Novel Surgical Correction of Intersphincteric Perianal Fistulas Preserves Anal Sphincter

Jacquelyn K Beals, PhD

October 16, 2008

October 16, 2008 (San Francisco, California) — A novel sphincter-sparing surgical technique for the repair of perianal fistulas has demonstrated a 58% success rate in an American patient population. First described in the Thai medical literature in 2007, the procedure is "simple, quick, inexpensive," and preserves continence, according to a presentation here at the American College of Surgeons 94th Annual Clinical Congress.

Husein Moloo, MD, a fellow in the division of colon and rectal surgery, department of surgery, at the University of Minnesota Medical School, in Minneapolis, noted during his presentation that treating fistula-in-ano is difficult, and the risks of recurrence and incontinence must be weighed carefully. Among current treatment techniques, fibrin glue or the anal fistula plug are associated with low to no risk for incontinence.

The new surgical procedure — ligation of the intersphincteric fistula tract (LIFT) — was introduced in the United States by Stanley M. Goldberg, MD, FACS, also from the division of colon and rectal surgery at the University of Minnesota, and director of Dr. Moloo's fellowship. Dr. Goldberg was a visiting professor in Thailand, brought the LIFT technique back to the University of Minnesota, and trained his 5 fellows in the procedure. The study data were obtained from their "well-established, high-volume, colorectal practice."

"The technique in the LIFT procedure is fairly simple: the fistula tract is identified in the intersphincteric space, and then it's ligated," explained Dr. Moloo. "As each of [the fellows] learned this technique from Dr. Goldberg, and this technique was presented at our weekly rounds, it was rapidly [adopted by the group] as a new sphincter-sparing technique."

Talking with Medscape General Surgery, Dr. Moloo added that this technique "may take a little bit longer in terms of operative time, so you get into that intersphincteric space, but it's a fairly simple procedure. If you're comfortable with the anatomy in that area, getting into the intersphincteric space is not terribly difficult.... I think part of the attraction of it is that it is very simple. It's quick, it's inexpensive — you're basically paying for the suture."

The study enrolled 31 patients (16 male, 15 female) with a median age of 46.5 years. Of that group, 26 patients had undergone previous, often multiple, fistula repairs using a variety of techniques. The median number of previous fistula repairs was 4 per patient, and included 22 transsphincteric, 6 horseshoe, 2 rectovaginal, and 1 suprasphincteric procedure.

Among the 28 patients followed for a median of 35 weeks, the success rate was 58% (18 of the 31 patients treated). When the Minnesota group reported their success rate with anal fistula plugs, it was around 40%, "so a success rate around 60% is actually very good," noted Dr. Moloo. Time until failure ranged from 4 to 63 weeks for LIFT (median, 19 weeks), suggesting the importance of longer follow-ups. None of the patients became incontinent.

Dr. Moloo pointed out an additional advantage of LIFT: "It doesn't preclude your using another technique in the future. So it's not like because you did the LIFT you can't use the plug. There were patients we did the LIFT on who recurred, and we went back and did another LIFT."

Medscape General Surgery also spoke with the session moderator, Najjia N. Mahmoud, MD, FACS, from the division of colon and rectal surgery, department of surgery, at the University of Pennsylvania Health System, in Philadelphia. "What we're really talking about is a completely different way of approaching fistula repair: disruption of the fistula tract with the LIFT procedure versus actually plugging the fistula tract with...a piece of biologic tissue. It's a philosophically different approach," she said.

"Neither of those approaches actually has tremendous long-term data behind it. Neither of those would I consider tried-and-true [compared with] what we've been doing for years and years with the trans anal advancement flap," Dr. Mahmoud noted. "Both techniques are recently evolved over the past 5 or so years, and are aimed at a better way of preserving the sphincter. So that's their advantage."

"The fact that ways of fixing fistulas continue to evolve means that we don't have a perfect way of fixing fistulas," continued Dr. Mahmoud. "And I think that the LIFT procedure is part of the evolution of treating ano-rectal fistulas."

The current study was not a randomized controlled trial comparing LIFT with other sphincter-preserving techniques, but it is a first step in that direction. Further studies are needed — for instance comparing outcomes with the LIFT technique and the anal fistula plug. "We need to do future studies with the proper kind of randomization," said Dr. Moloo. "It's the best way to do it; to compare them head-to-head and see what works."

"At the end of the day, I think the most important thing about the technique is that it's sphincter-sparing," Dr. Moloo concluded.

Neither Dr. Moloo nor Dr. Mahmoud disclosed any relevant financial relationships.

American College of Surgeons (ACS) 94th Annual Clinical Congress: Session GS70. Presented October 15, 2008.

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