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LIFT technique

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LIFT technique is the novel modified approach through the intersphincteric plane for the treatment of fistula-in-ano, known as LIFT (ligation of inter sphincteric fistula tract) procedure. LIFT procedure is based on secure closure of the internal opening and removal of infected cryptoglandular tissue through the intersphincteric approach. Essential steps of the procedure include, incision at the intersphincteric groove, identification of the intersphincteric tract, ligation of intersphincteric tract close to the internal opening and removal of intersphincteric tract, scraping out all granulation tissue in the rest of the fistulous tract, and suturing of the defect at the external sphincter muscle. [1] The procedure was developed by Thai colorectal surgeon, Arun Rojanasakul of Chulalongkorn University in Bangkok, Thailand. The fist reports of preliminary healing result from the procedure were 94% in 2007 [2]

Question about the originally creator of LIFT Technique ?'
In 1993 Matos et al. described a technique of total anal sphincter preservation in high fistula in ano, which is based on the concept of excision of intersphincteric anal gland infection through the intersphincteric approach.[3] This novel technique was also documented in Corman’s textbook of colon and rectal surgery.[4] However, the technique was not widely adopted.[5]
Between 2004 and 2005 we had used an almost similar technique. The technique included coring out the intersphinteric fistula tract from the external opening to the external sphincter , excision of the intersphincteric fistula tract and suture of the internal sphincter defect through the intersphincteric plane. The outcome in 20 patients was disappointing with only 9 (45%) successes. The proposed reasons for the unfavorable outcome include dissection in the intersphincteric plane damaging blood supply to the internal opening area, and suturing delicate ischemic areas with increased risk of suture break-down. We thought that ligation of the intersphincteric tract close to the internal opening might solve the problem. This idea became the essence of our LIFT technique. Later experience supported this hypothesis. We noticed that during intersphincteric plane dissection if the internal sphincter was damaged and the anal mucosa breached, failure was common despite meticulous repair.[6]
The comment of Lunniss on the LIFT technique, “the technique described by Rojanasakul is, at first pioneered and reported by Robin Phillips…” may be misleading.[7] Surgeons beginning to use the LIFT technique may use the procedure described by Matos with unsatisfactory results. The differences between the Matos and the Rojanasakul technique are worth noting.[8]
At present, with the experience of more than 300 cases, we rarely encounter difficulty in dealing with the intersphincteric tract, even in complex fistula. We agree that the LIFT technique may cause some injury to internal sphincter, but theoretically LIFT causes less trauma of the internal sphincter than the other fistula operations. We are also aware of the poor levels of evidence in anal fistula surgery including the LIFT technique. We are preparing a report of long term outcome of the LIFT technique in our patients. If the long term results are positive, a randomized trial may be difficult.
In conclusion, we realized that Matos et al. reported the technique of excision of the whole fistula tract plus primary repair, with intersphincteric plane approach for excision of the fistula tract and suturing of the internal anal sphincter defect, in 1993[9]. However, Rojanasakul reported the ligation of intersphincteric fistula tract in 2007 with apparent satisfactory results probably due to secured closure of the internal opening.[10] This represents a significant change from the originally described technique with improved outcomes .[11]

== Surgical technique ==

  • Identify the internal opening
  • Incision at intersphincteric groove
  • Dissection through intersphincteric plane to find intersphincteric fistula tract
  • Secure suture ligation of intersphincteric fistula tract
  • Remove the fistula tract
  • Curette fistula tract from external opening
  • Suture closure of external sphincter muscle defect
  • Closure of intersphincteric wound


You can watch the VDO clip show step by step of LIFT procedure from the group of originator surgeon at VDO clip show step by step of LIFT technique from the originator

References

  1. ^ Rojanasakul A. LIFT procedure: a simplified technique for fistula-in-ano. Tech Coloproctol. 2009 Sep;13(3):237-40. Epub 2009 Jul 28
  2. ^ 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 Mar;90(3):581-6.
  3. ^ Matos D, Lunniss PJ, Phillips RKS (1993) Total sphincter conservation in high fistula in ano: results of a new approach. Br J Surg 80:802-804
  4. ^ Corman M L (2004) Anal Fistula. In: Colon and Rectal Surgery. 5th edn. Lippincott Williams & Wilkins, pp 316
  5. ^ Lunnis PJ (2009) Invited comment: LIFT procedure: a simplified technique for fistula in ano. Tech Coloproctol 13:241-242
  6. ^ Rojanasakul A, Pattana-arun J, Sahakitrungruang C, Tantiohlachiva K (2007) Total anal sphincter saving technique for fistula-in-ano: the ligation of intersphinteric fistula tract. J Med Asso Thai 90:581-586
  7. ^ Lunnis PJ (2009) Invited comment: LIFT procedure: a simplified technique for fistula in ano. Tech Coloproctol 13:241-242
  8. ^ Rojanasakul A, Pattana-arun J, Sahakitrungruang C, Tantiohlachiva K (2007) Total anal sphincter saving technique for fistula-in-ano: the ligation of intersphinteric fistula tract. J Med Asso Thai 90:581-586
  9. ^ Matos D, Lunniss PJ, Phillips RKS (1993) Total sphincter conservation in high fistula in ano: results of a new approach. Br J Surg 80:802-804
  10. ^ Rojanasakul A, Pattana-arun J, Sahakitrungruang C, Tantiohlachiva K (2007) Total anal sphincter saving technique for fistula-in-ano: the ligation of intersphinteric fistula tract. J Med Asso Thai 90:581-586
  11. ^ Rojanasakul A. Comments to the invited comment "LIFT procedure: a simplified technique for fistula in ano" by P. J. Lunniss. Tech Coloproctol. 2010 Mar;14(1):53-4.


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