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 digital rectal examination (DRE), 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 Levator Ani Involvement

The optimal treatment for this middle-aged patient with internal soiling, mucosal bulge, and MRI evidence of a mass at the levator ani with no external opening is the LIFT (Ligation of Intersphincteric Fistula Tract) procedure (option D).

Clinical Assessment and Diagnosis

Based on the clinical presentation, this patient has:

• Internal cloth soiling
• Normal sigmoidoscopy
• PR examination showing mucosal bulge on the left side and posterior midline indentation
• MRI evidence of a mass at the levator ani
• No external opening

These findings are consistent with a complex transsphincteric fistula extending to the levator ani muscle without an external opening, which requires a sphincter-preserving approach.

Treatment Options Analysis

LIFT Procedure (Option D)

• Highest recommendation for complex perianal fistulas, particularly transsphincteric fistulas extending to the levator ani 1
• Preserves sphincter function with lower risk of incontinence
• High healing rates of 60-90% for complex fistulas 1, 2
• Particularly suited for transsphincteric fistulas extending to the levator ani 1
• Minimally invasive technique that should be routinely considered for complex anal fistulas 3

Seton Placement (Option A)

• Primarily used for drainage and inflammation control before definitive treatment
• Not optimal as a final solution for complex fistulas with no external opening 1
• Would not address the underlying pathology in this case

Lay Open from Inside (Option B)

• High risk of sphincter damage and subsequent incontinence in complex fistulas
• Not recommended for transsphincteric fistulas extending to the levator ani
• Would compromise sphincter function unnecessarily

Sealing by Glue (Option C)

• Lower success rates compared to LIFT for complex fistulas
• Not specifically recommended in guidelines for fistulas extending to the levator ani
• Higher recurrence rates compared to LIFT

LIFT Procedure Details

1. Preoperative Assessment:

   • Thorough MRI evaluation to identify any secondary tracts 1
   • Examination under anesthesia to confirm internal opening location

2. Surgical Technique:

   • Incision at the intersphincteric groove
   • Identification of the intersphincteric tract
   • Ligation of intersphincteric tract close to the internal opening
   • Removal of intersphincteric tract
   • Scraping out all granulation tissue in the rest of the fistulous tract
   • Suturing of the defect at the external sphincter muscle 4

3. Success Rates and Outcomes:

   • Primary healing rates of 60-90% 2
   • Low recurrence rates (reported as 18-27% in studies) 5, 3
   • No significant impact on continence 5, 3, 6

Potential Complications and Management

• Recurrence (18-27% of cases) may require additional procedures 5, 3
• Failure to heal (reported in 7% of cases) 5
• Post-procedure monitoring for healing and recurrence is essential 1

Conclusion

The LIFT procedure is the optimal treatment choice for this patient with a complex perianal fistula extending to the levator ani with no external opening. This approach provides the best balance of efficacy (high healing rates) and safety (preservation of sphincter function) compared to other options.