BJS Open, https://doi.org/10.1093/bjsopen/zrae055, published 06 June 2024
Dear Editor
We appreciate the thoughtful feedback on our article and welcome this opportunity to address some points raised in the letter and clarify aspects of our study.
While it is accurate that a significant proportion of patients in our study had undergone previous fistula-related surgery, only 31 (28% of patients) had undergone previous attempts specifically aimed at definitive fistula closure, with 22 out of these having had only one prior attempt at closure, as detailed in Table 1. The 92% figure mentioned in the letter refers to the proportion of patients who had undergone any type of previous surgery, including abscess drainage or insertion of seton(s). The majority of these procedures were not definitive repair attempts, so in most cases the intersphincteric plane was not previously entered. Also, we found no compelling literature indicating a direct correlation between previous fistula closure attempts and the healing outcomes of LIFT, nor did not observe this in our analysis. Interestingly, our data did reveal higher healing rates in patients with high trans-sphincteric fistulas, a finding that we acknowledge was somewhat unexpected.
The letter’s critique focuses primarily on the graph displaying outcomes for the entire cohort (Fig. 2). However, we believe that a more accurate representation of the LIFT procedure’s impact is shown in Figure 3 and Table 4, which specifically presents outcomes for patients who required no additional surgical interventions after LIFT. These prospective long-term continence data provide a clearer view of the direct effects of LIFT on continence status.
With regards to the standardization of the LIFT technique, we acknowledge the numerous modifications reported in the literature. While our approach did not include formal standardization, it adhered to the method outlined in the original publication (contrary to many other published papers), and the outcomes of our operations do not differ (1-3). In our opinion this minor criticism cannot distract from the important finding that, to the best of our knowledge, besides the data from the inventor of this technique (4), no high quality long-term follow-up is available for this technique. Nevertheless, this technique has been accepted globally by our community as an acceptable sphincter saving procedure and has even been incorporated as such in the recent ESCP Guideline (5).
Even though we support the application of LIFT, we point out a paucity of evidence for long term functional safety and look forward to more robust data by other groups, providing a more solid base for patient education and treatment selection.
Lastly, regarding continence outcomes, we took care to distinguish between reduced continence and full incontinence. This is an important distinction, as reduced continence refers to a range of symptoms that does not equate to total incontinence. Even though full incontinence after LIFT probably does not occur, minor continence impairment is an important part of decision making for both the patient and the surgeon, as the incidence of impaired continence limits the gap in outcomes between sphincter-preserving and non-sphincter-preserving techniques. Notably, most existing data on continence outcomes following LIFT are limited to short-term follow-up, leaving the long-term effects comparatively unexplored. We therefore reaffirm our challenge for additional long-term, multicentre studies with comprehensive continence assessments to enhance the understanding LIFT’s durability and its effects on quality of life.
Finally, we appreciate the engagement with our work and hope this response provides clarification on our findings and their implications.
References
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;90(3):581-586.
Vander Mijnsbrugge GJH, Felt-Bersma RJF, Ho DKF, Molenaar CBH. Perianal fistulas and the lift procedure: results, predictive factors for success, and long-term results with subsequent treatment. Tech Coloproctol. 2019 Jul;23(7):639-647. doi: https://doi.org/10.1007/s10151-019-02023-9. Epub 2019 Jul 17. PMID: 31317361; PMCID: PMC6692447.
Göttgens KWA, Wasowicz DK, Stijns J, Zimmerman D. Ligation of the Intersphincteric Fistula Tract for High Transsphincteric Fistula Yields Moderate Results at Best: Is the Tide Turning? Dis Colon Rectum. 2019 Oct;62(10):1231-1237. doi: https://doi.org/10.1097/DCR.0000000000001448. PMID: 31490832.
Malakorn S, Sammour T, Khomvilai S, Chowchankit I, Gunarasa S, Kanjanasilp P, et al. Ligation of Intersphincteric Fistula Tract for Fistula in Ano: Lessons Learned From a Decade of Experience. Dis Colon Rectum. 2017 Oct;60(10):1065-1070. doi: https://doi.org/10.1097/DCR.0000000000000880. PMID: 28891850.
Reza L, Gottgens K, Kleijnen J, Breukink S, Ambe PC, Aigner F, et al. European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula. Colorectal Dis. 2024 Jan;26(1):145-196. doi: https://doi.org/10.1111/codi.16741. Epub 2023 Dec 5. PMID: 38050857.
