Can LIFT (Ligation of Intersphincteric Fistula Tract) procedures fail years later in older adult patients with low transphincteric fistulas?

Can LIFT Procedures Fail Years Later?

Yes, LIFT procedures can and do fail years later, with progressive failure over time related to both treatment failure and recurrent disease, particularly in patients with complex fistulas or ongoing inflammatory activity. 1

Understanding the Timeline and Pattern of LIFT Failure

The British Society of Gastroenterology explicitly acknowledges that there is progressive failure over time with LIFT procedures, not just immediate failures. 1 This is a critical distinction that affects long-term patient counseling and follow-up planning.

When Failures Typically Occur

• Early failures occur at a median of 4 months when they happen, but this represents only part of the story. 2
• Late recurrences are increasingly recognized, with one prospective series revealing a 21% recurrence rate with adequate long-term follow-up, suggesting that initial optimistic reports of only 1.6% recurrence likely represent underreporting due to heterogeneous and insufficient follow-up periods. 2
• The true burden of late failure is higher than historically reported because many studies declare success based on short-term clinical healing without long-term radiological confirmation of tract obliteration. 2

Why LIFT Procedures Fail Over Time

Disease-Related Factors

• Ongoing inflammatory bowel disease activity, particularly in Crohn's disease patients, prevents tract healing and drives recurrence even years after initial apparent success. 2
• Active proctitis doubles the failure risk (HR 2.0) and can cause late breakdown of initially healed tracts. 2, 3
• The British Society of Gastroenterology emphasizes that outcomes deteriorate over time particularly in those with complex disease and ongoing disease activity. 2

Patient-Specific Risk Factors

• Smoking significantly increases failure risk (HR 3.2), and this risk persists throughout the follow-up period. 2, 3
• Complex fistulas (branching tracts, multiple openings) show only 50-53% success rates compared to 80% in simple fistulas, with failures occurring both early and late. 2, 4
• Recurrent fistulas (those that have failed previous treatments) demonstrate particularly poor outcomes with only 33% success rates and higher rates of late failure. 4

The Reality of Long-Term Outcomes

The British Society of Gastroenterology provides a sobering assessment in their Good Practice Recommendation 12: Surgical options for perianal Crohn's disease fistulae (including LIFT) should only be offered in selected patients after counseling as long-term results are poor, particularly for those with complex disease and ongoing disease activity. 1

Success Rates by Population

• Simple transsphincteric fistulas: 69-77% success in general populations, 80-82% in selected series. 2, 5
• Complex fistulas: Only 50-53% success rates. 2, 4
• Crohn's disease patients: 53-67% success, comparable to advancement flaps but with better continence profiles. 2
• Recurrent fistulas: Only 33% success with higher late failure rates. 4

What Happens When LIFT Fails

Anatomical Changes After Failure

• Failed LIFT can convert a transsphincteric fistula into either a persistent transsphincteric fistula (75% of failures) or an intersphincteric fistula (25% of failures). 6
• The European Society of Coloproctology warns that aggressive probing during examination of a failed LIFT can convert a manageable recurrence into a complex fistula. 3

Management Options After Failure

• Seton placement is the most common initial management (71.4% of cases), allowing for drainage and potential subsequent definitive repair. 6
• Fistulotomy can be performed in 50% of cases, particularly when the tract has been converted to intersphincteric. 6
• Advancement flap is attempted in 20-50% of failed cases. 6
• Long-term loose seton combined with medical therapy may be the most realistic option for patients who cannot maintain adequate hygiene or have ongoing disease activity. 3
• Overall, only 50% of patients who undergo surgery after failed LIFT achieve resolution, with 31.7% still undergoing treatment. 6

Critical Factors That Predict Late Failure

Inadequate Initial Assessment

• Failure to identify and treat active proctitis before attempting closure predicts late breakdown. 2
• Inadequate medical optimization in Crohn's disease patients leads to progressive failure. 2
• Smoking cessation counseling is essential, as continued smoking increases failure risk throughout follow-up. 2, 3

Incomplete Tract Obliteration

• MRI evidence of fibrotic tract post-LIFT predicts no reinterventions during long-term follow-up, while persistent fluid signal suggests eventual failure. 2
• Declaring success based on clinical healing alone without radiological confirmation underestimates true recurrence rates. 2

Monitoring Strategy to Detect Late Failures

The Society of Surgeons of the Alimentary Tract recommends specific monitoring intervals: 2

• Week 1-2: Assess for signs of infection
• Week 4: Evaluate external opening healing
• Week 8: Confirm healing trajectory
• Month 4-6: Identify early recurrence
• Beyond 6 months: Consider MRI if any clinical uncertainty about tract obliteration, particularly in patients with complex fistulas or active Crohn's disease. 2

The Bottom Line for Older Adults with Low Transphincteric Fistulas

In older adult patients with limited life expectancy and low transphincteric fistulas, fistulotomy achieves near 100% healing with minimal recurrence risk, making it superior to LIFT when continence preservation is less critical than complete healing within a limited timeframe. 7 The standard concern about sphincter division becomes less relevant when quality of life prioritizes complete healing over decades of continence preservation. 7

LIFT should be reserved for carefully selected patients with simple, non-branching fistulas, no active proctitis, controlled inflammatory disease, and realistic expectations about the 21% long-term recurrence risk. 2 Failed LIFT procedures consume precious time and may require multiple subsequent interventions, with only 50% ultimately achieving resolution. 6