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

Optimal Treatment for Complex Perianal Fistula with Levator Ani Involvement

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 with no external opening. 1

Clinical Assessment and Diagnosis

Based on the clinical presentation:

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

This presentation is consistent with a complex transsphincteric fistula extending to the levator ani muscle, which requires a sphincter-preserving approach.

Treatment Options Analysis

LIFT Procedure (Option D)

• Strongest recommendation based on ECCO guidelines for complex perianal fistulas, particularly those 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
• Optimal for cases with no external opening, as in this patient 1

Seton Placement (Option A)

• Primarily used for initial management and drainage before definitive treatment
• Not optimal as a final solution for complex fistulas with no external opening 1
• Better suited as a preparatory step rather than definitive management

Lay Open from Inside (Option B)

• High risk of sphincter damage and subsequent incontinence in complex fistulas
• Not recommended for complex fistulas extending to the levator ani
• Conventional fistulotomy is only appropriate for simple, distal fistulas 3

Sealing by Glue (Option C)

• Poor and variable healing rates (14-74%) 3
• High failure rates for complex fistulas
• Not recommended as first-line treatment for complex fistulas extending to the levator ani

Preoperative and Intraoperative Considerations

For optimal LIFT procedure outcomes:

• Thorough preoperative MRI assessment is essential to identify any secondary tracts 1
• Examination under anesthesia to confirm internal opening location
• Consider temporary seton placement if active inflammation is present before definitive LIFT procedure 1

Potential Complications and Management

• Success rates may be lower if there is active inflammation or abscess formation
• Recurrence is possible (reported in 10-40% of cases)
• Regular post-procedure monitoring for:
  • Healing progress
  • Signs of recurrence
  • Assessment for any incontinence 1

Common Pitfalls to Avoid

1. Failing to adequately identify and address all fistula tracts before definitive treatment
2. Attempting fistulotomy in complex fistulas, risking sphincter damage
3. Using glue as primary treatment for complex fistulas despite poor success rates
4. Not considering temporary seton placement if active inflammation is present

The LIFT procedure represents the optimal balance between efficacy and sphincter preservation for this patient with a complex perianal fistula extending to the levator ani with no external opening.