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2 0 1 4;3 4(2):109119
Journal of
Coloproctology
www.jcol.org.br
Original Article
a r t i c l e i n f o a b s t r a c t
Article history: Background: stula-in-ano is a common problem. Ligation of intersphincteric stula tract
Received 6 March 2014 (LIFT) is a new addition to the list of operations available to deal with complex stula-in-ano.
Accepted 15 March 2014 Objective: we sought to qualitatively analyze studies describing LIFT for crpytoglandular
Available online 18 April 2014 stula-in-ano and determine its efcacy.
Data sources: MEDLINE (Pubmed, Ovid), Embase, Scopus and Cochrane Library were
Keywords: searched.
Fistula-in-ano Study selection: all clinical trials which studied LIFT or compared LIFT with other methods of
Complex treatment for anal stulae, prospective observational studies, clinical registry data and ret-
Intersphincteric rospective case series which reported clinical healing of the stula as the outcome were
Ligation included. Case reports, studies reporting a combination with other technique, modied
Recurrence technique, abstracts, letters and comments were excluded.
Incontinence Intervention: the intervention was ligation of intersphincteric stula tract in crpytoglandular
Follow-up stula-in-ano.
Main outcome measure: primary outcome measured was success rate (stula healing rate)
and length of follow-up.
2014 Sociedade Brasileira de Coloproctologia. Published by Elsevier Editora Ltda.
Este um artigo Open Access sob a licena de CC BY-NC-ND
r e s u m o
Corresponding author.
E-mail: mjrexels@gmail.com (J. Murugesan).
http://dx.doi.org/10.1016/j.jcol.2014.02.008
2237-9363/ 2014 Sociedade Brasileira de Coloproctologia. Published by Elsevier Editora Ltda.
Este um artigo Open Access sob a licena de CC BY-NC-ND
110 j coloproctol (rio j). 2 0 1 4;3 4(2):109119
Recorrncia Fontes de dados: as bases de dados MEDLINE (Pubmed, Ovid), Embase, Scopus e Biblioteca
Incontinncia Cochrane foram pesquisadas.
Seguimento Seleco dos estudos: todos os ensaios clnicos que estudaram LIFT ou compararam LIFT com
outros mtodos de tratamento da fstula anal, estudos observacionais prospectivos, dados
de registros clnicos e srie de casos retrospectivos que relataram a cura clnica da fstula
anal como desfecho foram includos. Relatos de casos, estudos que relatam uma combinaco
com outra tcnica, tcnica modicada, resumos, cartas e comentrios foram excludos.
Intervenco: a intervenco foi ligadura interesncteriana do trajeto stuloso em fstula anal
criptoglandular.
Medida do desfecho principal: a medida do desfecho principal foi a taxa de sucesso (taxa de
cura da fstula) e perodo de seguimento.
2014 Sociedade Brasileira de Coloproctologia. Publicado por Elsevier Editora Ltda.
Este um artigo Open Access sob a licena de CC BY-NC-ND
vaginal stulas were also not included as were studies on Systematic review
LIFT that looked at outcome measures other than stula heal-
ing rates, e.g., incontinence or septic complications and did A total of 51 studies on LIFT were found (Fig. 1), of which
not report healing rates. Two studies which reported a mod- twenty-two studies fullled the inclusion criteria1940 (Table 1).
ication to standard LIFT procedure17,18 were also excluded. Among the included studies, one was a randomized control
When multiple articles or abstracts on LIFT from the same trial, fteen were prospective studies and six were retrospec-
author/institution were analyzed, only the most recent pub- tive case series.
lication was chosen for review if the same cohort of patients
were analyzed in an earlier report. Statistical analysis
PS, prospective study; RCS, retrospective case series; RCT, randomized control trial.
NR, not reported/cannot be concluded from the data provided.
Pre-operative bowel preparation MBP, mechanical bowel preparation (pre-operative), BE, Bowel enema (pre-operative).
MRI (Magnetic resonance imaging) or EUS (Endo anal ultrasound).
Operative position: Lithotomy (L); Prone jack knife (PJK); a used for Anterior stula; b used for Posterior stula.
Anaesthesia: General anaesthesia (GA); Loco-regional (LR); Local anaesthesia (LA).
Duration of admission: Day care (DC); Overnight (ON).
Downs and Black score ranges: excellent (2628); good (2025); fair (1519); poor (<=14).
113
114
Table 2 Characteristics of included studies.
Reference No. patients No. patients No. stulas No. Follow-up (range Success/Total Abscess/sepsis Other compli- Further Median Median time
with complex with IBD with multiple recurrent in months), patients No. (%) cations treatment healing time to recurrence
stula tracts stula patients followed (Healing rates given for (wks), range (weeks), range
treated up (%), method %) recurrence (weeks) (weeks)
of follow-up
Rojanasakul 5 0 0 0 (16.5), 100, C 17/18 (94.4) 1 (5.6) NR Repeat LIFT NR, (18) NR
19
(1/1)
Shanwani 12 0 4 5 (24), 100, C 37/45 (82.2) 8 (17.7) None Repeat LIFT 7, (410) NR, (1232)
et al. 20 (5/8)
Bleier et al. 21 10 NR 7 29 (014.5), 90, NR 20/35 (57) 4 15 (42.8) Anal ssure NR NR 10, (238)
pts NR (1/35)
Chronic anal
pain (1/35)
Aboulian 9 NR 2 8 (213), 100, C 17/25 (68) 8 (32) Vaginal Fistulotomy NR NR
et al. 22 fungal (1/8)
Lo et al. 33 25 NR 0 14 (121.5), 100, C 23/25 (89) 2 (11) None Fibrin glue (1) 2, (18) NR
Drainage + Seton
(1)
Tan et al. 24 0 NR 0 (467), 100, C 15/24 (62.5) 9 (37.5) NR Fistulotomy NR NR
(2012) 34 (4/9)
Seton (4/9)
I&D (1/9)
IBD, Inammatory bowel disease; Follow-up methods, clinical examination (C); EUS, Endoscopic ultrasound; TC, Telephone communication; NC, Nil change in continence; NR, Not reported; I&D,
Incision and Drainage; ERAF, Endorectal advancement ap.
115
116 j coloproctol (rio j). 2 0 1 4;3 4(2):109119
jeopardize continence, but healing rates can be very low. invasive and less morbid with little risk of incontinence. How-
Reported recurrence and incontinence rates range from 0% to ever further prospective randomized trials studies with longer
32% and from 0% to 63%, respectively. follow-up periods are warranted to further validate these
The LIFT procedure combines two important concepts: ndings.
removal of the infected cryptoglandular tissue through the One important observation was that even when the
intersphincteric approach and closure of the internal orice LIFT procedure fails to completely eradicate the stula,
with negligible trauma to the sphincters. Essential steps of it was able to downstage the original anatomy of a
the procedure include incision at the intersphincteric groove, trans-sphincteric stula to either an intersphincteric sinus
identication of the intersphincteric tract and ligation of the or stula. This medialization of the external opening to
intersphincteric tract close to the internal opening. All gran- the intersphincteric wound simplies subsequent manage-
ulation tissue is debrided and the defect in the external ment. Intersphincteric sinuses can be managed locally by
sphincter muscle is sutured at. This technique prevents the the application of silver nitrate, whereas an intersphinc-
entry of faecal material into the stula tract and eliminates teric stula can often be laid open. In those patients with
the formation of a septic nidus in the intersphincteric space complete failures it is imperative to perform a thorough
to allow healing of the stula-in-ano.19 In the initial publica- reevaluation before subsequent surgical management. It is
tion by Rojanasakul et al., a success rate of 94% was reported recommended that a seton is placed for 612 weeks if there
with no case of incontinence. Fistula healing rates range from is evidence of acute inammation, purulence or excessive
40% to 94% with variable follow-up as shown in Table 2. Others drainage.23
have conrmed the effectiveness of LIFT although with lower Thirteen studies (Table 1) looked at the use of setons prior
rates of success. to LIFT. None of them found any signicant changes in closure
The reported success rate of LIFT among the prospective rates. Further studies are needed to evaluate the role of the
studies, with a minimum follow-up greater than 6 months, seton in the LIFT procedure.
varied between 40% and 88.9%. In the six retrospective case LIFT seems to be very safe in terms of morbidity. Among
series analyzed, the success rate was between 40% and 86%. the studies, we observed a single episode of haemorrhoidal
From the only randomized control study, we can observe thrombosis, bleeding, anal ssure and chronic anal pain, while
that the success rate was 76%. These results are moderate two were reported to have vaginal fungal infections. Conti-
yet impressive considering that the procedure is minimally nence is consistently preserved.
118 j coloproctol (rio j). 2 0 1 4;3 4(2):109119
Limitations of the study 12. Neal Ellis C. Outcomes with the use of bioprosthetic grafts to
reinforce the ligation of the intersphincteric stula tract
All the studies included in this analysis are of small sample (BioLIFT procedure) for the management of complex anal
stulas. Dis Colon Rectum. 2010;53:13614.
size. In addition there is absence of long-term follow-up in the
13. Han JG, Yi BQ, Wang ZJ, et al. Ligation of the intersphincteric
available studies. Perhaps more importantly though is the fail-
stula tract plus bioprosthetic anal stula plug (LIFT-Plug): a
ure of gauging the impact of the LIFT procedure on continence new technique for Fistula-in-Ano. Colorectal Dis.
and lack of objective measurement of evidence of stula heal- 2013;15:5826.
ing (endorectal ultrasound or magnetic resonance imaging). 14. Cui JJ, Wang ZJ, Zheng Y, Han JG, Yang XQ. Ligation of the
However, the systematic analysis provides us with an insight intersphincteric stula tract plus bioprosthetic anal stula
into the initial results of a new procedure with encouraging plug (LIFT-plug) in the treatment of transsphincteric perianal
stula. Zhonghua Wei Chang Wai Ke Za Zhi. 2012;15:12325.
outcomes.
Chinese. PubMed PMID: 23268266.
15. Baharudin MN, Hassan ZM, Nor AM, Rahman AA. Recurrent
Conclusion infection of a sinus tract at the staple line after
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the intersphincteric stula tract (LIFT). Tech Coloproctol.
Despite the LIFT technique having been adopted in many
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centres around the world, there is a paucity of information 16. van Onkelen RS, Gosselink MP, Schouten WR. Is it possible to
regarding the patterns of failures and recurrences after the improve the outcome of transanal advancement ap repair
LIFT procedure and their subsequent management. for high transsphincteric stulas by additional ligation of the
The initial results with LIFT are promising, with success intersphincteric stula tract? Dis Colon Rectum.
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our study reect a simple and safe procedure with little mor-
simple modication to ligation of intersphincteric stula tract
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is limited, this review provides the most accurate estimate, Disease. 2011;13 Suppl. 5:66 [Posters].
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The authors declare no conicts of interest.
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