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 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. 1

Clinical Presentation Analysis

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 levator ani level
• No external opening

These findings are consistent with a complex transsphincteric fistula extending to the levator ani muscle.

Treatment Options Evaluation

LIFT Procedure (Option D)

• Strongest recommendation based on ECCO guidelines for complex perianal fistulas, particularly those with no external opening or 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
• Specifically suited for transsphincteric fistulas extending to the levator ani muscle 1

Seton Placement (Option A)

• Primarily used before definitive treatment rather than as a final solution 1
• Useful for drainage and inflammation control but not optimal for definitive management of complex fistulas with no external opening 1
• Would be appropriate as an initial step if active inflammation or abscess is present, but not as definitive treatment

Lay Open from Inside (Option B)

• Not recommended for complex fistulas extending to the levator ani due to high risk of sphincter damage and subsequent incontinence
• Would involve cutting significant portion of the sphincter, compromising continence

Sealing by Glue (Option C)

• Poor and variable healing rates (14-74%) 3
• High failure rates make this less suitable for complex fistulas extending to the levator ani

Management Algorithm

1. Preoperative Assessment

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

2. Initial Management

   • Rule out and drain any associated abscess 1
   • Consider temporary seton placement if active inflammation is present 1

3. Definitive Treatment

   • LIFT procedure as the primary treatment option 1, 2
   • The procedure involves:
     • Identification of the fistula tract
     • Ligation and division of the tract in the intersphincteric space
     • Removal of infected tissue

4. Postoperative Care

   • Regular monitoring for healing and recurrence 1
   • Assessment for any signs of incontinence 1
   • Consider additional imaging if symptoms persist or recur 1

Important Considerations and Caveats

• Success rates may be lower if there is active inflammation or abscess formation 1
• Recurrence is possible and may require additional procedures 1
• The absence of an external opening makes this a particularly challenging case, further supporting LIFT as the optimal approach 1
• Newer techniques like FiLaC (Fistula Laser Closure) and VAAFT (Video-Assisted Anal Fistula Treatment) show promise but have less established evidence compared to LIFT for this specific presentation 4, 5

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