OUR “LIGATION OF INTERSPHINCTERIC FISTULA TRACT” EXPERIENCE FOR COMPLEX ANORECTAL FISTULAS: IS IT A PREFERABLE METHOD?

T. Yoldas§, E. Ekmekçigil§, C. Karaca§, T. Sezer§, C. Çalışkan§, E. Akgün§, M. Korkut§

§

Ege University Faculty of Medicine, Department of General Surgery

Introduction and General Information

• Fistula in Ano– Difficult to manage– Difficult to succeed• Recurrence rates 0 to 30%• Incontinence rates 0 to 63%• Wide variation.. • Not sure what to do?

– Best operation of choice?

Relevant Anatomy 1

Relevant Anatomy 2

Relevant Anatomy 3

Relevant Anatomy 4

Goodsall's rule

Main Goal

“Healing the fistula while

avoiding recurrence and

incontinence”

Complex Fistula

• Involving more than 30 – 50 % of external sphincter

• Anteriorly located fistula in females• Fistula with multiple tracts• Patient with incontinency due to fistula• Patients with Crohn’s disease• Recurrent fistula

Surgery for Complex Fistula

Curretage and Fibrin

glue

Seton Ligation

Endorectal Mucozal

Flap

L.I.F.T.

Ligation of Intersphincteric Fistula Tract

• Rojanasakul M.D. in 2006

• 18 patients with complex fistula

• 94,4% success rate

Patients and Methods

• 11 patients with complex fistula– Exclusion criteria• Patients with Crohn’s disease• Recurrent fistula

• From November 2010 to April 2012 who underwent L.I.F.T.

• All patients were reevaluated with anamnesis and physical examination

Surgery 1

• Regional anesthesia• Internal orifice localized with SF• Tract hanged with a metal probe• An intersphincteric 2cm incision made• Tract is localized and ligated and divided– From the closest portion to the internal orifice– With 2/0 polyglactin material

Surgery 2

• Internal orifice sutured

• External orifice and remaining distal tract

is excised (core out)

• Intersphincteric space approximated

Results

• 7 males, 3 females• 1 patient was lost to follow up• Mean age: 44.8• Mean follow up time: 13.7 months• Mean hospital stay: 1.5 days• Complete healing rate 80%• 20% had ongoing/recurrent symptoms• No wound complication• No incontinence

Discussion 1

• Relatively easier

– Much easier than mucosal flapping

• Low recurrence rates

– Up to 63% with mucosal flaps

– Up to 84% with fibrin glue

• High success rates

– Original success rate reported 94.4%

– Our success rate 80%

Discussion 2

• Comfortable for patient

– Seton technique lowers quality of life

– Possible need for a second operation

• Wide variety of application environments

– Can be applied to patients who were previously treated with

seton

• Easy to treat ongoing and/or recurrent disease

• Perfect preservation of sphincter functions

Conclusion / Take home message

LIFT technique is a;» Successful» Easy to apply» Comfortable» Sphincter preserving

alternative to,» Seton technique» Mucosal flapping» Curettage and fibrin glue

for the treatment of complex anal fistulas.