J. Coloproctol. (Rio J.) vol.34 número4

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jcoloproctol(rioj).2014;34(4):250–253

Journal

of

Coloproctology

w w w . j c o l . o r g . b r

Original

article

Assessment

of

LIFT

(ligation

of

the

intersphincteric

fistula

tract)

technique

in

patients

with

perianal

transsphincteric

fistulas

Caroline

Sauter

Dalbem,

Sérgio

Danilo

Tanahara

Tomiyoshi,

Carlos

Henrique

Marques

dos

Santos

∗

UniversidadeFederaldeMatoGrossodoSul(UFMS),CampoGrande,MS,Brazil

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n

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o

Articlehistory:

Received26March2014 Accepted4September2014 Availableonline22October2014

Keywords:

Fistula Treatment Colorectalsurgery

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PerianalfistulasarearelativelycommonconditioninProctologyoffices,rangingfrom sim-plecaseswitheasilypalpablesuperficialtractstocomplexproblemswithdeeptractsacross significantportionsoftheanalsphincter,whichsectioncanleadtovaryingdegreesof incontinenceduringafistulotomy.

Objective:ToevaluatetheeffectivenessoftheuseoftheLIFT(ligationoftheintersphincteric fistulatract)techniqueinpatientswithperianaltranssphinctericfistulas.

Method:Aprospectivestudyofpatientswithperianaltranssphinctericfistulawho under-wentLIFT.Patientswithperianalfistulasofcryptoglandulartranssphinctericoriginwithno previoussurgicalinterventionswereincludedinthestudy.Patientswithperianalfistulas fromanothersource,suchasCrohn’sdisease,tuberculosis,analcancerandrecurrent fistu-las,wereexcluded.Allpatientsunderwentthesameanesthetictechnique,withsubsequent surgicaltreatmentintwostages:setonplacementand,after6weeks,completionofLIFT.

Results:Weevaluated22patients;themeanagewas45.6years.Thepost-LIFToutpatient follow-uprangedfrom4to24monthswithameanfollow-upof14months.Thehealing timevariedfrom4to8weeksaftertheprocedure.Seventeenpatientswerecured(77%)and fiverelapsed(23%);however,allofthemexhibitedtheintersphincterictype,havingbeen treatedbyfistulotomyandalsoachievingcompletecure.Onefemalepatientdevelopedmild fecalincontinence.

Conclusion:The LIFT technique proved to be safe and effective in the treatment of transsphinctericperianalfistulas.

∗ _{Corresponding}_author_.

E-mail:chenriquems@yahoo.com.br(C.H.M.dosSantos).

http://dx.doi.org/10.1016/j.jcol.2014.09.001

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251 Avaliac¸ão

da

técnica

LIFT

(Ligation

of

the

Intersphincteric

Fistula

Tract)

em

pacientes

com

fístulas

perianais

transesfincterianas

Palavras-chave:

Fístula Tratamento Cirurgiacolorretal

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s

u

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o

Asfístulasperianaissãoumacondiçãorelativamentecomumemconsultóriode proctolo-gia,podendovariardesdecasossimples,comtrajetossuperficiaisfacilmentepalpáveis, atécasoscomplexos,comtrajetosprofundos,atravessandoporçõesconsideráveisdo apar-elhoesfincteriano,cujasecçãopodelevaragrausvariáveisdeincontinênciaduranteuma fistulotomia.

Objetivo: AvaliaraefetividadedoempregodatécnicaLIFT(ligationoftheintersphincteric fistulatract)nospacientesportadoresdefístulasperianaistransesfincterianas.

Método: Estudoprospectivocompacientesportadoresdefístulaperianal transesfincteri-anasubmetidosàtécnicaLIFT.Foramincluídosnoestudopacientesportadoresdefistulas perianaisdeorigemcriptoglandulartransesfincterianasemintervençõescirúrgicasprévias. Foramexcluídospacientesportadoresdefístulasperianaisdeoutraorigem,comodoençade Crohn,tuberculose,neoplasiaanalefístulasrecidivadas.Todosospacientesforam submeti-dosàmesmatécnicaanestésicaeposteriortratamentocirúrgicoemdoistempos:colocação desedenhoeapósseissemanasrealizaçãodeLIFT.

Resultados: Foramavaliados22pacientes;amédiadeidadeobservadafoide45,6anos.O seguimentoambulatorialpós-LIFTvarioude4a24meses,commédiadeacompanhamento de14meses.Otempodecicatrizac¸ãovarioude4a8semanaspós-procedimento.Dezessete pacientesficaramcurados(77%)ecincoapresentaramrecidiva(23%),porém,todosnaforma interesfincterianaeforamtratadosporfistulotomia,alcanc¸andotambémacuracompleta. Umapacienteevoluiucomincontinênciafecalleve.

Conclusão:AtécnicaLIFTdemonstrouserseguraeeficaznotratamentodasfístulasperianais transesfincterianas.

Introduction

Theoccurrenceofperianaldiseasedatesbackfromantiquity. For the treatment of anal fistulas, Hippocrates recom-mended,amongotherprocedures,cauterizingandanodizing the fistula – which can be understood today as seton application.1

Overthe years,various studies and surgicaltechniques havebeendevelopedwiththeaimtofindthemostappropriate treatmentforthisdisease,whichhasanincidenceof1/10,000 inhabitantsperyearandrepresents5%ofallColoproctology officevisits.2,3

These defects are distributed in the following propor-tion,usingtheclassificationdescribedbyParksetal.(1976): intersphincteric(60–75%),transsphincteric(15–20%), supras-phincteric(5%)andextrasphincteric(1–3%)fistulas.2

Currently,thereislittledoubtastotheindicationof sur-gicaltreatmentasthebesttreatmentoption,andfistulotomy isthetechniqueofchoiceforthevastmajorityofcases. How-ever,morecomplexfistulae, whentreatedsimilarly,canbe cured–butonlyattheexpense ofvaryingdegreesoffecal incontinence.

Thus,manyother techniqueshavebeen developedwith theaimtoachievethesamecurerateforfistulotomy,but with-outcausingfecalincontinenceincasesofgreatercomplexity. However,thereisstillnocleardefinitionofthebestoptionin thesecases.

In2007,Rojanasakuletal.4 _described _a_new_therapeutic

optionforcaseslikethese,withverypromisinginitialresults. TheLIFT(ligation oftheintersphinctericfistulatract) tech-nique,asitbecameknown,hasshowngoodresultsalsoin otherstudies,5_not_inferior_to_traditional_techniques,_and_still

havingasgreatmeritthefactof(theoretically)notcausing fecalincontinence,consideringthatnosectionofthe sphinc-teroccurs.Astherearestillfewstudiesonthesubject,theaim ofthisresearchistoevaluatetheresultsofLIFTinpatients withtranssphinctericperianalfistulas.

Method

ThestudywasapprovedbytheEthicsCommitteeonResearch oftheUniversidadeFederaldeMatoGrossodoSul.For inclu-sion,thepatientswereinformedbytheresearchteamonthe surgicaltechniqueusedandonthepossiblecomplicationsof thesurgery;andagreedtoparticipateinthestudy,completing thefreeandinformedconsentterm.

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252

Coloproctology,HospitalRegionaldeMatoGrossodoSul,and fromtheprivatepracticeofoneoftheauthors.

Thestudy was conducted from May 2012 toSeptember 2013. Patients with perianal fistulas from another source, individuals with Crohn’s disease,tuberculosis, anal cancer andwhohadrecurrentfistulaswereexcluded.Patientswith intersphincteric,suprasphinctericandextrasphincteric peri-analfistulaswerealsoexcluded.Allpatientswere operated under spinal blockwith morphine. The surgicaltreatment wasperformedintwostages: first,theidentification ofthe fistula,thusconfirmingatranssphincteric tract.Thefistula wasthenrepairedbyapplyingalatexseton.Theplacementof thesetonwasintendedtoinduceamoreconsistentfibrosis, makingthefistuloustractwelldefined.Thesecondstepwas performedafter6weeks:theremovalofthelatexseton, curet-tageofthetract,anopeningoftheskinapproximately1cm perpendiculartothe fistuloustractand dissectionbetween the internal and external sphincters, to the identification and repair of the fistula. Then a transfixing ligature with polyglactin zero and the section of the tract between the sphincterswereperformed,followed bythe introductionof aprobe toconfirm the closing ofthe segments ofthe fis-tuloustractandofskinclosure.Thecrypt(innerhole)was cauterizedwithelectrocauteryandtheexternaloswaskept open.

Thepostoperativefollow-upwasperformedinan outpa-tientcliniconthe15thdayandthenevery30daysuntilthe completehealingofthefistula.Thereafter,thevisitsoccurred bimonthlyorbeforethattime,ifnecessary.

Intheoutpatientfollow-up,perioperativeinfection, heal-ingtime,pain,recurrenceandfecalcontinencechangewere evaluated.

Results

During the study period, 41 patients with transsphinc-teric perianal fistulaswere selected, of which 22 met the inclusion and exclusion criteria and were kept in the study.

Ofthese22patients,12(55%)weremaleand10(45%)were female.Theagerangedfrom17to62years,withameanof45 years.Thetimeelapsedfromtheonsetofacomplaint com-patiblewithperianalfistulatothediagnosisrangedfrom3to 36months,withameanof11months(Table1).

Ineachcase,thepatientwasdischargedwithin24h.During theoutpatientfollow-up,localinfection(drainageofpusfrom surgicalwound)occurredinfivepatients(23%),whowereonly followedwithoutfurtherinterventionandwithspontaneous resolution.

Thepost-LIFT outpatientfollow-up rangedfrom 4to24 months,withameanfollow-up of14months.Thehealing timevariedfrom4to8weeksaftertheprocedure.

Seventeen(77%)patientsobtainedcompleteresolutionof their fistula with the technique adopted, while five (23%) relapsed.Ofthesefive,allhadarecurrenceintheformofan intersphinctericfistula,beingsubsequentlyoperatedby fis-tulotomy,with complete resolution– thus,athird surgical procedure. A female patient developed mild fecal inconti-nence(Fig.1).

Table1–Patientswithperianaltranssphinctericfistula treatedwithLIFTtechnique.

Patient Gender Age(years) Timefromdiseaseto treatment(months)

1 Male 24 5

2 Male 28 9

3 Female 17 14

4 Male 45 14

5 Male 60 3

6 Male 46 12

7 Female 38 10

8 Female 60 10

9 Male 34 9

10 Female 57 5

11 Male 35 4

12 Male 56 36

13 Female 50 18

14 Female 49 13

15 Female 62 10

16 Male 48 16

17 Female 49 7

18 Male 49 9

19 Female 48 12

20 Male 49 6

21 Male 39 12

22 Female 47 8

Mean 12M/10F 45 11

20

15

10

5

0

Healing Recurrence

Fig.1–AssessmentofprimaryhealingindexafterLIFTin thetreatmentofperianaltranssphinctericfistulas.

Discussion

Many studies on the LIFT surgical technique are still in progress;thisisstillconsideredanoveltechniqueforusein thetreatmentofperianalfistulas.

In the original publication describing the technique, Rojanasakulet al.4 _applied_LIFT _in₁₈_consecutive _patients,

observingprimaryhealingin17ofthem.Thisresult encour-agedotherauthorstoevaluateLIFTinstudiesworldwide.

Inthisseriesofcases,aprimaryhealingrateof77%was observed. InAmerican studies that included patients who failedaprevioustreatment,thehealingraterangedfrom55 to 64%.6 _In _Australia, _Ooi_et _al.,7 _who _also_included_in _the

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253

other hand,Shanwanietal.5 _reported _cure_in_82%_of_their

sample.Europeanstudiesshowedresolutionratesof71–83% forprimaryhealing,andinsomeofthemupto100% heal-inginthesample,inthosestudiesthatconsideredsecondary healingpatients.Thisdemonstratesthattheresultsobtained inthisstudywerewithintheexpected,accordingtothe avail-ableliterature,whichcanbeconsideredagoodoutcomefora stillrecenttechnique.6

Themeanfollow-upinthisserieswas14monthsandthe relapseratewas23%.InstudiesofYassinetal.6_and_Liu_et_al.8

themeanfollow-upwas19and28months,respectively,and therecurrenceratewas36%and32%,respectively. Possibly thelowerrelapseseen inthispaperisinferiortotheother studiespresentedhereduetoashorterfollow-up,although themostimportantpublicationsonLIFTdemonstratenolate recurrenceoffistulas.Whenrelapseoccurs,itisusuallyinthe firstweeks,afactalsoobservedinourfivepatientsinwhom recurrencewasobserved.

Thehealingtimeobservedinthisstudyrangedfrom4to8 weeks.Ooietal.7_and_Shanwani_et_al.5_reported_a_mean

heal-ingtimeof6and5weeks,respectively,i.e.,thesamemean hereobtained.Theoccurrenceofslightvariationsis proba-bleinaccordancewithwhatisconsideredas“healing”.Here, weconsideredas“completehealing”theinterruptionofthe flowofpurulentsecretionwithcoaptationoftheedgesofthe wound.

Intheliterature,dataarelackingforcomparisonwiththe resultspresentedherewithrespecttopostoperativeinfection, probablybecausethisanalysisisquitesubjective.Moreover, this analysisisless importantcompared withfistula heal-ingandthe evaluationofcontinence–parametersthatare effectivelyanalyzedbymostpublicationsonLIFT.

Although generally the results obtained in this study demonstratethatLIFTisaverypromisingtechnique,inline withdatafromtheliterature,weconsiderasbeingquite dis-turbingtheobservationoffecalincontinenceinoneofour patients, bybeing ayoung woman withno other risk fac-tors for this condition. Considering that one of the main expectedadvantagesofthe techniqueisaloworzero pos-sibilityofanimpairedsphincterfunction(sincethereisno sectionofthesphincter),thisresultwasquitesurprising.That patienthasbeentreatedwithpelvicfloorphysicaltherapy, withimprovement.NoAmerican, Asianor Oceanian study reported damage to the sphincter function. However, in a reviewconductedbyYassinet al.,6 _it _was_observed_that _in

11%oftheirsampletherewassomesortofchangein con-tinence.Thismaybeassociatedwiththeinclusionofpatients withrecurrentperianalfistulawhohadgonethroughprevious treatments.

Ofthefivepatientswhodidnotachieveaprimaryhealing inthisstudy,allshowedrecurrenceintheincisionforligation ofthefistuloustract,i.e.,theirdefectsturnedinto intersphinc-tericfistulas,andcouldbesubsequentlytreatedbyfistulotomy withcompleteresolutionandwithnofecalincontinence.This developmenthasalreadybeenreportedbyothersandcanbe consideredanadvantageofthemethod,whichenablesa pri-marycureinmostcases,but,whenthisdoesnotoccur,atleast reducesthecomplexityofthefistuloustract.6–9

Conclusion

TheLIFTtechniquewaseffectiveinthetreatmentofperianal transsphinctericfistulas.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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