Can a Failed LIFT Procedure Result in a Complex Fistula?
A failed LIFT procedure does not typically create a more complex fistula than what existed preoperatively; in fact, 75% of recurrent fistulas after failed LIFT remain transsphincteric (the same complexity), while 25% actually downgrade to simpler intersphincteric tracts that are more amenable to definitive treatment like fistulotomy. 1
What Happens After LIFT Failure
Pattern of Recurrence
- When LIFT fails, the fistula tract recurs in a predictable pattern: 75% remain transsphincteric (same complexity as original) and 25% become intersphincteric (actually simpler) 1
- The median time to failure is approximately 3-4 months when it occurs 2, 1
- Recurrence rates range from 12-23% in most series, with one study showing 37.7% failure rate 2, 3, 1
Factors That Predict LIFT Failure
- Multiple or branching fistula tracts are significantly associated with failure (p < 0.001) 3
- Anterior fistulas have significantly worse outcomes (47% success) compared to non-anterior locations (84% success; p = 0.03) 4
- Fistula tract size >5mm increases failure risk 2
- Failure to ligate the tract in one attempt during surgery predicts recurrence 2
- Active proctitis trends toward increased failure (HR 2.0) 5
- Smoking at time of surgery significantly increases failure (HR 3.2) 5
Management After Failed LIFT
Treatment Algorithm for Persistent Fistula
- For recurrent transsphincteric fistulas (75% of failures): Place a seton for drainage, followed by either advancement flap (20% of cases) or fistulotomy if the tract has been downstaged (50% of cases) 1
- For recurrent intersphincteric fistulas (25% of failures): Place seton followed by fistulotomy (50%) or advancement flap (50%), as these simpler tracts are more amenable to definitive treatment 1
- Secondary success rate after managing LIFT failures reaches 88% with appropriate salvage procedures 4
- Overall healing rate after salvage surgery for failed LIFT is 50%, with 31.7% still undergoing treatment 1
Special Considerations for Your Patient
Incontinence and Hygiene Concerns
- LIFT failure does not worsen incontinence—in fact, 53% of LIFT patients experience improvement in fecal continence postoperatively 5
- Post-LIFT manometry shows only 9% reduction in resting pressure and 11% reduction in squeeze pressure (not statistically significant) with no clinical incontinence 4
- Incontinence rates after LIFT are dramatically lower (1.6%) compared to advancement flaps (7.8%) 5
Critical Pitfall to Avoid
- Do not perform aggressive probing during examination of a failed LIFT, as this creates iatrogenic complexity that was not present before 6, 7
- The European Society of Coloproctology warns that aggressive probing can convert a manageable recurrence into a truly complex fistula 7
Hygiene Maintenance Strategy
- If your patient cannot maintain adequate perineal hygiene, consider long-term loose seton placement combined with medical therapy as an alternative to repeat definitive surgery 6
- The American Gastroenterological Association recommends considering temporary fecal diversion in patients with uncontrollable diarrhea or severe limitations preventing adequate hygiene 6
Bottom Line for Clinical Practice
The evidence strongly suggests that failed LIFT does not create complexity—it reveals the underlying anatomy. Most recurrences (75%) remain at the same complexity level, and a quarter actually simplify 1. Your patient's existing incontinence and hygiene difficulties are not contraindications to LIFT, but they do require careful postoperative monitoring and possibly long-term seton drainage rather than repeated attempts at definitive closure 6.