LAUSR

Ligation of the intersphincteric fistula tract (LIFT) is one of many methods for treating transsphincteric anal fistulas. During this procedure, the fistula tract is dissected and ligated in the intersphincteric space, to close its lumen and prevent the fistula from recurring. The main advantage of this procedure over classic fistulectomy or fistulotomy operations is that both internal and external sphincters are left intact [1] and the risk of fecal incontinence after the operation is minimal. However, as in most techniques used to treat perianal fistulas, results vary depending on the complexity of the fistula. Due to this variability, many surgeons develop modifications of this technique, to achieve better results [2]. Video-assisted anal fistula treatment (VAAFT) was supposed to provide minimally invasive treatment by cauterization of the fistula tract from inside, under direct vision by means of a rigid small-caliber fistuloscope [3]. The early results in the literature were promising; however, later studies gave mixed results and we were not able to reproduce completely satisfactory results [4]. As most authors emphasize that the results of this endoscopic treatment depend on the method of internal opening closure during VAAFT (stapler, suture, advancement flap) [5], tight ligation of the fistula tract right after the internal opening (exactly as in the LIFT procedure), might give better results, than other methods of closure. According to some researchers, recurrences after the LIFT procedure may be caused by omitted side branches, or by improper fistula tract identification in the intersphincteric space, thus leading to recurrence in form of a persistent transphincteric tract, downstaging to a intersphincteric fistula, or as a residual external tract [6]. A hypothesis arose, that the diagnostic value of fistuloscopy may improve the results of the LIFT procedure. As our unit is experienced in both the LIFT technique, and the VAAFT procedure, we designed a pilot feasibility study in 2014 to combine both methods, LIFT and VAAFT, in an attempt achieve better results than in VAAFT alone, and to potentially increase the healing rates of the standard LIFT procedure, especially in patients with complex perianal fistulas.