eP466 - Modified "Pull Through" LIFT Procedure: A New Technique

Purpose/Background: Ligation of the intersphincteric fistula tract (LIFT) was first described by Rojanasakul et al in 2007 for treatment of transsphincteric and intersphincteric anal fistulas. During the procedure, an incision is made in the intersphincteric groove and dissection is carried through the intersphincteric plane where the intersphincteric portion of the tract is ligated and excised. LIFT has better success rates than other sphincter preserving techniques and rarely causes continence problems. However, many patients fail due to persistent intersphincteric fistulas. The modified LIFT: high ligation of the fistula track by lateral approach was first described by Chen et al in 2012. The procedure avoids creating an intersphincteric incision by coring out the fistula tract from the external opening towards the internal opening. The intersphincteric portion of the tract is ligated close to the internal opening. Initial studies showed encouraging results. Here, we describe a new modified LIFT procedure with “pull through” technique.Methods/Interventions: This is a case report of a healthy 29yo female with multiple episodes of perianal abscesses in the past 6 months, who was found to have a left anterior transsphincteric anal fistula. We performed the modified “pull through” LIFT procedure with patient in prone jackknife position under general anesthesia. The internal opening was identified with the probe introduced through the external opening. Due to the length of the anal fistula tract, an incision was made in the perianal skin and the dissection was started midway of the fistula tract, just distal to the external sphincter muscles. Meticulous dissection was performed circumferentially of the fistula tract and care was taken to avoid injuries to the sphincter muscles. The fistula tract was transected distally at the external anal sphincter and tied with 0 silk. The entire fistula tract was then inverted, pulled through proximally through the internal opening and secured with 3-0 Monocryl figure of eight sutures at the internal opening. A counter incision was made in the rectal mucosa and the rest of the fistula tract was tunneled through. Interrupted 3-0 Monocryl was used to close the rectal mucosa. The distal end of the fistula tract was oversewn with 3-0 Monocryl. The intersphincteric plane and sphincter muscles were approximated with interrupted 3-0 Monocryl and the external opening on the perianal skin was left open.Results/Outcomes: The patient was seen in clinic for postoperative visit 2 weeks after surgery. She is recovering well without any signs of recurrence.Conclusion/

Discussion: Here, we describe a new modified “pull through” LIFT procedure where the intersphincteric fistula tract is inverted and pulled through the internal opening, rather than excised and ligated. We hypothesize the new technique can prevent persistent intersphincteric fistulas after modified LIFT procedure. We aim to enroll more patients with longer period of follow-up to evaluate the efficacy and durability of this technique.Modified "pull through" LIFT procedure