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The ligation of the intersphinetric tract procedure of the perianal fistula: case report/Intrasfinktericno ligiranje perianalne fistule: prikaz slucaja.

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Perianal fistulae develop in 90% of the cases as a result of the anal gland inflammation (cryptoglandular theory). Other causes are Crohn's disease, tuberculosis, trauma, and post radiation effects [1]. According to Parks, 1976, they are classified as: intersphincteric (60-75%), transsphincteric, low and high level (15-20%), and suprasphincteric (5%) [2]. Extrasphincteric fistulae (1-3%) are not of cryptoglandular origin. Furthermore, fistulae can be simple and complex. It is believed that ligation of intersphincteric fistula tract (LIFT procedure) is the method of choice for some complex fistulae [3].

According to some sources, the method was first described in 2006, but the work of Matos and associates was mentioned as early as 1993 as the initial stage in introducing this method [4]. Nowadays the original work of the Thai surgeon Royanasakul has been accepted since he popularized this method in his works in 2007 [5] and 2009 [6]; it is still considered a novel method and its evaluation is under way. The purpose of this work is to demonstrate that the procedure can be performed with safety even in secondary hospital centers.

Case Report

A 60-year old male patient was admitted for a more detailed examination of the change in the left perianal region due to the inflammatory scarring change suggesting that the inflammation resulted from a high level fistula. Before admission to hospital, the patient was actively treated for almost 3 years by a dermatologist and conservatively by 2 surgeons, with antibiotics and once surgically. The total treatment lasted for about 30 years with occasional inflammatory exacerbation and incisions.

The diagnosis was made by means of magnetic resonance imagining (MRI), X-ray of the lungs, abdominal ultrasound, injecting hydrogen-peroxide, probing the fistula, the fistula cannulation with a rubber band and colonoscopy with biopsy. Fistulography was not used due to a low success rate, which is about 30% [7]. All laboratory test results (blood tests, albumins, proteins, hepatogram, electrolytes) were within normal values, including the C-reactive protein (CRP) which was less than 1 mg/L after the gluteus scar and pseudotumor excision. The MRI clearly indicated a fistula characterized as high trans-sphincteric without any tumor mass. The inner ostium was identified following the injection of hydrogen-peroxide into the external opening of the fistula. Probing had been done and the rubber band was placed there until the surgery (Figure 1). Systemic examinations showed normal limits.

The patient was admitted for surgery the day before and was prepared by having his colon cleansed with a factory solution of sodium picosulfate, magnesium oxide, and anhydrous citric acid. An hour prior to the surgery, the patient was administered 1 g metronidazole and 2 g cephalosporin. The patient was in the lithotomy position. The operation was performed per technique of Rojanasakula et al. There was no combination using a bio-flap, with the plug implantation in the external part of the tract and without partial fistulotomy.

During the surgery, we probed the fistula with a metal probe again (Figure 2). Then the mucosa between the external and the internal sphincter was cut with a semicircular incision of 2-3 cm. Intersphincteric area was slowly entered to the depth of the fistula through which a metal probe had been inserted (Figure 3). llie fistula with a probe was looped with a seton and the metal probe removed. Two smaller straight clamps were placed to both ends of the fistula in the intersphincteric area and the fistula was cut. Then both ends were ligated with a transfixation suture and the area was washed (Figure 4). We did not suture the area of the entrance in the intersphincteric tract. The external part of the tract was curetted and the internal opening of the rectum (anal gland) was excised. The patient was on a liquid diet for three days to avoid having a stool throughout his hospital stay. The checks were carried out every 3 days during the first 15 days, then once a month. After 3 months the patient had no discharge on the external opening of the fistula which was excised.


The purpose of perianal surgery is to achieve treatment without further discharge, without the risk of incontinence or any other adverse consequences. All treatment methods, including surgeries, compare the healing percentage, the recurrence percentage, incontinence and/or other side effects, together with the total cost of the treatment. The possibility of performing the surgery in as many hospitals as possible is also a relevant factor [8]. This procedure is still not widespread in Serbia.

All methods that use medical preparations (botulinum toxin preparations, fibrin glue, cyanoacrylate glue, collagen substance) are not financially accessible to most of our hospitals, and on the other hand some of these treatment methods have disappointing results. The success rate of fibrin glue and collagen paste (Permacol[R]) is 16-25% [9] and up to 54% [10], respectively in the multi-center study, but the total number of studies is still insufficient and financially costly for a complete treatment.

The success rate of isolated anal-plug technique ranges from 29 to 87%, as cited by Sirikurnpiboon et al, 2015 [11]. Mucosa-advancement flap has a high success rate but is considered the most complex surgical procedure [2]. Fistulotomy and fistulectomy are best known to solve the problem radically up to 90% [12]; however, they also have the highest percentage of different degrees of incontinence. The risk of incontinence is correlated with the treatment in a wide range of 10-57% [13]. Placing seton which cuts the sphincter slowly but without losing the function is a good method but the treatment can last from 3 to 9 months.

The LIFT procedure is performed without cutting the sphincter muscles and the success of the operation is remarkably high. In 2007, Rojanasakul reported the success rate of 94% [5]. Overtime, other studies have shown the real success of the procedure of 40-95% with a recurrence rate of 6-28% [14].


Compared to other methods, the ligation of intersphincteric fistula tract procedure is safe and inexpensive, it does not require special equipment, there is hardly any incontinence (with the muscles not being cut), the postoperative pain is of low intensity and the success rate is high. Its wider application is encouraged by this patient's report.

LIFT    --ligation of intersphincteric fistula tract
CRP     --C-reactive protein (test)
MRI     --magnetic resonance imaging

DOI: 10.2298/MPNS1610298S


[1.] Gottgens KWA, Smeets RR, Stassen LRS, Beets G, Breukink SO. Systematic review and meta-analysis of surgical interventions for high cryptoglandular perianal fistula. Int J Colorectal Dis. 2015-30:583-93.

[2.] Sirany AM, Nygaard RM, Morken JJ. The ligation of the intersphincteric fistula tract procedure for anal fistula: a mixed bag of results. Dis Colon Rectum. 2015'58(6):604-12.

[3.] Matos D, Lunniss PL Phillips RK. Total sphincter conservation in high fistula in ano: results of a new approach. Br J Surg. 1993-80:802-4.

[4.] Rojanasakul A, Pattanaarun J, Sahakitrungruang C, Tantiphlachiva K. Total anal sphincter saving technique for fistulain-ano; the ligation of intersphincteric fistula tract. J Med Assoc Thai. 2007-90:581-6.

[5.] Rojanasakul A. LIFT procedure: a simplified technique for fistula-inano. Tech Coloproctol. 2009-13:237-40.

[6.] de Groof EJ, Cabral VN, Buskens CJ, Morton DG, Hahnloser D, Bemelman W A: research committee of the European Society of Coloproctology. Systematic review of evidence and consensus on perianal fistula: an analysis of national and international guidelines. Colorectal Dis. 2016-18(4):0119-34.

[7.] Haim N, Neufeld D, Ziv Y, Tulchinsky H, Koller M, Khaikin M, et al. Long-term results of fibrin glue treatment for cryptogenic perianal fistulas: a multicenter study. Dis Colon Rectum. 2011-54:1279-83.

[8.] Giordano P Sileri P Buntzen S, Stuto A, Nunoo-Mensah J, Lenisa L, et al. A prospective multicentre observational study of Permacol(tm) collagen paste for anorectal fistula: preliminary results. Colorectal Dis. 2015-18:286-94.

[9.] Sirikurnpiboon S, Awapittaya B, Jivapaisarnpong P. Ligation of intersphincteric fistula tract and its modification: results from treatment of complex fistula. World J Gastrointerst Surg. 2013;5(4): 123-8.

[10.] Mizrahi N, Wexner SD, Zmora O, Da Silva G, Efron J, Weiss EG, et al. Endorectal advancement flap: are there predictors of failure? Dis Colon Rectum. 2002;45(12):1616-21.

[11.] Vergara-Fernandez O, Espino-Urbina LA. Ligation of intersphincteric fistula tract: what is the evidence in a review? World J Gastroenterol. 2013;19(40):6805-13.

[12.] Lange EO, Ferrari L, Krane M, Fichera A. Ligation of intersphincteric fistula tract: a sphincter-sparing option for complex fistula-in-ano. J Gastrointest Surg. 2016;20:39-4.

Rad je primljen 2. IV 2016.

Recenziran 12. VII 2016.

Prihvacen za stampu 18. VII2016.



General Hospital Vranje

Department of Surgery

Corresponding Author: Prim, dr sc. med. Momcilo Stosic, Opsta bolnica, Hirursko odeljenje, 17500 Vranje, Vojvode Misica 17, E-mail:

Caption: Figure 1. Looped high fistula, clamps on the thickened wall, external excision Slika 1. Zaomcena visoka fistula; peanom uhvacen zid fistule; spoljna ekscizija

Caption: Figure 2. Entrance to intersphincteric area Slika 2. Ulazak u intersfinktericni sloj

Caption: Figure 3. Open intersphincteric tract, looped fistula with blue sutures Slika 3. Otvoren intersfinktericni prostor, zaomcena fistula plavim koncem

Caption: Figure 4. Ligation of the inner opening of the external area with non-resorbable sutures Slika 4. Presiveni unutrasnji otvor spoljasnjeg dela fistule neresorptivnim koncem
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Title Annotation:Case report/Prikaz slucaja
Author:Stosic, Momcilo; Stojanovic, Igor; Mihajlovic, Svetlana
Publication:Medicinski Pregled
Article Type:Case study
Date:Sep 1, 2016
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