Azmi Nor

Ligation of the intersphincteric fistula tract (LIFT): a sphincter-saving technique for fistula-in-ano.

PURPOSE: This study was designed to assess the total anal sphincter–saving technique of ligating the intersphincteric fistula tract for the treatment of fistula-in-ano. METHODS: We performed a prospective observational study of patients with fistula-in-ano treated with the ligation of the intersphincteric fistula tract technique from May 2007 through September 2008. All patients had fistulas arising from cryptoglandular infections. Recurrence rate, healing time, and morbidities related to the procedure were determined with a standard follow-up protocol. RESULTS: Forty-five patients with transsphincteric (n = 33) or complex (n = 12) fistulas were included in the study. Five patients (11.1%) had recurrent fistula-in-ano after prior surgery using other recognized treatment procedures. The median age was 41.5 (range, 27–56) years; median follow-up, 9 (range, 2–16) months. Primary healing was achieved in 37 patients (82.2%), with a median healing time of 7 (range, 4–10) weeks. Eight patients (17.7%) had recurrence of fistula between 3 and 8 months after the operation. No clinically significant morbidity was noted in any of the 45 patients. CONCLUSIONS: The ligation of the intersphincteric fistula tract technique for fistula-in-ano surgery, which aims at total anal sphincter preservation, appears to be both safe and easy to perform, with encouraging early outcomes.

Recurrent infection of a sinus tract at the staple line after hemorrhoidopexy: extending the indications for ligation of the intersphincteric fistula tract (LIFT).

Perianal sepsis is a recognized complication of stapled hemorrhoidopexy. The incidence of local abscesses and fistulas varies from 0 to 3% in reported series. It commences with breakdown of the staple line followed by local infection. These infections range from mild perianal sinus and fistula to life-threatening pelvic sepsis. A 46 year-old gentleman who presented with third degree hemorrhoids reported intermittent minor bleeding of 2 years duration. He underwent stapled hemorrhoidopexy at our institution in September 2009. On postoperative day 3, he developed fever and severe pain in the right perianal area which worsened on defecation. He was started on intravenous antibiotics and the symptoms resolved after 5 days. Four months later, he experienced pain in the perianal region. Perianal examination revealed an indurated, cordliked thickening which extended radially toward the anus under the skin in the 5 o’clock position and was slightly tender. No external opening was noted. Endoanal ultrasound examination showed heterogeneous echogenicity in the 5 o’clock position. Ligation of the intersphincteric fistula track (LIFT) was performed as a day case procedure with the patient under general anesthesia a week later after a course of antibiotics. No mechanical bowel preparation was prescribed. After general anesthesia was administered, the patient was placed in a prone position and the buttocks were taped apart. The sinus tract was again confirmed by palpating a cord-liked fibrous band in the right perianal area. The intersphincteric groove at the site of the sinus tract was entered via a curvilinear skin incision using a scalpel. A Lone Star retractor was used to expose the intersphincteric space and Langenback retractors were used to deepen the exposure. The intersphincteric portion of the sinus was identified by meticulous dissection using electrocautery and scissors. The tract was hooked using a small, right-angled clamp and isolated. The tract was ligated close to the internal sphincter with polyglactin 3/0 and divided distal to the point of ligation. The remnant sinus tract was excised as far as the external sphincter from its distal end. The intersphincteric incision was loosely approximated with interrupted polyglactin 3/0. The skin was closed with the same suture material. Postoperatively, the patient was prescribed an antiinflammatory analgesic, a stool softener and oral amoxicillin/clavalunate for 5 days. He was asked to perform sitz bath 2–3 times a day until the wound healed. The wound was healed at 2-week follow-up. Histopathology examination confirmed a perianal sinus with evidence of infection (Fig. 1). Stapled hemorrhoidopexy was popularized by Longo for the treatment of prolapsed hemorrhoids. The procedure gained wide popularity because of its association with low levels of postoperative pain and an early return to work [1]. However, devastating complications have been reported to arise from this procedure including, rectovaginal fistula, chronic proctalgia, rectal hematoma and perforation with pelvic sepsis [1]. Localized abscess and fistula developed as a complication of the procedure for prolapsed hemorrhoids (PPH) in up to 3% of patients [1]. Guy et al. [2] M. N. Baharudin Z. M. Hassan A. M. Nor (&) Colorectal Unit, Department of Surgery, Faculty of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia e-mail: azmimdnor75@gmail.com