Identifying predictors of success of the LIFT procedure in the treatment of fistula-in-ano: does location matter?

Transcription

1 Identifying predictors of success of the LIFT procedure in the treatment of fistula-in-ano: does location matter? Department of Colorectal Surgery Cleveland Clinic Florida Sami Chadi MD, Daniel Bekele MD, Fabio G. Rodrigues MD, Eric G. Weiss MD, David J. Maron MD, Giovanna da Silva MD, Steven D. Wexner MD, Juan J. Nogueras MD ACPGBI 2016 Annual Meeting Edinburgh 4-6th July 2016

2 Disclosures None of the authors have any relevant financial conflicts of interest to disclose

3 Ligation of the Intersphincteric Tract (LIFT) Originally proposed in Varying success rates (50-94%) 2 Few comparative studies of LIFT vs Endorectal Advancement Flap (EAF) No studies describing anatomic predictors of successful treatment 1. Rojanasakul et al. J Med Assoc Thai, Sirany et al. DC&R, Wexner and Fleshman. Mastery Techniques in General Surgery: Anorectal Operations LipincottWiliamsand Wilkins, 2012.

4 Hypothesis Posterior fistulas are less amenable to LIFT due to

5 Hypothesis Posterior fistulas are less amenable to LIFT due to Wider tracts

6 Hypothesis Posterior fistulas are less amenable to LIFT due to Wider tracts Deeper intersphincteric portion from anal verge

7 Hypothesis Posterior fistulas are less amenable to LIFT due to Wider tracts Deeper intersphincteric portion from anal verge Involvement of the deep postanal space

8 Objectives 1. To identify anatomic predictors of success in patients with transsphincteric fistulae treated with the LIFT procedure 2. To compare the outcomes of LIFT and EAF based on the anatomic location of the fistula

9 Methods Retrospective review of IRB approved prospective institutional database Inclusion criteria: All adult patients treated for transsphincteric fistula with LIFT or EAF from Jan 2008 to Aug 2015 Exclusion criteria History of inflammatory bowel disease History of pelvic radiation History of rectourethral or rectovaginal fistulae

10 Methods Primary outcome Complete healing of both the external opening and intersphincteric incision with resolution of symptoms, without additional interventions at 90 days Patients with inadequate follow-up (<90 days) were contacted

11 Methods Location was defined as the site of the internal opening stratified as posterior vs. non-posterior Anterior BM bulbocavernosus muscle TM transversus perineus muscle E External sphincter muscle Posterior

12 Data analysis Overall Crude data analysis Univariable statistical comparisons Multivariable Logistic regression Based on variables with potential effect on outcomes Actuarial data presented as Univariate Log-rank comparison Multivariate Cox-proportional Hazard ratio

13 Overall LIFT Results 107 LIFT procedures performed 64% male Mean age 46 ± 13 years Mean BMI 28 ± 5 Kg/m 2

14 n = 107 History of Smoking n (%) 17 (16) Previous Fistula Intervention n (%) Any Intervention Previous LIFT or EAF Classification of Fistula n (%) Location of Fistula n (%) Overall LIFT Results Simple Complex Posterior Non-posterior Management of external opening n (%) None Dilatation & Curettage Resection Suture closure 25 (23) 12 (11) 44 (41) 63 (59) 36 (34) 71 (66) 29 (31) 34 (32) 31 (29) 11 (10)

15 LIFT Results Complications 13.1% ( 14 patients) Minor bleeding 6.5% Fecal incontinence 2.8% Dehiscence 1.9% Perianal pain 0.9% Urinary retention 0.9%

16 LIFT Results Failures 46 5 local (discharge from intersphincteric wound with no internal opening) 8 partial (tract from the internal opening to the intersphincteric wound) 29 complete (tract from the internal opening to the external opening) Tan K-K et al, DCR 2011

17 Healing by Fistula Location for LIFT procedures Overall healing rate: 56% 70% 60% 66% Median follow-up of 107 days 50% 40% 30% 20% 10% 35% 0% Non-posterior Posterior

18 Healing by Fistula Location for LIFT procedures Overall healing rate: 55% 70% 60% 66% Median follow-up of 107 days Worse outcome in posterior vs. nonposterior fistulae (p=0.001) 50% 40% 30% 20% 10% 35% 0% Non-posterior Posterior

19 Healing by Fistula Location with LIFT procedure Multivariable Logistic Regression When adjusting for known risk factors Age, gender, BMI, smoking, previous surgery, fistula classification, location & management of external opening Posterior location associated with LIFT failure (OR 3.9; p=0.004)

20 LIFT vs. EAF Variable LIFT (n=107) EAF (n=46) P value Age mean (SD) 46 (13) 50 (12) 0.06 Gender (male) n (%) 68 (64) 29 (63) 0.95 BMI Kg/m 2 mean (SD) 28 (5) 27 (5) 0.40 Smoking status n (%) 17 (16) 6 (13) 0.65 Previous Fistula Intervention n (%) Any intervention Previous LIFT or EAF Fistula classificationn (%) Simple Complex Fistula location n (%) Posterior Non-posterior 25 (23) 12 (11) 44 (41) 63 (59) 36 (34) 71 (66) 21 (46) 5 (11) 12 (26) 34 (74) 23 (50) 23 (50)

21 Comparison of LIFT and EAF by non-posterior location 68% 66% 64% 62% 60% 58% 56% 54% 52% 50% 66% LIFT p= % EAF

22 Comparison of LIFT and EAF by posterior location 70% 60% 50% 40% 30% 20% 10% 0% p= % LIFT 61% EAF

23 Comparative Healing by Location Multivariate analysis controlling for known risk factors Non-posterior fistulae: No difference in outcome of healing with EAF or LIFT

24 Comparative Healing by Location Multivariate analysis controlling for known risk factors Non-posterior fistulae: No difference in outcome of healing with EAF or LIFT Posterior fistula: Endorectal advancement flap procedures associated with higher rate of fistula healing as compared to LIFT (OR 3.92, p=0.008)

25 Univariate comparison Posterior location p=0.005 Cox proportional hazard Posterior location HR 1.92 (p=.018) Results Time-to-event

26 Conclusion Improved success rates of the LIFT procedure with non-posteriorly located transsphincteric fistulae

27 Conclusion Improved success rates of the LIFT procedure with non-posteriorly located transsphincteric fistulae Endorectal Advancement Flaps used in the treatment of posteriorly located fistulae are associated with higher healing rates compared with LIFT

28 Conclusion Improved success rates of the LIFT procedure with non-posteriorly located transsphincteric fistulae Endorectal Advancement Flaps used in the treatment of posteriorly located fistulae are associated with higher healing rates Comparative trials of LIFT versus EAF should stratify patients by location of fistula

29 Thank you!