Ligation of Intersphincteric Fistula Tract Technique (LIFT) as a Management of Transsphincteric Anal Fistula

Abstract

Perianal fistula is a disease of antiquity. Even with all that work and research, started 2500 years ago, or may be more, man didn’t find “the” treatment for perianal fistulas. A lot of work is still required in a trial to reach that treatment. It’s basically a pathological tract joining a part of rectum or anal canal to the skin. In 90% of the cases it is cryptoglandular in origin following a perianal or ischiorectal abscess. But it may be presented as a perianal fistula from the start. This may happen due to spread of infection from one of the anal glands. In 10% of the cases the perianal fistula is secondary to other diseases or conditions, e.g. Corhon’s disease, AIDS, trauma, etc…. The anatomy of the region add special difficulties when planning to treat the patient, as the anal mucosa is surrounded by sphincters to achieve good continence to air, fluids and stools. The inner most is the involuntary internal sphincter, which is surrounded by the voluntary external sphincter. The fistula is classified in relation to those sphincters. The most popular classification, although it is not the best is for Parks. He classifies fistula into 4 groups: inersphincteric, trassphincteric, suprasphinctric and extrasphincteric. Although not popular, Abdel Kawy’s classification seems to be more useful. He divided fistulas into 2 main groups each has 3 subdivisions, which make the total types 6: The cryptoglandular type which is sub-divided into (intersphincteric, trans-sphincteric and suprasphincteric types), The Non-cryptoglandular anal fistulas including (low, high and extrasphincteric types). The perianal fistula is diagnosed clinically by good history and good examination including digital rectal examination, investigations may add nothing after good examination. But for the minority of cases, and for fear of complications like incontinence after surgery, especially in this era of medicoligality, investigations are sometimes required. Fistulography shouldn’t be done any more except in suspected traumatic fistula. Endoanal ultra-sonography is a very good tool to delineate the fistula and the sphincter, although it’s operator dependant. MRI is now the gold standard for the diagnosis and pre-operative classification of perianal fistula, whither it is done with a surface coil or endoanal coil. Examination under anesthesia is a good investigatory tool especially if it’s combined by endoanal ultra-sonography, moreover simple fistula can be treated in the same session. Other investigations like CT, anal manometry, Barium studies, etc… are done only in special situations. Medical treatment is of no use, except if patient can’t do surgery or refusing surgery for fear of incontinence or for those complicated cases in whom surgery will add nothing except complications, or during the preparation for surgery Surgical treatment can essentially divided into 2 main groups. The sphincter conserving surgeries and the sphincter sacrificing surgeries with or without immediate repair.