Type of the Paper (Article LMRJ Volume 3 Issue 3 53 | P a g e Research article LIGATION OF INTERSPHINCTERIC FISTULA TRACT AS AN ALTERNATIVE TREATMENT FOR PERIANAL FISTULA AT TERTIARY CARE HOSPITAL Nawaz Ali Dal1, Ishrat Raheem Katyar1, Mohammad Qasim Mallah1, Ahsan Laghari1, Shiraz Shaikh1, Abdul Ghafoor Dalwani1 1 Department of Surgery, Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan ABSTRACT This study was aimed to evaluate clinical outcome of patients with perianal fistula operated with the ligation of intersphincteric fistula tract (LIFT) technique. The study was conducted at Department of Surgery, Liaquat University of Medical & Health Sciences, Jamshoro from July 2018 and August 2019. A total of 22 patients diagnosed with perianal fistula operated with the Ligation of Intersphincteric Fis- tula Tract (LIFT) technique were selected using non-probability consecutive sam- pling technique. Physical examination and magnetic resonance imaging (MRI) and/or endosonography (ES) were performed to make a confirmed diagnosis of fistula. They were classified according to Parks classification. All patients were subjected to intersphincteric fistulous tract ligation using the technique defined by Rojanasakul modified. There were 16 males and 6 females. Mean age was 42 years (range 23-68 years of age). Out of 22 patients, 17 patients had a history of perianal abscess drainage prior to surgery and an average preoperative symptom presen- tation was 2.2 years (range 0-10 years). Therapeutic success with first surgery was achieved in 77% and with a second surgery in 90%. None of this patients modified their preoperative Wexner. It was concluded that LIFT technique appears to be a convenient, reproducible, and effective surgical alternative. This provides an ap- propriate closing rate and without continence modification, Therefore indicated for complex cryptoglandular fistulas. Key Words: Ligation of intersphincteric fistula tract (LIFT); perianal fistula; magnetic resonance imaging; endosonog- raphy; fistulotomy. INTRODUCTION Anorectal fistula represents the chronic phase of anorectal abscess and is defined as the persistence of a fi- brous path covered by granulatory tissue between an internal primary hole and one or multiple external secondary holes in the skin of the perianal region, clinically resulting in fouling, wet anus, cyclic perianal pain and chronic drainage of associated purulent material, abscess formation and intermittent spontaneous drainage.1 Its origin is cryptogladular in about 90% of cases and in the remaining it is due to other conditions such as Crohn's disease, local radiation, cancer and trauma. The cryptoglandular theory is based on the con- stant exposure of fecal load in the internal fistulous orifice associated with the tightness of the path, ulti- mately causing the septic focus to be perpetuated.2 The surgical treatment of the fistula is basically aimed at achieving healing of the fistulous tract without altering function of the anal sphincter and avoiding the recurrence of the path as much as possible.3 The literature shows a variety of surgical techniques for resolution of the complex fistulas, although some achieve efficient control of the disease, with an average recurrence of 5%. However incontinence resulting from pro- cedures range between 10% and 57%.4 Currently, the best surgical alternative in complex anorectal fistula is being sought, unfortunately the evi- dence is low, given the series reported are heterogeneous, with variable and short post-operative follow-up.5 Classical techniques such as fistulotomy and the seton or cutting line technique have a recurrence rate of up Correspondence: Nawaz Ali Dal Department of Surgery, Lia- quat University of Medical & Health Sciences, Jams- horo, Pakistan Email: drnawazdal001@gmail.com DOI: 10.38106/LMRJ.2021.3.03-02 Received: 09. 06.2021 Accepted: 28. 08..2021 Published: 30. 09.2021 LMRJ Volume 3 Issue 3 54 | P a g e to 9%, causing variable deterioration of anorectal function with the figures already described. Fecal inconti- nence is one of the main problems of fistula treatment, since in both techniques the internal anal sphincter is sectioned.6 When considering aspects related to preservation of sphincter continence and rate of recurrence new tech- niques have been brought in order to solve the problem. Such as biological sealants have emerged (ie. Fibrin Glue Injection), use of caps of different materials, advanced therapies related to the use of Stem Cells and novel surgical techniques including LIFT.7 The LIFT fundamentally considers ligation and excision of the intersphincteric path, managing to block the entry of fecal material into it, eliminating the chronic cryptoglandular septic sinus.8 The technique contem- plates the preservation of both anal sphincters, an aspect that almost completely reduces the risk of inconti- nence.9 The first report of this technique was a Thai experience developed by Rojanasakul et al.,10 In 2007, as a modification to the technique described by Matos et al. where the description of this technique was made in 18 patients with a rate of success as 94%, without reporting alterations in continence. Since then, other authors have published their experiences with success rates in relation to cure between 47% and 95%, not forgetting the real benefit regarding the maintenance of fecal continence.8,9 One of the most important bias identified in systematic reviews was the variability detected in the technique with respect to the classic LIFT. In addition, hybrid LIFT techniques have been incorporated with the com- bined use of biomaterials, which makes evaluating the potential of the technique even more complex. The objective of this study was to present our results in terms of clinical efficacy and incontinence with the LIFT technique and to enhance its role as a treatment alternative for anorectal fistula. METHODOLOGY This study was conducted at department of Surgery, Liaquat University of Medical & Health Sciences, Jams- horo, from July 2018 and August 2019. Twenty-two patients diagnosed with perianal fistula operated with the LIFT technique were selected using non-probability consecutive sampling technique. Patients included in this study were informed of the procedure to be performed and the possible complications of the proce- dure. Detailed written informed consent for the operation was obtained from the hospital treatment chart. This study was approved by local Ethics Committee. A physical examination and magnetic resonance imaging (MRI) and/or endosonography (ES) were per- formed to confirm diagnosis of fistula. They were classified according to Parks classification11. Complex fis- tulas identified as medium and high trans-sphincter were exclusively included, depending on the proportion of external anal sphincter involved (> 30%) and anterior fistulas in women. Patients with fistulas whose origin was not cryptoglandular were excluded. Colonoscopy was performed on all patients to rule out Crohn's disease. All patients were subject to LIFT using the technique defined by Rojanasakul modified10. Surgical procedure The procedure was carried out under regional anesthesia. Curved incision in the intersphincteric space over the path of the fistula was made and dissected until it was released. Ligation and cutting of the fistula was done, curettage of the distal path and enlargement of the external orifice (OFE) was performed. The modified technique included curettage of the proximal path with gauze and invagination of the ligation ends with resorbable material. The internal orifice (OFI) was not closed (modification proposed in other series) due to the theoretical risk of a new abscess. Demographic and clinical data were recorded in a prospective database, all patients had a preoperative clinical evaluation and an average postoperative follow-up of 48 weeks. Clin- ical success was defined as the absence of symptoms and signs of fistula within 3 months of surgery. Incon- tinence was measured and classified by the Wexner scale12. Statistical methods Data was recorded and analysed by using Statistical Package for Social Sciences (SPSS version 22.0). Mean of the continuous variables is presented along with range and frequency distribution was presented for cate- gorical variables. LMRJ Volume 3 Issue 3 55 | P a g e RESULTS Out of 22 patients underwent surgery for perianal fistula using the LIFT technique, 16 were males and 6 were females, as shown in Figure 1. The mean age was 42 years ranging between 23 and 68 years. 18 patients were ASA I and 4 ASA II while 17 patients had a history of perianal abscess drainage prior to surgery and mean preoperative symptom presentation was 2.2 years (range 0-10 years). In 16 patients, it was decided to install a non-cutting seton prior to final surgery. This was done in order to manage the infectious part of the fistula and to obtain a more fibrous path. Mean time between seton and LIFT was 60 days. The LIFT was performed on 6 patients without prior settling. In the preoperative study, 20 patients underwent enhanced contrast pelvic MRI and 1 endosonography as described in Table 1. Twenty patients had a Wexner score of 0 points and 2 of 1 point in the preoperative assessment. Mean duration of surgical procedure was 39.7 minutes. All patients received a prophylactic antibiotic with 1 gram IV ceftriaxone and 500 mg IV metronidazole. None of the patients had intraoperative complications and all were discharged 24 hours post - operatively. At discharge, all patients were given oral antibiotics for 7 days (ciprofloxacin 500 mg every 12 hours and metronidazole 500 mg every 8 hours), pain relievers and nonsteroidal anti- inflammatory drugs for 3-5 days. An average follow-up of 48 weeks was performed with a range of 24 to 96 weeks. Complete closure was achieved in 77% (n=17 patients). In postoperative follow-up, fistula recurrence was observed in 5 patients (23%) with a simpler fistula. All of them underwent fistulotomy along the way. After this second intervention, 90% clinical success was obtained in the follow-up. None of the 5 cases had reported any incontinence. No patient out of 22 has modified their Wexner at follow-up as shown in Table 2. Figure 1. Distribution of the Gender of the patients included in the study 16 6 73.0 27.0 0 10 20 30 40 50 60 70 80 Male Female Frequency Percentage LMRJ Volume 3 Issue 3 56 | P a g e Tables 1. Characteristics of the study patients (n=22) CHARACTERISTICS NO. (% OR RANGE) Mean age 42 years (23-68 years) Mean symptoms time 2.2 years (0-10 years) Previous abscess drainage 17 Fishing line 60 days prior 16 MRI-endosonography 20-2 Table 2. Summary of results (n=22) Operated 22 patients Mean operating time 39.7 minutes ATB prophylaxis 22 Mean days of hospitalization one Mean postoperative EVA - High 0-1 Early complications 0 Tracing 48 weeks (24-96 weeks) Full closure In 2 stages *77% (17/22 patients)90% (20/22 patients) Recurrence (all were treated with a simple fistulotomy) 23% (5 patients with OFE secretion, down staging) Recurrence and previous line 4/5 had no line ** Wexner Modification 0 * After the first LIFT, primary closure was obtained in 77% of the cases, 90% of closure was achieved after a second intervention in the relevant cases. ** Recurrence occurred in 4 out of 5 patients, in whom a seton was not positioned in the first fistulotomy. DISCUSSION For a long time, the anal rectus mucosa advancement flap was considered the gold standard for the surgical treatment of complex fistulas with retention of sphincter function, showing success rates between 27-100%, but with incontinence rates of up to 35%8,9. Precisely in order to improve these results, the LIFT procedure has recently emerged as an attractive alternative for the surgical treatment of complex anorectal fistulas. Its principle is to treat the fistula and its origin without compromising the apparatus of the sphincter. It presents a final closing rate of 47% to 94% in different reported series, with no continence commitment in any of these series13. Other advantages of the procedure are low postoperative pain, quick reintegration into the work- place and lower economic costs compared to other techniques requiring the use of biological materials. Re- viewing the literature, there is only one national publication on the subject, from the Bahawal Victoria Hos- pital Bahawalpur Pakistan. This work shows an experience in 30 patients subjected to ligation of Intersphinc- teric fistula tract. Twenty-five (83%) patients were cured and only five (17%) patients had fistula recurrence and were thus considered as not cured. None of the patient was presented with incontinence14. The present study shows similar results of those who experienced the LIFT treatment, recorded in the liter- ature. While the number of patients was small, the proportion of patients who had an indication to fistulot- omy or other non-surgical procedures for a complicated and alternative treatment was similar to that. It should be noted that during the study period, 240 fistulas were operated at the main study center (Depart- ment of Surgery at Liaquat Univeristy hospital, LUMHS Jamshoro), of which only 22 (9%) were operated in LMRJ Volume 3 Issue 3 57 | P a g e the LIFT; this indicates that the option of performing the technique is very limited and is not currently one of preferred techniques of colorectal surgeons. In relation to the patients in the present case, as in the series of patients with perianal fistula of cryptoglan- dular origin, these occur at intermediate ages, without significant comorbidities, and an outpatient procedure can be provided comfortably, with regional anesthesia, without greater analgesic requirements and with rapid functional and occupational recovery. No patient without recurrence had to consult urgently when monitoring patients during the postoperative period and all were able to control their surgery-related dis- comfort with the indications provided at discharge15. Analyzing the findings, considering the closure of the fistula as the main goal, this series indicates a closure of 77% only with the LIFT treatment and if we find closure in two stages after a more basic (intersphincteric) recurrence, the closure rate is close to 90% (20 out of 22 patients), with 100% of them without sphincter con- tinence modification, which is the main objective. When analyzing the recurrence cases (ie 5 patients, which makes only 23% of the total), 4 of them had a recurrence that was intersphincteric, as the literature indicates as a "downstaging" of a complex process in which the recurrence corresponds to the most frequent, proximal portion of the fistula, and that a simple fistulotomy can show good results and protection in the sphincter can be solved in a second period. It is interesting that most primary success patients have previously installed a line, indicating that previous drainage and pathway conduction may affect the success of fistula healing, but the literature is not categorical in this regard, given the limited number of cases, and this variable cannot be assigned a meaning. Neither can we assume that the modifications in the procedure affect the success rate, but we postulate that the in- stallation of a line in advance, the curettage with gauze of the fistulous tract, the closure of the internal orifice and the invaginating muscle plasticity of the ends of the ligation may impact better healing of the closure by decreasing the risk of recurrence. CONCLUSION In conclusion, the LIFT technique appears to be a convenient, reproducible, and effective surgical alternative. This provides an appropriate closing rate and without continence modification, so we suggest it as a good option for cryptoglandular fistulas. Ethical Consideration: The study was approved by Ethics Committee of Liaquat University of Medical & Health Sciences, Jamshoro, Pakistan Conflict of Interest: There is no conflict of interest. Funding: This study was not funded by any agency REFERENCES 1. Whiteford M. Perianal Abscess/Fistula Disease. Clin Colon Rectal Surg. 2007 May;20(2):102–9. 2. 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