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

Management of Complex Perianal Fistula with No External Opening

The LIFT (Ligation of Intersphincteric Fistula Tract) procedure is the optimal treatment for this patient with a complex perianal fistula extending to the levator ani muscle with no external opening.

Clinical Assessment and Diagnosis

The patient presents with:

• Internal cloth soiling
• Normal sigmoidoscopy
• PR examination showing mucosal bulge on left side at fingertip
• Indentation in midline posterior
• MRI showing mass on left side at the levator ani
• No external opening

This clinical picture is consistent with a complex transsphincteric fistula extending to the levator ani muscle without an external opening.

Treatment Options Analysis

A. Seton Placement

• Setons are primarily indicated as an initial step to control sepsis and create a patent tract
• They are typically used before definitive treatment rather than as a final solution 1
• Not optimal as definitive treatment for this complex fistula with no external opening

B. Lay Open from Inside

• High risk of sphincter damage and subsequent incontinence in complex fistulas
• Not recommended for transsphincteric fistulas extending to the levator ani
• Particularly problematic when there's no external opening

C. Sealing by Glue

• Lower success rates compared to LIFT for complex fistulas
• Higher recurrence rates in transsphincteric fistulas
• Not optimal for fistulas extending to the levator ani

D. LIFT Procedure

• Specifically designed for transsphincteric fistulas extending to the levator ani 1
• Preserves sphincter function with minimal risk of incontinence 2, 3
• High healing rates (60-90%) in complex perianal fistulas 1, 2
• Particularly suitable for fistulas with no external opening as it addresses the internal opening and intersphincteric portion

Evidence for LIFT Procedure

The LIFT procedure has demonstrated excellent outcomes in multiple studies:

• Primary healing rates of 73-83% 2, 4
• Overall healing rates approaching 100% when combined with secondary procedures 3
• No reported cases of postoperative incontinence 2, 5, 3
• Low recurrence rates (18-27%) 2, 5
• Minimal complications 2, 4

A systematic review and meta-analysis of 1,110 patients showed a mean success rate of 76.4% with 0% incontinence rate 6.

Procedure Details

The LIFT procedure involves:

1. Identification of the internal opening (already located in this patient)
2. Making an incision in the intersphincteric groove
3. Identifying the fistula tract as it crosses the intersphincteric space
4. Ligation of the tract close to the internal anal sphincter
5. Removal of the infected tissue
6. Closure of the internal opening

Special Considerations for This Patient

• The absence of an external opening makes the LIFT procedure particularly suitable as it focuses on the internal opening and intersphincteric portion
• The location of the fistula at the levator ani level makes LIFT preferable to more invasive procedures
• MRI confirmation of the fistula tract is essential for proper surgical planning
• Examination under anesthesia should be performed immediately before the procedure to confirm the internal opening location

Postoperative Management

• Regular follow-up to monitor healing
• Assessment for recurrence, typically presenting between 4-8 weeks postoperatively 2
• If recurrence occurs, options include repeat LIFT or conversion to other techniques

Conclusion

Based on the patient's clinical presentation with a complex perianal fistula extending to the levator ani with no external opening, the LIFT procedure (option D) offers the best balance of efficacy and sphincter preservation, with high healing rates and minimal risk of incontinence.