessrateforothercomplexfistulas.
Conclusion
Thisstudywasdoneforlesspatientsbyourcolorectalteam withadifferentresult.Butoverall,bothofthemshownew techniqueforfistulainanosurgeryhasearlyresults compa-rabletoothersphinctersparingprocedures.Thisisasafeand easytoperformprocedure.Tohaveaquorumasapopular fis-tulainanoprocedure,randomizedcontroltrialsisnecessary.
Conflicts
of
interest
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