Recurrence of Complex Anorectal Fistulas after Surgery: A Comparative Trial of Two Techniques

Background: Although several sphincter-saving procedures that propose a conservative approach have been described, the ideal surgery for the treatment of complex anorectal fistulas (CAF) remains debatable.
Objective: To compare the success between the ligation of intersphincteric fistula tract (LIFT) and rectal advancement flap (RAF) techniques as the definitive procedure.

Settings: Division of Colorectal Surgery, General University Hospital Reina Sofia in Murcia (Southeastern Spain), National Health System, between March-2013 and February-2015.

Methods: Prospective, randomized controlled study including 72 patients with CAF. Participants were randomly assigned to LIFT Group or to RAF Technique. Outcome measures included surgical time, recurrences, postoperative pain, hospital readmissions, re-do in recurrent cases and fecal incontinence. Primary endpoint was a between-group comparison of anal fistularecurrence at 12 months.

Results: We identified 72 patients, 49 (68.1%) male, with a median age of 47.1 (range25-74) years. There were 36 patients in the LIFT group and 36 patients in the RAF group. Over a follow-up of 12 months, 13 (36.1%)patients with LIFT and 14 (38.9%)with RAF had recurrence (p=0,808). LIFT was shorter than RAF (P<.001). Complications, postoperative pain and hospital readmissions were similar. None of the patients developed fecal incontinence. Hence when performed as the initial definitive procedure, the LIFT had a significantly higher success rate in comparison with the RAF approach (p= 0.006).

Conclusions: The LIFT procedure is simple, safe and shorter. It is associated with better short-term outcomes in comparison with the RAF technique.

Keywords: complex anorectal fistulas, fistula-in-ano, ligation of intersphincteric fistula tract, rectal advancement flap, recurrence.