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Results of Ligation of Intersphincteric Fistula Tract and Advancement Flap for Treatment of Complex Transsphincteric Anal Fistula: Anatomy of the Recurrence.
Darcy Shaw*1, Charles Ternent1, Sean Langenfeld2, Garnet Blatchford1, Jennifer S. Beaty1, Noelle Bertelson1, Maniamparampil Shashidharan1, Jai Bikhchandani1, Alan G. Thorson1
1Colon and Rectal Surgery, Creighton University, Omaha, NE; 2Colon and Rectal Surgery, University of Nebraska, Omaha, NE
Background:
Management of complex transsphincteric anal fistulas is often associated with high rates of recurrence. Ligation of intersphincteric fistula tract (LIFT) and rectoanal advancement flap (AF) coverage are two muscle-sparing approaches. Previous reports have suggested that the LIFT procedure can "downstage" fistulas from transsphincteric to intersphincteric, therefore simplifying further treatment options. We reviewed these procedures to determine treatment failure, the effect of prior procedures on recurrence, and the anatomy of fistula recurrences. We hypothesize that LIFT is associated with a higher rate of recurrence than AF, but these recurrences are less complex in nature.
Methods:
A retrospective chart review was performed for all patients undergoing LIFT or AF procedures at two institutions for the treatment of transsphincteric fistulas from 2012-2014. Data was obtained from 8 surgeons. Background demographics, comorbidities, and related surgeries were recorded. Clinical outcomes of repair failure, anatomy of recurrence, and subsequent procedure also were analyzed.
Results:
A total of 51 patients were identified (35 LIFT, 16 AF). Mean age of patients was 46 years (Range 22-88), with an average BMI of 33.6 which did not differ between LIFT and AF (p=NS). Crohn's disease was present in 6% of LIFT patients and 13% of AF patients (p=NS). Follow-up times for LIFT and AF patients was 6.8 and 4.4 months, respectively (p=NS). Setons were placed prior to LIFT procedures in 63% of patients, and in 81% prior to AF (p=NS). Setons were placed 13.2 weeks prior to LIFT (range 3-52), and 14.1 weeks prior to AF (range 6-52) (p=NS). Seton use did not alter recurrence for either group (p=NS).
Overall treatment failure was 48.6% in LIFT patients and 31.3% in AF patients (p=NS). Recurrence in LIFT patients was transsphincteric, intersphincteric, and subcutaneous in 53%, 23%, and 6% respectively. Recurrence in AF patients was transsphincteric or intersphincteric in 80% and 20%, respectively. Transsphincteric recurrence occurred equally between LIFT and AF (p=NS). Recurrence after LIFT was 29% without prior fistula surgery, and 61% with prior operations (p=NS). No recurrences were observed in AF patients without prior surgical procedures, and a 66% recurrence rate was found in patients with prior repairs (p=0.03). The average time to recurrence for LIFT and AF was 2.8 and 3 months (range 1-9 months), respectively (p=NS).
Conclusion:
Overall treatment failure is high after LIFT and AF for complex transsphincteric fistula. Seton drainage has no effect on the rate of recurrence. Previous operations predict recurrence for AF procedures, but not for LIFT in our series. Our results show that most recurrences following LIFT and AF are transsphincteric. LIFT and AF "downstage" fistulas equally.
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