Can a LIFT (ligation of intersphincteric fistula tract) for a low transphincteric anal fistula in an adult with normal continence and no Crohn’s disease fail or recur years after the original operation?

Can LIFT Surgery Fail Years After the Initial Operation?

Yes, LIFT procedures can and do fail years after the original operation, though most failures occur within the first 4–8 months; late recurrences beyond one year are documented but less common, and the overall recurrence risk is 18–27% with adequate long-term follow-up. 1

Understanding the Timeline of LIFT Failure

The failure pattern of LIFT is not confined to the immediate postoperative period:

• Early failures (within 4 months) account for the majority of recurrences, with a median time to failure of approximately 4 months when it occurs 1, 2
• Late recurrences can appear years after surgery, particularly in patients with complex anatomy or ongoing subclinical inflammation 1
• The British Society of Gastroenterology emphasizes that failure after LIFT is often progressive over time, not limited to immediate postoperative periods 1

True Recurrence Rates: The Reality Behind the Numbers

Early optimistic reports significantly underestimated the true failure burden:

• Initial meta-analyses quoted recurrence rates as low as 1.6%, but this reflected under-reporting due to heterogeneous follow-up periods and variable definitions of success 1
• Contemporary series with adequate follow-up demonstrate recurrence rates of 18–27% 1
• A prospective cohort with proper surveillance documented a 21% recurrence rate, revealing the true long-term burden 1
• In your specific scenario (low transphincteric fistula, no Crohn's disease, normal continence), you fall into the "simple fistula" category with better outcomes than complex cases, but recurrence risk still exists 1

Patient-Specific Risk Factors That Predict Late Failure

Certain factors increase the hazard of recurrence throughout the entire follow-up period:

• Active smoking at the time of LIFT increases failure risk by approximately 3.2-fold, and this elevated risk persists long-term 1, 3
• Active proctitis doubles the hazard of recurrence (HR ≈ 2.0) and may lead to late breakdown of an initially healed tract 1, 3
• Complex fistulas (branching or multiple tracts) achieve only 50–53% primary healing compared to about 80% in simple fistulas 1, 4

Factors that do not significantly worsen outcomes:

• Prior seton drainage does not increase recurrence risk 1
• Previous repair attempts do not significantly worsen postoperative outcomes 1
• Use of biologic therapy does not negatively impact LIFT success rates 1

Surveillance Strategy to Detect Late Failures

Clinical surveillance must extend well beyond the early postoperative period:

Time Point	Assessment Focus	Clinical Rationale
Week 1–2	Signs of infection	Early detection of postoperative sepsis [1]
Week 4	External opening healing	Verify tract closure [1]
Week 8	Continued healing progress	Ensure trajectory toward complete closure [1]
Month 4–6	Actively screen for early recurrence	Most failures occur in this window [1]
Beyond 6 months	Ongoing surveillance for late recurrences	Capture late failures that may arise years later [1]

• Surveillance should continue beyond six months to detect late failures, especially in patients with complex anatomy or ongoing inflammation 1
• When clinical uncertainty exists regarding tract obliteration—particularly in complex fistulas—MRI is recommended; a fibrotic (non-enhancing) tract on MRI predicts no need for further interventions during long-term follow-up 1

Anatomy of Recurrence: What Actually Fails

Understanding the pattern of failure helps guide management:

• Early failures typically present with discharge at the intersphincteric wound, with either an unhealed internal opening or isolated failure at the intersphincteric wound 2
• Late recurrences demonstrate a tract from the previous internal opening to an external opening, with healing of the intersphincteric wound initially achieved 2
• The median time to recurrence in documented late failures was 22 weeks (range 15–33 weeks) from the LIFT procedure 2

Management of Failed LIFT

When recurrence occurs, approach with caution:

• Gentle examination is essential; aggressive probing of a failed LIFT can convert a manageable recurrence into a more complex fistula 1
• Endoanal ultrasonography or MRI should be performed to characterize the anatomy of the recurrent tract 2, 5
• Treatment options for recurrence include fistulotomy (if anatomy permits without compromising continence), repeat LIFT, advancement flap, or long-term seton with medical therapy 2, 6
• Following failed LIFT, approximately 50% of patients who undergo subsequent surgery achieve resolution 6

Critical Pitfalls to Avoid

• Declaring success prematurely: Clinical healing at 2–3 months does not guarantee long-term success; continue surveillance 1
• Inadequate patient counseling: Patients must understand that recurrence can occur years later, not just in the immediate postoperative period 1
• Failure to address modifiable risk factors: Smoking cessation counseling is mandatory, as smoking triples failure risk throughout follow-up 1, 3
• Underestimating the progressive nature of failure: The British Society of Gastroenterology emphasizes that failure is often progressive, requiring ongoing vigilance 1