World Journal of Surgery and Surgical Research Research Article

Published: 25 Mar, 2020

Ligation of Intersphincteric Fistula Tract (LIFT) For

Fistula-in-Ano: Feasibility and Our Experience
Nisar A Chowdri1, Salim Nazki2*, Zamir Ahmad Shah3 and Gowhar Aziz Bhat4
1
Department of General and Minimal Invasive Surgery and Colorectal Division, Sher-i-Kashmir Institute of Medical
Sciences Srinagar, India
2
Department of General Surgery, Sher-i-Kashmir Institute of Medical Sciences Srinagar, India
3
Department of Cardiovascular and Thoracic Surgery, Sher-i-Kashmir Institute of Medical Sciences Srinagar, India
4
Department of Colorectal Surgery, Sher-i-Kashmir Institute of Medical Sciences Srinagar, India

Abstract
Background: A sphincter saving technique known as Ligation of Intersphincteric Fistula Tract
(LIFT) has become popular for treatment of fistula-in-ano. This technique involves ligation and
division of the fistula tract in the intersphincteric space without using any biological material.
Aim: The aim of the study was to see the feasibility and results of LIFT technique in managing
different types of fistula-in-ano and the postoperative complications and recurrence rates.
Method: A prospective study conducted in the department of colorectal surgery, a division of
General and Minimal Invasive Surgery, Sher-i-Kashmir Institute of Medical Sciences (SKIMS)
Srinagar over a period of 26 months. Patients with fistula-in-ano were enrolled for the study.
Detailed history, clinical examination & evaluation were done as per the protocol. Patients were
subjected to standard surgical treatment. LIFT was used where found to be feasible depending on
type and nature of fistula. All patients were followed regularly and results analyzed statistically.
Results: The LIFT technique seems to be safe and simple but our study revealed that only 38.2%
cases of all Fistula-in-Ano could be treated by this technique. Procedure is difficult in patients
having horse shoe fistula, non-location of internal opening or tract, scarring due to previous surgery
multiple tracts, complex fistulas, abscesses, high fistula, curved and short tract. None of the patients
had post-operative incontinence however 6.4% had post-operative infection and 12.9% had wound
dehiscence. Recurrence was observed in only one patient. Most of the patients (77.41%) had less than
OPEN ACCESS 1 day stay in hospital post procedure. On satisfaction score, 67.74% patients who underwent LIFT
*Correspondence:
technique were satisfied and 22.58% were non-satisfied. The median follow up was 17.6 months.
Salim Nazki, Department of General Conclusion: The ligation of the intersphincteric fistula tract technique for fistula-in-ano surgery,
Surgery, Sher-i-Kashmir Institute of which aims at total anal sphincter preservation is safe and easy to perform but has its demerits too.
Medical Sciences Srinagar, India, Further modifications are needed to treat the complex fistulae and fistulas having multiple tracts.
E-mail: saalim_nazki@yahoo.co.in
Received Date: 15 Feb 2020 Introduction
Accepted Date: 22 Mar 2020 Fistula-in-ano is a common condition but a potentially complex disease process. A fistula can
Published Date: 25 Mar 2020 be found in 26% to 38% of all anorectal abscesses [1,2]. A fistula-in-ano is characterized by chronic
Citation: purulent drainage or cyclical pain associated with abscess re-accumulation followed by intermittent
Chowdri NA, Nazki S, Shah ZA, spontaneous decompression. Fistula-in-ano is categorized on the basis of location relative to the anal
Bhat GA. Ligation of Intersphincteric sphincter muscles by Parks classification where the fistula can be intersphincteric, transsphincteric,
Fistula Tract (LIFT) For Fistula-in-Ano: suprasphincteric, or extrasphincteric. The goal of surgical management is to effectively eradicate
Feasibility and Our Experience. World J current and recurrent septic foci, associated epithelialized tracts and preserve continence.
Surg Surgical Res. 2020; 3: 1209. An ideal procedure for treating a fistula-in-ano should be minimally invasive with minimal
Copyright © 2020 Salim Nazki. This is failure rates and morbidity. However, no single technique is appropriate for the treatment of all
an open access article distributed under fistula-in-ano and the surgeon’s experience and judgment should guide treatment decision. Ligation
the Creative Commons Attribution of the Intersphincteric Fistula Track (LIFT) has recently been described by Rojanasakul et al. [3].
License, which permits unrestricted
Since the initial description in 2006, several studies on LIFT have been reported in literature with
variable results and indications.
use, distribution, and reproduction in
any medium, provided the original work The primary aim in the treatment of an anal fistula are to eliminate the fistula opening and
is properly cited. associated tracts and any secondary openings without a change in continence. The Ligation of the

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Salim Nazki, et al., World Journal of Surgery and Surgical Research - General Surgery

Intersphincteric Fistula Tract (LIFT) 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. The
success rate is comparable with other sphincter preserving techniques.
Importantly, it appeared to effectively preserve continence. The
ligation of intersphincteric fistula is a promising sphincter-preserving
procedure that is simple and safe.
Material and Methods
The study was conducted for a period of three years in the
Figure 1: Cases done using LIFT technique.
department of colorectal surgery, a division of general and minimal
invasive surgery, Sher-i-Kashmir Institute of Medical Sciences.
All the cases diagnosed to have fistula-in-ano from their medical
history, clinical and physical examination out of which the cases were
chosen to be feasible for the LIFT technique. The common complaint
in patients that were dealt was LIFT technique were perianal
discharge, perianal swelling, constipation, perianal pain, itching and
incontinence. All patients underwent Digital Rectal Examination
(DRE) for the clinical assessment. Proctoscopy/sigmoidoscopy with
or without fistulogram was done in patients were found to be feasible
in the group of patients for LIFT technique. MRI was resorted for
cases that had a preoperative suspicion of complex fistula, recurrence
or had multiple openings externally.
A questionnaire was made that was relevant for the LIFT Figure 2: Reasons for not doing LIFT.
technique. Questions included were if the surgery helped in treating
the problem? How long did it take to heal? Is there any other abscess following technique, sphincter preservation, wound healing and fecal
or discharge postoperatively? Ability to hold the gas and feces incontinence.
postoperatively? Need to change the undergarments frequently? Any Results
accidental passage of stools any time?
For a period of three years (2012 to 2015), 81 cases of fistula-in-
A satisfaction score was made to check for the level of satisfaction. ano were treated in the department of colorectal surgery, a division
At the end satisfaction score was broadly divided into satisfied and of General and Minimal Invasive surgery, Sher-I-Kashmir Institute
non-satisfied, ranging from 1 to 2. of Medical Sciences.
Cases that were not found fit to undergo LIFT technique were Out of the 81 patients 31 (38%) were dealt with LIFT technique
preceded by other techniques like fistulectomy which involves for fistula-in-ano, either exclusively or with some modification or
excision of whole of the fistulous tract or fistulotomy in which the some additional procedure. Out of 31 cases, exclusive LIFT technique
tract is laid open. Some patients who had complex fistula underwent was done in 22 (71%) cases while a modified LIFT technique was
Seton procedure. Incision and drainage was also done in patients who performed in 1 (3.22%) case. In 7 cases (22.58%), coring of tract was
had associated perianal abscess. done along with LIFT technique and in 1 (3.225) that had a rectal
polyp, excision of polyp was done along with LIFT technique (Figure
Surgical Procedure
1).
The procedure is performed in Trendelenburg lithotomy position
The common complaint in patients that were dealt with by LIFT
under monitored regional anesthesia (spinal or epidural) and local
technique were perianal discharge in (96.7%), perianal swelling
anesthetic block. Essential steps of the procedure include, incision
(77%), constipation (35%), perianal pain (32.2%), itching (16%)
at the intersphincteric groove, identification of the intersphincteric
and incontinence (3%). All the 31 patients underwent DRE for
tract, ligation of intersphincteric tract close to the internal opening
the clinical assessment. Out of total 31 patients 18 patients were
and removal of intersphincteric tract, scraping out all granulation
evaluated by Proctoscopy/Sigmoidoscopy. Fistulogram was done in
tissue in the rest of the fistulous tract, and suturing of the defect at the
12 patients. Five of 31 patients were evaluated by MRI. Out of the
external sphincter muscle.
50 cases which were not subjected to LIFT technique, 7 (14%) had
Patients were discharged on the next day or the consequent Horse shoe fistula, 8 (16%) were the cases in which internal opening/
days of surgery depending upon the post operative condition. All tract couldn’t be located, 11 (22%) had perianal scarring, 6 (12%)
patients were followed weekly for one month, biweekly for three with multiple fistulous tracts, 2 (4%) had associated perianal abscess
months after surgery and thereafter monthly for one year, for the and 7 (14%) were because of complex fistula. In 3 (6%) of case LIFT
satisfaction score based on visual analogue score and questionnaire technique couldn’t be done because of short tract while as in 6 (12%)
postoperatively. Satisfaction score for all the patients in any technique LIFT technique was not possible due to inflammation and induration
was seen using a questioner provided to patients at 3 months of (Figure 2). Cases that were dealt with LIFT technique, 6 (19.3%) had
follow up post operatively. The study bears significance in terms of post-operative complications like wound dehiscence 4 (12.9%) or
feasibility of technique for management of different types of fistula- post-operative infections 2 (6.4%) however none of the patients had
in-ano, surgical results, post-operative complications and recurrence incontinence. All these complications were managed conservatively

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Salim Nazki, et al., World Journal of Surgery and Surgical Research - General Surgery

Figure 6: Satisfaction score post LIFT.

Figure 3: Post-op complication after LIFT.

et al. [4] who compared the LIFT technique, with LIFT along with
the additional step of coring fistulectomy and found no significant
difference in success rate between them.
Though LIFT technique is considered a promising technique
for fistula-in-ano but not all patients (50/81) could be dealt with
this technique because of some reasons and were either dealt by
fistulectomy 32 (64)%, Coring of tract 10 (20%) or fistulotomy in
3 (6%) and Seton 5 (10%). Among these cases 2 (4%) were having
perianal abscess and 6 (12%) were having inflammation with
induration and these factors could be attributed to the resolution
Figure 4: Culture sensitivity of wounds. of inflammatory phase that would have resulted in fibrosis and
obliteration for intersphincteric plane, thus making dissection
difficult [5]. Eleven (22%) cases were having perianal scarring due to
previous procedures or incision and drainage of abscess that made
the LIFT impossible. In 8 (16%) cases LIFT technique couldn’t be
performed because internal opening couldn’t be located. The location
of internal opening forms an important step of procedure as the tract
is ligated close to the internal opening [3]. In 3 (6%) cases tract was
too short to be ligated and thus interfere with one of the basic steps of
LIFT technique [3]. Multiple tracts were present in 6 (12%) cases thus
making the LIFT impossible [3]. In 7 (14%) with horse shoe fistula
and in 7 (14%) of cases with complex fistula, LIFT technique couldn’t
Figure 5: Recurrence Post LIFT.
be done and was abandoned by the surgeons, who had experience
of treating fistula-in-ano for more than 20 years and did not find it
(Figure 3). Post-operatively swabs were sent for cultural examination
feasible which is also in accord with the study that techniques offered
where 87.09% cases showed sterile culture post-operatively while as
depend on the surgeon's experience and knowledge of the disease [6].
9.6% and 3.2% had growth of E-coli and staphylococcus respectively
Chowdri in 2017 reported that LIFT technique is not feasible in all the
(Figure 4).
patients with fistula-in-ano and results are not encouraging in fistulas
Twenty four (77.41%) cases had less than 1 day post-operative with any scarring, inflammation side branches and with complex and
stay in hospital and 7 (22. 58%) had more than one day hospital recurrent fistulae [7].
stay among the cases dealt with LIFT technique Most patients who
The success of surgery depends on the procedure employed and
underwent LIFT technique were followed up for more than one year. post-operative outcome. In the present study 19.35% (6/31) patients
One patient was followed up for more than 24 months, 14 patients had complications after LIFT technique which is in accordance with
were on a regular follow up of more than 18 months while 4, 3 and the findings of Aboulian et al. [8] who reported complete healing in 17
9 patients were on follow up for less than 6 months, 6 months to (68%) patients out of 25 patients who had undergone LIFT technique
12 months and 12 months to 18 months respectively. The median while as 8 (32%) showed post-operative complications while the other
follow up was 17.6 months. One (3.22%) patient had recurrence at study reported complication in 13.3% of cases that underwent LIFT
a follow up of three months (Figure 5). On satisfaction score, 21 technique for fistula-in-ano [9]. Although Rojanasakul et al. [10]
(67.74%) patients who underwent LIFT technique were satisfied and himself reported no major post-operative complications in patients
10 (22.58%) were dissatisfied with the procedure (Figure 6). dealt with LIFT technique. The low post-operative complications
Discussion observed in LIFT technique could be attributed to its more secure than
over sewing and removal of infected granulation tissue by curettage
In the present study LIFT technique was done in 31 (38.27%) is also less time consuming and more practical than total excision of
of 81 cases of fistula-in-ano. However in some patients can either tract and primary repair [3]. Among the post operative complications
modification of LIFT was done or additional procedures were most of them (12.9%) had a wound dehiscence. Rojanasakul and Ooi
performed along with LIFT technique like polypectomy or coring. No reported wound dehiscence in 5.55% and 4% cases respectively in
significant difference was observed in the outcome of LIFT technique patients who underwent LIFT technique for fistula-in-ano [10,11].
alone or when LIFT was accompanied by additional procedures. Incontinence is known complication post surgery for fistula-in-
Our findings are in agreement with those reported by Siripoung ano, but the present study along with the other literature found no

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Salim Nazki, et al., World Journal of Surgery and Surgical Research - General Surgery

incontinence post LIFT technique [10]. The low incontinence rate References
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