What is the optimal treatment plan for a patient with an intersphincteric fistula (Ligation of Intersphincteric Fistula Tract) without an external opening?

Optimal Treatment for Intersphincteric Fistula Without External Opening

The LIFT (Ligation of Intersphincteric Fistula Tract) procedure is the optimal treatment for this patient with an intersphincteric fistula without an external opening, as it offers the best balance of healing rates and sphincter preservation. 1

Rationale for LIFT Procedure

• LIFT is specifically recommended by the European Crohn's and Colitis Organisation (ECCO) for intersphincteric fistulas 1
• Key advantages of LIFT include:
  • Preservation of sphincter function and maintenance of continence
  • High success rates of 65-77% in complex fistulas 1
  • Low complication rates (up to 14%), primarily wound dehiscence 1
  • Particularly suitable for single, non-branching fistula tracts 1

Evidence Supporting LIFT

• Systematic reviews show a mean success rate of 76.4% with virtually no incontinence (0%) and low complication rates (5.5%) 2
• Prospective multicenter studies demonstrate primary healing in 73% of patients with complex anal fistulas 3
• Long-term follow-up studies report success rates of 75% at mean follow-up of 14.6 months 4

Why Other Options Are Less Suitable

Seton (Option A)

• Setons are useful for establishing drainage and minimizing abscess formation 1
• However, they primarily control sepsis rather than heal the fistula
• Not ideal as definitive treatment for intersphincteric fistulas without an external opening 1

Lay Open from Inside (Option B)

• Fistulotomy (laying open) is only recommended for simple, superficial fistulas involving minimal sphincter 1
• Not recommended for intersphincteric fistulas without an external opening due to:
  • Technical difficulty
  • Risk of sphincter damage
  • Potential for incontinence 1

Sealing by Glue (Option C)

• Not mentioned in recent guidelines as a preferred treatment option for intersphincteric fistulas 1
• Limited evidence and lower success rates compared to LIFT 1

Important Considerations for LIFT Procedure

• Modified approaches to LIFT have shown improved outcomes:
  • High ligation of anal fistula tract by lateral approach has shown 75% success rate 5
  • Modified LIFT with curved incision and purse-string suture has demonstrated 83.9% success rate in long-term follow-up 6

Post-Procedure Management

• Regular assessment for at least 6-12 months
• MRI evaluation to confirm complete healing
• Long-term monitoring for recurrence 1

Potential Complications and Risk Factors

• Recurrence rates of 12-27% have been reported 3, 4
• Recurrences are significantly related to fistulas with multiple tracts 4
• Most recurrences occur between 4-8 weeks postoperatively 3

In this specific case, with MRI showing a mass on the left side at the levator ani, normal sigmoidoscopy, and no external opening, the LIFT procedure offers the best chance of successful treatment while preserving sphincter function and continence.