What is the optimal treatment plan for a middle-aged patient with internal cloth soiling, a normal sigmoidoscopy, a PR (per rectal) mucosal bulge on the left side, and a pelvic MRI showing a mass on the left side at the levator ani, with no external opening?

From the Guidelines

The optimal treatment plan for this patient is surgical excision of the abscess or fistula, specifically through a procedure known as LIFT (Ligation of Intersphincteric Fistula Tract), given the presence of a mass on the left side at the levator ani without an external opening, as indicated by the pelvic MRI 1.

Key Considerations

• The patient's symptoms of internal cloth soiling, normal sigmoidoscopy, and left-sided PR mucosal bulge, along with the pelvic MRI findings, suggest a complex anorectal condition, likely an intersphincteric abscess or fistula.
• The absence of an external opening and the location of the mass at the levator ani level indicate a need for careful surgical planning to avoid complications such as fecal incontinence.
• Preoperative preparation with broad-spectrum antibiotics, such as ciprofloxacin and metronidazole, is recommended to reduce the risk of infection, as suggested by guidelines for anorectal emergencies 1.

Surgical Approach

• The LIFT procedure is specifically designed for intersphincteric fistulas, which seems to be the case here given the location and absence of an external opening.
• This approach involves ligation of the fistula tract, which can help in preventing recurrence and minimizing the risk of complications.

Postoperative Care

• Postoperative care should include sitz baths, regular dressing changes, and pain management with NSAIDs and acetaminophen to ensure proper healing and patient comfort.
• Follow-up within 1-2 weeks after surgery is crucial to assess the healing process and address any potential complications early.

Rationale

• The choice of LIFT over other options like seton placement, laying open the fistula from the inside, or sealing with glue is based on the specific anatomy of the patient's condition, as indicated by the pelvic MRI, and the goal of minimizing recurrence and complications while preserving anal function.
• The recent guidelines on anorectal emergencies emphasize the importance of a thorough clinical examination and appropriate use of imaging studies like MRI in diagnosing and planning the treatment of complex anorectal conditions 1.

From the Research

Optimal Treatment Plan

The optimal treatment plan for a middle-aged patient with internal cloth soiling, a normal sigmoidoscopy, a PR mucosal bulge on the left side, and a pelvic MRI showing a mass on the left side at the levator ani, with no external opening, can be determined based on the following considerations:

• The patient's symptoms and diagnostic results suggest the presence of an anal fistula.
• The Ligation of the Intersphincteric Fistula Tract (LIFT) procedure is a minimally invasive technique that has been shown to be effective in treating complex anal fistulas with a low recurrence rate and minimal risk of incontinence 2, 3, 4.
• The LIFT procedure involves ligating the intersphincteric fistula tract, which can help to eradicate the fistula while preserving the anal sphincter.
• Studies have shown that the LIFT procedure has a shorter healing time and lower incidence of postoperative anal incontinence compared to conventional fistulotomy 2.
• However, it is essential to note that the LIFT procedure may not be suitable for all patients, and the decision to undergo this procedure should be made on a case-by-case basis.

Treatment Options

The following treatment options are available:

• A. Seton: This involves placing a seton around the fistula tract to help drain the infection and promote healing.
• B. Lay open from inside: This involves surgically opening the fistula tract from the inside to allow it to heal.
• C. Sealing by glue: This involves using a special glue to seal the fistula tract.
• D. LIFT (Ligation of the Intersphincteric Fistula Tract): This involves ligating the intersphincteric fistula tract to eradicate the fistula while preserving the anal sphincter.

Recommended Treatment

Based on the available evidence, the recommended treatment for this patient would be:

• D. LIFT (Ligation of the Intersphincteric Fistula Tract) 2, 3, 4. This procedure has been shown to be effective in treating complex anal fistulas with a low recurrence rate and minimal risk of incontinence. However, it is essential to consult with a healthcare professional to determine the best course of treatment for this patient's specific condition.

Key Considerations

When considering the LIFT procedure, the following key considerations should be taken into account:

• The patient's overall health and medical history.
• The location and complexity of the fistula.
• The potential risks and benefits of the procedure.
• The patient's preferences and values. It is crucial to discuss these considerations with a healthcare professional to determine the best course of treatment for this patient's specific condition 5.