Did a patient with a history of receptive anal sex and a low transsphincteric fistula make the wrong choice by opting for fistulotomy over LIFT (Ligation of Intersphincteric Fistula Tract) surgery?

Did the Patient Make the Wrong Choice?

Yes, the patient likely made the wrong choice by opting for fistulotomy over LIFT for a low transsphincteric fistula, particularly given their history of receptive anal sex, which makes any degree of incontinence functionally devastating for quality of life.

Critical Context: Why This Decision Matters

The key issue is that any transsphincteric fistula involves sphincter muscle, and dividing this muscle—even in the lower third—carries significant continence risks that are particularly problematic for this patient's sexual practices 1.

Incontinence Risk Profile

• Simple fistulotomy without reconstruction carries a 10-20% risk of continence disturbances 1
• The patient's engagement in receptive anal intercourse makes any degree of incontinence functionally devastating for quality of life 1
• Even division of the lower third of the external anal sphincter carries a non-insignificant risk of impaired continence, especially in patients with diminished anal sphincter function 2

What the Guidelines Actually Recommend

For Low Transsphincteric Fistulas

The most recent 2024 ECCO guidelines recommend LIFT as a treatment option for selected patients with complex perianal fistulae, with success rates of 77% in non-Crohn's patients and 53% in Crohn's disease patients 3. While the 2024 guidelines mention fistulotomy for "carefully selected CD patients with a simple fistula," they specifically classify this for simple fistulas (intersphincteric or superficial), not transsphincteric fistulas 3.

The Sphincter-Preserving Imperative

• For patients with any history that increases sphincter injury risk, a sphincter-preserving approach is strongly recommended to prevent catastrophic incontinence 1
• The assumption that "low" transsphincteric fistulas are safe to treat with fistulotomy is incorrect, as any transsphincteric fistula involves sphincter muscle and requires a sphincter-preserving approach in high-risk patients 1

LIFT vs. Fistulotomy: The Evidence

LIFT Outcomes

• Primary healing rates of 73-82% in prospective studies of low transsphincteric fistulas 2, 4
• 100% overall healing rate when accounting for conversion to intersphincteric fistulas that can then undergo safe fistulotomy 2
• No significant change in continence scores at 6 months post-operatively 2
• Zero risk of incontinence in multiple prospective series 4, 5
• Median healing time of 4-8 weeks 5, 6

Fistulotomy Outcomes

• 93-100% healing rates for simple low fistulas 5
• 10-20% continence disturbance rate 1
• Risk is not insignificant even for lower third external sphincter division, especially in patients with compromised sphincters 2

The Optimal Treatment Algorithm for This Patient

First-Line Approach: LIFT Procedure

1. LIFT should have been the primary choice given the transsphincteric nature and the patient's sexual practices 3, 1, 2
2. If LIFT fails (18-27% failure rate), the fistula often converts to an intersphincteric tract that can then undergo safe fistulotomy without dividing the external sphincter 2
3. This staged approach preserves continence while still achieving 100% eventual healing 2

Alternative Sphincter-Preserving Options

• Advancement flap: 61-66% success rate with sphincter preservation 3
• Loose non-cutting seton drainage: Can achieve fistula closure in 13.6-100% of cases and may be definitive treatment 1

Critical Pitfalls the Patient Fell Into

The "Low Fistula" Misconception

• The classification of "low" transsphincteric is misleading—it still involves the external sphincter 1, 2
• Guidelines recommend fistulotomy only for simple intersphincteric or subcutaneous fistulas, not transsphincteric fistulas 3

Failure to Consider Functional Impact

• Standard continence questionnaires may not capture the specific functional requirements for receptive anal intercourse 1
• Even minor continence changes (soiling, gas incontinence) can be devastating in this context 1

What Should Happen Now

If the fistulotomy has already been performed:

• Close monitoring for continence changes is essential, as these may manifest gradually 2
• Pelvic floor physical therapy may help optimize remaining sphincter function
• If continence issues develop, sphincter repair or augmentation may be considered, though outcomes are generally inferior to primary prevention

The Bottom Line

The patient made a suboptimal choice. The 2024 ECCO guidelines, combined with specialized guidance on high-risk populations, clearly favor sphincter-preserving approaches like LIFT for transsphincteric fistulas in patients where continence is critical 3, 1. While fistulotomy offers slightly higher healing rates (93-100% vs. 73-82%), the 10-20% risk of continence disturbance is unacceptable given this patient's functional needs 1, 5. LIFT would have provided an 82% primary healing rate with zero continence risk, and even in the 18% who fail, conversion to an intersphincteric fistula allows subsequent safe fistulotomy without external sphincter division 2.