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

Optimal Treatment for Trans-Levator Fistula

The LIFT (Ligation of Intersphincteric Fistula Tract) procedure is the optimal treatment for this patient with a complex trans-levator fistula. 1

Diagnosis Analysis

Based on the clinical presentation and imaging findings, this patient has:

• Internal fecal soiling
• Normal sigmoidoscopy
• PR mucosal bulge on left side at fingertip
• Posterior midline indentation
• MRI showing mass at levator ani level
• No external opening

These findings are consistent with a complex trans-levator fistula, which is considered a complex trans-sphincteric or supra-sphincteric fistula according to current guidelines 1.

Treatment Options Assessment

1. LIFT Procedure (Option D)

   • Preferred for complex fistulas involving the levator ani
   • Sphincter-preserving technique that minimizes risk of incontinence
   • Particularly appropriate for this case with no external opening
   • Recurrence rate between 10-40% 1

2. Seton Placement (Option A)

   • Useful for draining and controlling sepsis
   • Less effective as definitive treatment for complex trans-levator fistulas
   • More appropriate for staged treatment or recurrent cases

3. Lay Open from Inside (Option B)

   • High risk of incontinence for trans-levator fistulas
   • Not recommended for complex fistulas involving the levator ani muscle
   • Could compromise sphincter function

4. Glue Sealing (Option C)

   • Less effective for complex fistulas without external drainage
   • High failure rates in complex tracks 1
   • Poor long-term outcomes for trans-sphincteric fistulas

Rationale for LIFT Procedure

The LIFT procedure is optimal in this case because:

1. MRI confirms the trans-levator involvement, making this a complex fistula requiring a sphincter-preserving approach 1, 2

2. The absence of an external opening makes glue sealing particularly ineffective 1

3. The location at the levator ani level makes lay-open techniques high-risk for incontinence

4. LIFT provides the best balance of efficacy and sphincter preservation for complex fistulas 1

Procedure Planning

• Preoperative MRI is essential for surgical planning, as it accurately delineates the fistula anatomy 2, 3
• MRI has been shown to significantly contribute to surgical management in 33.8% of fistula cases, particularly for complex fistulas 2
• Follow-up should include clinical examination at 2 weeks, 6 weeks, and 3 months 1
• Repeat MRI is recommended if symptoms recur 1

Potential Complications

• Persistent drainage
• Wound healing issues
• Recurrence (10-40% risk) 1

The LIFT procedure provides the best balance of efficacy and sphincter preservation for this patient with a complex trans-levator fistula with no external opening, making it the optimal treatment choice.