Ligation of the Intersphincteric Fistula Tract and Endorectal Advancement Flap for High Perianal Fistulas in Crohn’s Disease: A Retrospective Cohort Study

Abstract

<jats:title>Abstract</jats:title> <jats:sec> <jats:title>Background and Aims</jats:title> <jats:p>Ligation of the intersphincteric fistula tract [LIFT] and advancement flap [AF] procedures are well-established, sphincter-preserving procedures for closure of high perianal fistulas. As surgical fistula closure is not commonly offered in Crohn’s disease patients, long-term data are limited. This study aims to evaluate outcomes after LIFT and AF in Crohn’s high perianal fistulas.</jats:p> </jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>All consecutive Crohn’s disease patients ≥18 years old treated with LIFT or AF between January 2007 and February 2018 were included. The primary outcome was clinical healing and secondary outcomes included radiological healing, recurrence, postoperative incontinence and Vaizey Incontinence Score.</jats:p> </jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Forty procedures in 37 patients [LIFT: 19, AF: 21, 35.1% male] were included. A non-significant trend was seen towards higher clinical healing percentages after LIFT compared to AF [89.5% vs 60.0%; p = 0.065]. Overall radiological healing rates were lower for both approaches [LIFT 52.6% and AF 47.6%]. Recurrence rates were comparable: 21.1% and 19.0%, respectively. In AF a trend was seen towards higher clinical healing percentages when treated with anti-tumour necrosis factor/immunomodulators [75.0% vs 37.5%; p = 0.104]. Newly developed postoperative incontinence occurred in 15.8% after LIFT and 21.4% after AF. Interestingly, 47.4% of patients had a postoperatively improved Vaizey Score [LIFT: 52.9% and AF: 42.9%]. The mean Vaizey Score decreased from 6.8 [SD 4.8] preoperatively to 5.3 [SD 5.0] postoperatively [p = 0.067].</jats:p> </jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Both LIFT and AF resulted in satisfactory closure rates in Crohn’s high perianal fistulas. However, a discrepancy between clinical and radiological healing rates was found. Furthermore, almost half of the patients benefitted from surgical intervention with respect to continence.</jats:p> </jats:sec>

The LIFT procedure for a perianal Crohn's fistula – a video vignette

“…Studies suggest that it has comparable success rates to the more commonly used advancement flap [2]. Even in patients with Crohn's fistulas, promising results concerning clinical and radiological healing as well as low rates of incontinence have been reported [3]. The video (Video S1 in the online Supporting Information) starts with MRI images of a patient with a transsphincteric fistula for which he has had seton drainage for the last 5 months to create an epithelialized tract to prevent (recurrent) abscess formation [4].…”

“…In a cadaveric model, Pauli et al [2] described a novel method of open PH repair utilizing retromuscular dissection, posterior component separation via transversus abdominis release (TAR) and lateralization of the bowel utilizing a modified Sugarbaker mesh configuration within the retromuscular space. Belyansky et al [3] applied a robotic technique for PH in an effort to reduce wound morbidity and length of hospitalization, while still providing a secure and durable repair. In this educational video, we describe a robotic retromuscular PH repair with TAR, along with lateralization of the stoma conduit (the modified Sugarbaker technique).…”

Magnetic resonance imaging after ligation of the intersphincteric fistula tract for high perianal fistulas in Crohn's disease: a retrospective cohort study

“…We performed a sub‐study of a previously performed retrospective cohort study conducted at the Amsterdam University Medical Centres [10]. That study included all consecutive Crohn's patients treated for high perianal fistulas with LIFT or AF between January 2007 and February 2018.…”

“…So far, there are limited data on the behaviour and structural assessment of perianal fistulas after the LIFT procedure. The clinical and radiological healing, recurrence and incontinence rates of Crohn's patients undergoing LIFT and AF were evaluated in a retrospective study [10]. This study demonstrated MRI healing in 53% of LIFT procedures; however, no standardized assessment of radiological healing was used.…”

Modern surgical strategies for perianal Crohn's disease

“…Healing of the excluded fistula pathway is expected over time. In the absence of proctitis or stenosis, this is a good therapeutic option with the advantage of avoiding extensive or difficult-to-heal wounds and a success rate of approximately 50%[ 10 , 19 ] (Table 2 )[ 20 - 25 ].…”