Gopi Krishna Mishra¹, Sachin Prabhakar Naik², Ajit Genuji Jadhav^3*

¹Senior Resident, Department of Surgical Oncology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

²Professor & Head of Department, ³Assistant Professor, Department of General Surgery, MIMER Medical College, Talegaon Dabhade Maval Pune 410507, INDIA.

Email: gopikrishnamishra8@gmail.com, Sachinnaik70@gmail.com, drajit7766@gmail.com

INTRODUCTION

“All is well that ends well” is a sartorical humour aptly metaphorised by Shakesphere in one of his plays, referring to fistula in ano. The condition fraught with anxiety and frustration with lack of adequate treatment at that time.¹ This vexing situation has prevailed and perplexed man since ages. Fistula in ano is a hollow tract lined with granulation tissue connecting a primary opening inside anal canal to a secondary opening in perianal skin. It is usually caused by previous anorectal abscess but can also develop secondary to Crohn’s disease, anal fissures, anorectal carcinoma, radiation therapy, tuberculosis, actinomycosis, chlamydial infections and trauma.² Symptoms comprise of intermittent perianal discharge, pain and fever if associated with abscess and pruritus ani with a chronic history of resolution and recurrence.² Peri-anal abscess and fistula-in-ano disease are relatively common conditions, having high recurrence rate after seemingly adequate surgery. The search is always on for ideal method to surgically treat fistula-in-ano while preventing recurrence and incontinence.³ Fistulotomy is the procedure of choice for simple low fistulas, where the tract is submucosal, inter-sphincteric or located in the lower third of the external anal sphincter. A fistulotomy lays open the fistulous tract, which usually involves a large wound taking long time to heal and causes more morbidity. A variable part of sphincter can also be damaged depending on the level of the tract. Although it has an acceptable healing rate it may result in a large open wound and Or incontinence^.2 Rojanasakul A et al. developed the technique of LIFT as a method for treatment of fistula-in-ano through intersphincteric approach.⁴ It is based on the principle that removal of the intersphincteric part of the tract removes the cryptoglandular tissue and thus the source of infection. Ligating the tract at the internal opening effectively closes the communication. As it avoids injury to the sphincter and the wound is smaller the morbidity is less.⁴ Studies comparing LIFT and fistulotomy have shown that LIFT may be used effectively for anal fistula, however, the anal fistulae in those studies were not exclusively trans-sphincteric.^5,6 This study was planned with the aim to assess if indeed LIFT offers any advantage over standard fistulotomy when treating trans-sphincteric fistula-in-ano.

AIM AND OBJECTIVES

To compare outcomes between Ligation of Intersphincteric Fistula Tract (LIFT) and conventional fistulotomy for treatment of low trans-sphincteric fistula in ano in terms of: Operative time, Hospital stay, Duration of follow up, Healing time, Post-operative anal incontinence, Recurrence rate (till six months).

MATERIAL AND METHODS

Study Area and design

Randomised control study done in 50 patients of low transsphincteric fistula in a tertiary care hospital.

Sample Size Calculation

Consecutive type of non-probability sampling was used for the selection of the study subjects. A total of 50 cases were randomly divided into two group of 25 each: Group A: LIFT technique; Group B: Conventional Fistulotomy

Inclusion Criteria: Age more than 18 years. Patients with Low trans-sphincteric Fistula in Ano. Patients without cognitive impairment or Mental Retardation.

Exclusion Criteria: Recurrent Fistula, High Fistula in Ano, Multiple Fistula in Ano, Immuno Compromised, Severe Hepatic or Renal illness, Neurotic or psychiatric disease.

 Methodology

A total of 50 patients scheduled for surgery for Fistula in Ano were enrolled. MR Fistulogram was done to confirm the Low fistula. With due pre-anaesthetic care patient was planned and posted for surgery. Patients were randomly divided into two groups (25 each) using computer generated random numbers. Group A patients were posted for Ligation of the intersphincteric fistula tract (LIFT) while Group B patients were posted for Conventional Fistulotomy.

Comparison Parameters: Operative time, Post-operative hospital stay, Healing time, Post-operative anal incontinence, Recurrence upto 6 months, Complications.

Statistical Analysis

The quantitative data was represented as their mean ± SD. Categorical and nominal data was expressed in percentage. The t-test was used for analysing quantitative data, non parametric data was analyzed by Mann Whitney test and categorical data was analyzed by chi-square test. Significance threshold of p-value was set at <0.05. All analysis was carried out by using SPSS software version 21.

OBSERVATION AND RESULTS

Age: Mean age of study group was 43.75 years with no difference between the two treatment groups  (P-0.44).

1. Gender: Male preponderance was seen with 90% males to 10% females with no difference between groups with respect to gender distribution (p-1.0).

Figure 1: Mean duration of symptoms (month)

1. Presentation: Commonest presenting complaint was discharge (94%), swelling (86%) and pain (68%) in both groups. No difference was observed between groups with respect to complaints (p>0.05).
2. Duration: Mean duration of symptoms was 7.2 months with no difference between groups with respect to duration (p-0.71).
3. Operative time: Mean duration of operation was significantly less in cases operated with LIFT technique as compared to fistulotomy (31.98 vs 40.32 mins; p<0.05).
4. Hospital stay, post-operative pain and analgesic requirements: Mean hospital stay (1.69 vs 2.91 days; p<0.05), post-operative pain (VAS – 2.91 vs 4.41; p<0.05) and need for analgesics (2.86 vs 4.67 days; p-0.11) was significantly less in cases operated with LIFT.

Table 1

Healing time: Mean time for complete healing was significantly less in cases operated with LIFT as compared to fistulotomy (5.66 vs 7.91 weeks; p<0.05).

1. Complications: Wound infection was reported in 1 (4%) and 2 (8%) cases operated by LIFT and fistulotomy respectively while anal incontinence was reported in 3 cases of fistulotomy as compared to none in LIFT.

Figure 2: Complications

Recurrence: At 6 months follow up, recurrence was reported in 3 (12%) and 1 (4%) Cases operated by LIFT and fistulotomy respectively.

DISCUSSION

The present study is aimed to compare outcomes between Ligation of Intersphincteric Fistula Tract (LIFT) and conventional fistulotomy for treatment of low trans-sphincteric fistula in ano. It includes 50 patients of low trans-sphincteric fistula in ano, randomly divided into two groups. LIFT technique was performed in group A (25 patients) while Conventional Fistulotomy was performed in Group B (25 patients).

Demography

Mean age of study group was 43.75 years with 90% males to 10% females with no difference between groups with respect to gender distribution (p>0.05). Nirmala AMS et al.¹ observed mean age as 39.8 years with 80% males to 20% females. Vinay G et al.² in a similar study observed the mean age as 44.6±8.34 and 41.3±9.71 years among fistulotomy and LIFT procedure groups respectively. The gender distribution showed 38 (76%) males compared to 12 females (24%). Gender distribution in study by Ayyar PV et al.³ was 51 men and 9 women with age ranging from 19 to 65 years. Dhanraj M et al.⁴ observed the male to female ratio as 4:1 in their study.

Clinical Presentation

Most common presenting complaint was discharge (94%), swelling (86%) and pain (68%) in both groups. Ayyar PV et al.³ observed commonest complaint as discharge (88.3%) followed by swelling (71.7%) and pain (35%). Dhanraj M et al.⁴ reported discharge from the external opening as the commonest symptom.

Operating Time

Mean duration of operation was significantly less in cases operated with LIFT as compared to fistulotomy (31.98 vs 40.32 mins; p<0.05). The shorter operative time is probably due to smaller incisions and precise surgical steps. Ayyar PV et al.³ observed significantly shorter operative time in LIFT cases as compared to fistulotomy (32.5 vs 40.17 mins; p<0.05). Rojanasakul A et al. ^[6] recorded a mean operating time of 40 minutes, while Ooi K et al., reported a median operating time of 39 minutes for LIFT.⁷

Hospital stay

Mean hospital stay (1.69 vs 2.91 days; p<0.05) was significantly less in cases operated with LIFT. Nirmala AMS et al.¹ observed minimum hospital stay in cases of LIFT while maximum stay was observed in cases of fistulotomy. Ayyar PV et al.³ also observed significantly lesser hospital stay in cases operated with LIFT technique. (1.64 vs 2.53 days; p<0.05). Dhanraj M et al. ^[4] observed mean hospital stay of 8.5 days for fistulotomy and 5 days for LIFT.

Post-op Pain

Mean post-op pain (VAS – 2.91 vs 4.41; p<0.05) and need for analgesics (2.86 vs 4.67 days; p-0.11) was significantly less in LIFT as compared to fistulotomy. Ayyar PV et al.³ also observed less postoperative pain in patients operated by LIFT (VAS – 4.41 vs 5.67; p<0.05). Similar results were observed by Nirmala AMS et al. ^[1] and Dhanraj M et al.⁴

Decreased postoperative pain noted after LIFT procedure would mean a decreased need for pain medication and more patient comfort.

Healing/ Recovery

Mean time for complete healing was significantly less in cases operated with LIFT as compared to fistulotomy (5.66 vs 7.91 weeks; p<0.05). Smaller wound in the LIFT leads to faster healing and lesser morbidity. Vinay G et al.² observed average healing time for fistulotomy was 8 weeks compared to 3 weeks for LIFT. Ayyar PV et al.³ also observed significantly shorter healing time in cases with LIFT as compared to fistulotomy (5.64 vs 6.89 weeks; p<0.05). Rojanasakul A et al.⁶ reported a success rate of 94.4% with mean healing time of four weeks.

Complications

Wound infection was reported in 1 (4%) and 2 (8%) cases operated by LIFT and fistulotomy respectively while anal incontinence was reported in 3 cases of fistulotomy and none in LIFT group. Nirmala AMS et al.¹ observed anal incontinence in 4 (13.3%) cases of fistulotomy as compared to none in LIFT group. Fever and wound infections were reported in 4 (13.3%) and 1 (3.3%) cases respectively. Vinay G et al.² reported wound infection in 1 (4%) and 2 (8%) cases operated by LIFT and fistulotomy respectively while anal incontinence was reported in 1 case of fistulotomy as compared to none in LIFT. Ayyar PV et al.³ observed anal incontinence in 3 (10%) cases of fistulotomy and none in LIFT. Our results also co-relates well with results in study done by Yardimci E et al.⁸ and Sakda A. et al.

Recurrence

At 6 months follow up, recurrence was reported in 3 (12%) and 1 (4%) cases operated by LIFT and fistulotomy respectively. Nirmala AMS et al.¹ observed recurrence in 4 (13.3%) cases of fistulotomy as compared to 6 (20%) in LIFT. Vinay G et al.² reported recurrence in 3 (12%) and 0 (0%) cases operated by LIFT and fistulotomy. Ayyar PV et al.³ observed recurrence in 3 (10%) cases of fistulotomy as compared to 5 (16.7%) cases in LIFT group. Our recurrence rate also co-relates well with results in study done by Sakda A et al.⁹ Factors associated with recurrence have been identified as complex fistula, horseshoe extension, lack of identification or lateral location of the internal fistulous opening and previous fistula surgery.¹⁰ Though LIFT seemingly has higher recurrence rate, it does not bar further procedures to treat the fistula. As Bleier JI and Moloo H, put it ‘An important point regarding the use of

LIFT is that it appears to burn no bridges’; even if it does not work, other approaches can still be used.¹¹ Studies have shown LIFT to be effective and safe procedure with low incidence of incontinence and faster healing time. In the LIFT cases done by us, the intersphincteric incision was kept open instead of primary closure due to high incidence of breakdown in primarily closed perianal wounds. Yet complete healing was observed. At times, friable fistula tract disrupted during dissection prior to ligation, making identification of the tract difficult due to retraction of the ends. In such cases, tissue in the intersphincteric region representing cryptoglandular tissue was scooped or excised along with the scooping of the distal tract.

SUMMARY

A hospital randomized control study was conducted in tertiary care Hospital, aimed to compare outcomes between the Ligation of Intersphincteric Fistula Tract (LIFT) technique and conventional fistulotomy for the treatment of low trans-sphincteric fistula in ano. It included 50 patients of low trans-sphincteric fistula in ano and was randomly divided into two groups of 25 each:

Group A: LIFT technique and

Group B: Conventional Fistulotomy.

Mean age was 43.75 years with no difference between the two treatment groups (p-0.44).

1. Overall male preponderance was observed with 90% males to 10% females.
2. Common presenting complaint was discharge (94%), swelling (86%) and pain (68%) in both groups.
3. Mean duration of symptoms was 7.2 months with no difference between study groups (p-0.71).
4. Mean duration of operation was significantly less in cases operated with LIFT as compared to fistulotomy (31.98 vs 40.32 mins; p<0.05).
5. Mean hospital stay (1.69 vs 2.91 days; p<0.05), post-op pain (VAS – 2.91 vs 4.41; p<0.05) and need for analgesics (2.86 vs 4.67 days; p-0.11) was significantly less in cases operated with LIFT as compared to fistulotomy.
6. Mean time for complete healing was significantly less in cases operated with LIFT as compared to fistulotomy (5.66 vs 7.91 weeks; p<0.05).
7. Wound infection was reported in 1 (4%) and 2 (8%) cases operated by LIFT and fistulotomy respectively while anal incontinence was reported in 3 cases of fistulotomy as compared to none in LIFT group.
8. At 6 months follow up, recurrence was reported in 3 (12%) and 1 (4%) cases operated by LIFT and fistulotomy respectively

CONCLUSION

Ligation of Intersphincteric Fistula Tract (LIFT) procedure is effective and preferred sphincter saving technique for fistula-in-ano. Despite slightly more recurrence, LIFT has certain advantages over standard fistulotomy like shorter operative time, less postoperative pain, shorter hospital stay, faster wound healing and early resumption of duties.

REFERENCES

1. Cosman BC. All's Well That Ends Well: Shakespeare's treatment of anal fistula. Dis Colon Rectum. 1998 Jul;41(7):914-24.
2. Abcarian H. Anorectal infection: abscess–fistula. Clinics in Colon and Rectal Surgery. 2011;24(1):014-21
3. Abcarian H. Anorectal infection: abscess-fistula. Clin Colon Rectal Surg, 2011;24:14-21.
4. Rojanasakul A, Pattanaarun J, Sahakitrungruang C, Tantiphlachiva K. Total anal sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract. J Med Assoc Thai. 2007;90(3):581-86.
5. Alapach S, Khaimook A. Comparison between Ligation of Intersphincteric Fistula Tract (LIFT) technique and conventional fistulotomy in the treatment of fistula-in-ano at Hat Yai regional hospital. Thai Journal of Surgery. 2014;35(1):20-23.
6. Vinay G, Balasubrahmanya KS. Comparative study on efficacy of fistulotomy and lift procedure in management of fistula-in-ano. International Surgery Journal. 2017;4(10):3406-08.
7. PD Srivastava, MP Sahu."Efficacy of Kshar Sutra (medicated seton) therapy in the management of Fistula-in-Ano." World Journal of Colorectal Surgery 2.1 (2010): 6.
8. H.M.Veerendra Kumar."A Clinico-Pathological study of Fistula in ANO." (2010).
9. Ratcliffe, John. "CORNELIUS CELSUS AND THE TREATMENT OF FISTULA IN ANO A Surprise and a conundrum."
10. Steichen, Felicien M. "Improving craft through science in health care." Surgical Laparoscopy Endoscopy and Percutaneous Techniques 10.1 (2000): 48-53.
11. McCourtney, J. S., and I. G. Finlay. "Setons in the surgical management of fistula in ano." British journal of surgery 82.4 (2005): 448-452.
12. Deeba, Samer, et al. "Fistula-in-ano: advances in treatment." The American Journal of Surgery 196.1 (2008): 95-99.
13. Wikipedia contributors. "Louis XIV of France." Wikipedia, The Free Encyclopedia. Wikipedia, The Free Encyclopedia, 2 Nov. 2012. Web. 5 Nov. 2012.
14. Percivall Pott, James Earles (Sir.) “The chirurgical works of Percival Pott”,Vol 1,(1808) :39.
15. Patriotic and People-oriented Science and Technology Foundation,Indian Institute of Technology,Bombay.‘Congress on Traditional Sciences and Technologies of India, Indian Institute of Technology, Bombay: keynote papers and extended abstracts’, 28 Nov.-3 Dec. 1993, Volume 2.