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A Retrospective Study Comparing the Clinical Outcomes of the Ligation of Intersphincteric Fistula tract (LIFT) versus Fistulotomy in simple

fistula-in-ano from January 2010 –October 2010

Presented by: Michelle Chungait, MD 4th year surgical resident

Noted and Approved by:

Dr. Gene Estandian (Training officer)

Dr. Romeo Concepcion Jr. (Chairman)

Introduction
Background of the Study The surgical treatment for simple fistula-in-ano in our institution is fistulotomy that is frequently resulting in post-op anal pain, recurrence and anal incontinence. These had been a major concern for surgeons in treating fistula-in-ano. These undesirable outcomes could be due to many factors. However, the surgical approach is a major contributory factor. Ligation of intersphincteric fistula tract (LIFT) procedure was first described by a Thai surgeon in 2006, Dr. Arun Rojanasakul, a colorectal surgeon at Chulalongkorn University. This technique aimed at preserving the anal sphincters and eliminates the intersphincteric septic nidus. This procedure does not sever the anal sphincters and post-operative anal function can remain intact. This technique is new in our institution and had been started to be performed by our senior residents last April 2010 but the procedure was known to them last December 2009 from the Philippine College of Surgeons (PCS) annual convention. 1 The technique was not immediately accepted by the institution due to lack of data on the clinical outcomes. However, initial results showed promising clinical outcomes. The technique was again shown in the 1st Philippine Society of Colorectal Surgeons last March 25, 2010 by Dr. Arun Rojanasakul at Diamond Hotel, Manila when he was invited as a speaker for the said convention. 2 The technique is simple and can be done under local or spinal anesthesia similar to fistulotomy procedure. Initial clinical outcomes such as decreased post-operative pain, negligible anal incontinence and lesser recurrence rate lead to the approval of this technique to be used among patients in our institution. The procedure was explained properly to the patient and possible complications of bleeding, recurrence and anal incontinence were presented. Percentage of incidence of recurrence and anal incontinence for both LIFT and fistulotomy were also presented to the patient. It was also disclosed to the patient that LIFT technique is a new procedure and that it is new to the surgeon. The consent for the

recurrence. this will serve as a reference for future researchers wherein a prospective study with larger number of cases will be reviewed to determine the long term clinical outcomes and the use of this technique on complex and recurrent fistulas. mean operative time. It had been observed that our patients who undergone the procedure had no post-op pain and one week post-operatively. Significance of the Study The undesirable outcome of the traditional technique in the management of fistula-in-ano in our institution which is post-operative pain. no anal incontinence was noted. This study reviewed the incidence of post-operative anal pain. The results of this procedure might also convince other surgical consultants to consider this technique on their patients. recurrence and anal incontinence among patients with fistula-in-ano at Baguio General Hospital and Medical Center from January to Ocytober 2010. The early outcome is quite impressive and the results of this study initially justified the use of this procedure as an alternative or standard form of treatment in the treatment of fistula-in-ano in our institution.operation after explaining the procedure was similar to all patients who will undergo the operation. mean length of hospital stay after the operation. anal incontinence. Likewise. . This study is conducted to compare the clinical outcomes of LIFT versus Fistulotomy in fistula-in-ano from January –October 2010 in reference to post-operative pain. recurrence and anal incontinence inspired the surgical residents to do the LIFT technique.

Review of Related Literature Fistula-in-ano is the chronic phase of anorectal infection and is characterized by chronic purulent drainage or cyclical pain associated with abscess reaccumulation followed by intermittent spontaneous decompression. suprasphincteric and the extrasphincteric. and authorities are still searching for such an ideal technique. 2010 to October 31. which have superior outcomes. transsphincteric. such as fistulotomy or placement of seton. anal incontinence ranging from 0-63% 3.6 . Secondary measures included the mean operative time of LIFT versus fistulotomy and the mean length of hospital stay of patients after the operation. 5 . 5 . 2010 who were treated by our institution using fistulotomy and LIFT technique.Limitations of the Study The study reviewed the medical records of patients with fistula-in-ano from January 1. there is no single technique appropriate for all types of fistula-in-ano. The surgical treatment of this disease frequently resulted in recurrence ranging from 0-32% 3. The third concept is the closure of the internal opening as exemplified by the use of intra-anal advancement flap. 4 The Parks classification system defines four types of fistula-in-ano that result from cryptoglandular infections. The first concept is cutting through the whole tissue overlying the fistula tract. At present. and anal pain. 6 The second concept is removal of the infected cryptoglandular tissue in the 6 intersphincteric plane as advocated by Sir Alan Parks. These are the intersphincteric that is the most common of anal fistulae.3 Multiple series have shown that the formation of a fistula tract following anorectal abscess occurs in 7-40% of cases. The primary outcome measure of this study was limited on severity of anal pain. either simple or complex. Current surgical techniques for fistula-in-ano are based on three main concepts. incidence of anal incontinence and 1-week post-operation wound discharges.

The preliminary outcomes using the LIFT technique among patients with simple and complex fistula-in-ano had been satisfactory with 5. Arun’s group . 9 That idea became the essence of the LIFT technique. 3 In 2006. Dr. The outcome in 20 patients was disappointing with only 9 (45%) successes. Arun Rojanasakul as a form of treatment for fistula-in-ano. Arun’s group thought that the ligation of intersphincteric tract close to the internal opening might solve the problem. 9 The proposed reasons for the unfavorable outcome include dissection in the intersphincteric plane damaging the blood supply to the internal opening area and suturing delicate areas with increased risk of suture breakdown. However. Arun’s group last 2004-2005. a new technique was introduced by Dr. The Matos technique was used by Dr.9% with a functional impairment at 017%. 7 Likewise the novel technique was also documented in Corman’s textbook of colon 8 and rectal surgery. extrasphincteric fistulas and other complex fistulas.al stated that simple anal fistula may be treated by fistulotomy with a class II level of evidence. In order to solve this problem. al.6% recurrence rate. that is based on the concept of excision of intersphincteric anal gland infection through the intersphincteric approach. This technique is based on the concept of secure closure of the internal opening and concomitant removal of infected cryptoglandular tissue in the intersphincteric plane.The Practice Parameters for the treatment of perianal abscess and fistula-in-ano by Whiteford et. 3 The fundamentals of fistulotomy include defining the entire tract from internal opening to the external opening with identification and obliteration of primary and secondary tracts.6 The technique is almost similar to the procedure described by Matos et. decreased post-op pain and negligible incontinence. 6 It had been realized by Dr. the rates for minor and major incontinence are significant with 34-63% and 2-26% respectively. The recurrence rate for fistulotomy is generally 2. suprasphincteric. when used in complex fistulas such as high transphincteric fistula.

A study done by Dr. Shanwani et. A. a colorectal surgeon from University of Minnesota and who was a visiting professor in Thailand. Robin Phillips from St. The LIFT technique howerever.12 . Peter J. al. No clinically significant morbidity was noted in any of the 45 patients wherein LIFT technique was done. 11 LIFT technique was also popular among colorectal surgeons of Hongkong and Singapore. Lunniss however was commented back by Dr.12 It likewise demonstrated that LIFT technique can be used again for recurrent fistula-inano with no difficulty. was claimed to be pioneered by Dr. The study demonstrated a 58% success rate in an American patient. Arun Rojanasakul explaining the difference of his technique as previously described earlier in the literature. 10 The statement given by Dr.from Malaysia revealed that LIFT technique was both safe and easy to perform with encouraging early outcomes. 1 LIFT was introduced in the United States by Dr. The results of these studies will be published soon. wherein the excision of the whole fistula tract plus primary repair with intersphincteric plane approach for excision of fistula tract and suturing the internal anal sphincter defect will result to unsatisfactory outcomes. al study. Marks hospital according to Dr.that the technique reported by Matos et. Lunniss as described by Matos et. There had been ongoing researches on the efficacy of LIFT in the management of simple and complex fistula-in-ano as was presented last PCS annual convention of 2009. The technique was introduced to his five rotating fellows and a study was conducted on 31 patients wherein LIFT technique was done. Stanley Goldberg last 2008. al. The technique became popularly known among Asian countries and was adopted in their own institution.

Specific objectives: 1. To compare the mean operative times of LIFT vs fistulotomy 2. One week post-operative wound discharges b. To measure the incidence of post operative complications in patients who underwent LIFT compared to patients who underwent fistulotomy in terms of: a. Anal Incontinence 3.in-ano. To compare the mean length of hospital stay of patients who underwent LIFT vs patients who underwent fistulotomy .Objectives of the Study General Objective: The study aimed to determine the efficacy of LIFT compared to Fistulotomy in treating patients with simple fistula. To compare the severity of post operative pain of patients who underwent LIFT vs patients who underwent fistulotomy 4.

perianal abscess. fournier’s gangrene Intervention: Ligation of intersphincteric fistula tract Control: Fistulotomy Outcome: Length of surgery Incidence of anal incontinence and wound discharge Severity of post op pain Length of hospital stays after the operative procedure . Patients with recurrent fistulas 3. Patients with synchronous rectoanal pathology ex. Patient with simple fistula-in-ano who underwent LIFT performed by a senior resident or consultant 3. Patient with simple fistula-in-ano who underwent fistulotomy performed by any member of the surgery staff Exclusion criteria: 1. All patients 18-60 years who underwent either LIFT or Fistulotomy are included 2.Methodology Study Design: The study is a retrospective cohort Population: all patients at BGH-MC who underwent LIFT and Fistulotomy for simple fistula-inano Inclusion criteria: 1. Rectal ca. Patients with complex fistulas 2.

50% of the external sphincter Complex fistula-in-ano: the track crosses >30-50% of the external sphincter which includes: high transphincteric. incidence of anal incontinence and 1-week post-operation wound discharges and secondary measures such as: mean operative time of LIFT versus fistulotomy and the mean length of hospital stay of patients after the operation were gathered. 2010 with simple fistula-in-ano who were treated with fistulotomy and LIFT were noted from the Operation Record logbook and the charts were gathered from the Medical Records of Baguio General Hospital and Medical Center (BGHMC). local irradiation. The primary outcome measure of this study such as: severity of anal pain. suprasphincteric.13 LIFT – ligation of intersphincteric fistula tract after defining the internal opening with curetting the fistulous tract and closure of the external sphincter defect Fistulotomy – lay-open technique of the fistulous tract after defining the internal opening of the fistula-in-ano Anal incontinence – involuntary or uncontrolled passage of stool Wound discharge – presence of purulent material 7 days post-operation Recurrence – formation of a new fistula at ≥ 3 months after fistulotomy/LIFT Description of the Study Procedure All patients from January 1. the track crosses < 30% . have multiple tracks. or Crohn’s disease. Likewise. 2010 to October 31.Operational Definitions: Simple fistula-in-ano: includes intersphincteric and transsphincteric fistula-in-ano. is recurrent or the patient has pre-existing incontinence. the data on the presence or absence of anal incontinence and wound discharge one week post- . anterior in a female. and extrasphincteric. The Operative technique was evaluated for the length of the surgical procedure and the progress notes done by the surgical residents on the evaluation of severity of post-operative pain using the Numerical Pain Scale were collected.

There were 12 cases of patients who underwent fistulotomy and 8 patients who underwent LIFT but only 11 charts for fistulotomy and 6 charts for LIFT were available for review. The general data of the patient and the results gathered with regards to the length of the surgical procedure in minutes. Incidentally. There were no records of cases of complex fistula-in-ano or recurrent fistulas that had been admitted and operated on with fistulotomy or LIFT for the entire covered period of this study. the severity of postoperative pain. (table 1) . however. Records of repeated follow-ups from patients were also gathered. There were three missing charts and not available at the time of data gathering. presence or absence of anal incontinence and presence of wound discharges after a week post-operation were all placed in a dummy table. all cases were simple fistula-in-ano. length of hospital stay post-operation in days. only 17 charts were available for review. It had been found out that there were 20 recorded operations for fistula-in-ano.operation was taken from the medical records of Out-patient department.

the average time in minutes for each technique was computed and the standard deviation was computed based from the mean operative time. the p value taken was 0.1818 minutes Fistulotomy mean Standard deviation 18. T test was used to compare whether the results are statistically significantly. the null hypothesis is rejected.56243 respectively as compared with LIFT which is 58. The two operative means differ significantly.1667 minutes and 17.93786 21.93786 respectively.1667 minutes 17. The null hypothesis stated that there is no difference in the mean operative time between fistulotomy and LIFT.00215. using the t-test.56243 .05 at 95% level of significance.00215 P value The table shows above the mean and standard deviation of fistulotomy which is 21. (table 2) Table 2: operative time Operative (minutes) time mean LIFT Standard deviation 58. Using the significance level of 0.1818 minutes and 18. Operative Time In order to compare the mean operative time for LIFT technique and fistulotomy.RESULTS A. .

There are 27.27% 63. (table 3) Table 3 Frequency LIFT Anal Incontinence 0 Fistulotomy 3 7 Percentage LIFT 0% 0% Fistulotomy 27.B.63% Presence of wound discharge 1-week 0 post-operation Table 3 shows that there are no anal incontinence and no wound discharges present after a week for LIFT as compared with fistulotomy showing 3 patients with anal incontinence and 7 patients with wound discharges after a week post-operation. .63 % of patients presented with a wound discharge 1-week post-operation for fistulotomy procedure.27% of anal incontinence and 63. Incidence of Anal Incontinence and wound discharges 1-week post-operation The incidence of anal incontinence and incidence of the presence of wound discharges 1week post-operation were noted using frequency tables.

In order to compare if the results taken were different between the two groups. using the 0. The null hypothesis stated that there is no difference between the two techniques in terms of occurrence of anal incontinence post-operation. using the fistulotomy procedure. the fisher’s exact test was used. Table 4 Anal incontinence LIFT With anal incontinence Without anal incontinence Total Fistulotomy Total P value 0 6 6 3 8 11 3 14 17 0. . The p value taken using the fisher’s exact test was 0.05 level of significance at 95% confidence level.242647 Table 4 showed that there are no anal incontinence using the LIFT technique however.242647. there are 3 patients who presented with anal incontinence. the null hypothesis is accepted.

however. .05 level of significance at 95% confidence level. Using the 0. The null hypothesis stated that there is no difference in the occurrence of wound discharges one-week post-operation between the two procedures.Table 5 Wound discharges 1-week post-operation LIFT With wound discharges Without wound discharges Total Fistulotomy Total P value 0 6 6 7 4 11 7 10 17 0. there are 7 out of 11 patients who presented with wound discharges using the fistulotomy procedure. the null hypothesis is rejected. The two groups differ significantly.016968 Table 5 showed that there are no patients who presented with wound discharge after a week post-operation using the LIFT technique.

818 respectively.3013 Table 6 showed that the mean pain scale for LIFT and fistulotomy is 0 and 3. . a numerical pain scale ranging from 0-10 was used. The null hypothesis stated that there is no difference in the severity of post-operative pain between the two procedures. The mean pain scale did not differ between the two groups. To test whether the mean pain scale for LIFT technique is statistically significant compared with fistulotomy.3013 p value.81818 1. the t-test was employed showing a 1. The p value taken using the t-test is > 0.05 level of significance at 95% confidence level.60114 1. The t-test was employed to determine if the two groups are statistically significant. Severity of Post-operative Pain To compare the severity of post-operative pain among patients who underwent LIFT and fistulotomy. the null hypothesis is accepted.C. Mean pain scale was calculated to determine which procedure has lesser post-op pain. (Table 6) Table 6 Severity of Post-op Pain LIFT mean standard deviation Fistulotomy mean standard deviation P value 0 0 3.

67021 0. the null hypothesis is accepted.26273 hours Standard deviation 28.43667 hours Standard deviation 13. (Table 7) Table 7 Length of Hospital stay after operation LIFT mean 27. The null hypothesis stated that there is no difference in the mean length of hospital stay between the two procedures.06633 FISTULOTOMY mean 38. In order to minimize bias. . the mean length of hospital stay after operation for both LIFT and Fistulotomy was the one included in the study. T-test was employed to compare if the two groups are statistically significant.26273 hours respectively. the p value taken is 0. Length of hospital stay after Operation There are factors that affected the length of hospital stay such as delayed operation scheduling and medical comorbidities that is to be corrected prior scheduling.43667 hours and 38.05 level of significance at 95 % confidence level. Using the 0.30362 P value Table 7 showed the mean hospital stay of patients after the operation for LIFT and fistulotomy of 27. Standard deviation was computed based on the mean.30362.D. The results are not statistically different between the two procedures. Using the t-test.

The techniques previously mentioned. then secure suture ligation of the tract. it is debilitating to the patient. The technique disconnects the internal opening from the fistulous tract and removes the infected anal gland residual. known as LIFT (ligation of intersphincteric fistula tract) procedure. followed by the incision at the intersphincteric groove. likewise. excision and closure of the internal opening. fibrin glue and fistula plug. dissection through intersphincteric plane to find the intersphincteric fistula tract. fistulotomy causes some various injuries to the anal sphincter causing incontinence. anoderm island flap. However.DISCUSSIONS Fistulotomy has been the standard form of treatment for fistula-in-ano at Baguio General Hospital and Medical Center. researchers are still looking for the ideal technique. but when it occurs. The remaining fistula tract distally will be curetted from external opening followed by suturing and closing the external sphincter muscle defect then . despite some recurrences. thus. endorectal advancement flap. The LIFT technique is the novel modified approach through the intersphincteric plane for the fistula-in-ano. without dividing any part of the anal sphincter complex. These techniques have less risk of anal incontinence. however. are technically demanding. causing the wound not to heal or could heal longer leaving a wound discharges for many weeks. leave the wound open attracting infections from the fecal matter that comes out from the anal opening. operator dependent and reoperation cannot occur because of the previously applied materials that cause scarring. There is no single technique appropriate for all types of fistulas at present. Fistulotomy. This may however not generally seen among patients who undergo fistulotomy. The LIFT procedure is started by identifying the internal opening. The literature cited some technique to minimize anal incontinence such as placement of seton but with moderate success. The outcome is generally acceptable.

3 There is no single technique appropriate for the treatment of fistula-in-ano.98 minutes. unidentified fistula tract or complex fistulas. poor compliance to antibiotics. it can be deduced that the LIFT is superior to fistulotomy. It had been found out from the study that using the LIFT technique in simple fistula-inano. The goals in the treatment of fistula-in-ano are eliminating the septic foci and any associated epithelialized tracts and minimizing functional derangement. however. The LIFT is a new procedure among the surgeons and it is a new technique to be learned. Primary healing among patients with fistulotomy could be longer for the surgical site is left open. (figure 1)14 The technique is easy and safe. it could be hygiene. is longer than fistulotomy with a difference of 36. However. It is easily learned. Comparing the results taken from LIFT with that of fistulotomy. These could be cause by many factors. no post-operative complications were noted. The two among the seven patients. it might explain the difference in performing it as compared with fistulotomy. The mean operative time however.closure of the intersphincteric wound. The t-test (table 2) showed that the difference is statistically significant. no anal pain and wound discharges noted after a week post-operation on their follow-up. The patient could go home after a day post-operation. during follow-up. There is no difference in the length of hospital stay after the operation. who had their follow-up on the third and 7th week still presented with wound discharges (table 1). using the t–test and fisher’s exact test. There is no anal incontinence. persistent or recurrent wound discharges were noted among seven patients who were operated on with fistulotomy (table 1). introduction of a safe and a . unidentified medical comorbidities predisposing to non-healing and synchronous rectoanal pathology. therefore. there is no difference between the two procedures in the occurrence of anal incontinence and post-operative pain (table 4 and 6).

. The outcome among the six patients in this study was successful and comparable to fistulotomy.new technique is welcome.

The early clinical outcomes were satisfactory.CONCLUSIONS The LIFT technique is simple. anal pain and presence of wound discharges were not seen after doing the LIFT procedure. It is equally effective with fistulotomy in the treatment of simple anal fistulas. . safe. and based on surgical principles in the treatment of fistula-in-ano. post-operative complications such as anal incontinence. Although the procedure is longer than fistulotomy.

The study failed to present the long term follow-up of patients to assess recurrence rate. Randomized controlled trials for future studies e. The use of LIFT on recurrent anal fistulas . f.Recommendations The author wish to recommend the following: a. it is recommended that long-term follow-up study in the future will be carried out c. The use of LIFT for simple fistula-in-ano at BGHMC b. The study presented only with 6 cases of LIFT as compared to 11 cases of fistulotomy. it is then recommended that more patients should be enrolled using the LIFT technique to assess its efficacy. Study on the use of LIFT on complex fistulas since it was initially used in complex fistulas before Dr. d. Arun’s group used in other simple fistulas.

. All data from the study was confidential unless needed for verification of results. An initials was used to identify the patients under study.Ethical Considerations The study is a retrospective cohort on the clinical outcomes of LIFT and fistulotomy on simple fistula-in-ano. The identity of the patients included in the study was strictly confidential.

29 male LIFT 48 minutes 2 days J. 49 LIFT male 90 minutes 2 days N.A. with post-op pain at 1 week post-op 2/10 Presence or absence of anal incontinence Presence or absence of wound discharges R.D.Dummy Table and Figures Table 1: Dummy table for general data of patient Patient’s Surgical Initials Procedure done Length of surgical procedure (minutes) Length of hospital stay (days) 4 days Length of hospital stay after OR 34 hours and 30 minutes Severity of postop pain (0-10 numerical scoring) 1/10. P. 29 male fistulotomy 10 minutes No anal With incontinence discharge on 1 week postop R. 36 fistulotomy male 72 minutes 8 days 39 hours and 40 minutes 22 hours and 18 minutes 24 hours and 3 minutes 17 hours and 25 minutes 27 hours and 50 minutes 24 hours and 33 minutes 4 days. 25 male fistulotomy 10 minutes 1 day J. 44 female fistulotomy 12 minutes 3 days M. E. 41 male fistulotomy 22 minutes 3 days J.C.A. 23 male LIFT 50 minutes 4 days M.Q. P. 21 hours and 18 minutes 3/10 0/10 with anal With incontinence discharge on 1 week postop No anal With incontinence discharge at 1 week postop No anal None incontinence 0/10 No anal None incontinence 0/10 No anal None incontinence 3/10 No anal None incontinence 4/10 With anal incontinence at 1st and 3rd week postop With discharge at 1st and 3rd week postop .

M. 37 male fistulotomy 24 minutes 3 days 6/10.F. 38 fistulotomy male 22 minutes 4 days R. 39 LIFT male 67 minutes 5 days With anal None incontinence at 1 week and 3 weeks post-op No anal None incontinence R. 25 male fistulotomy 10 minutes 3 days 3/10 No anal None incontinence R. 49 male Fistulotomy 26 with seton minutes 2 days 12 5/10 hours and 31 minutes 52 hours and 18 minutes 38 hours and 8 minutes 44 hours and 37 minutes 47 hours and 40 minutes 24 hours and 23 minutes 26 hours and 40 minutes 15 hours and 15 minutes 16 hours and 21 minutes 0/10 J. 37 male fistulotomy 2 minutes 3 days 4/10 R.D.B. 26 male LIFT 40 minutes 2 days 0/10 No anal With incontinence discharge 1 week postop No anal None incontinence R. G.T.D. 28 fistulotomy male 23 minutes 3 days 6/10 D. 6/10 2 weeks post-op 5/10 No anal Wound incontinence discharges persisted on the 7th week No anal None incontinence C. A. 50 male LIFT 54 minutes 2 days 0/10 With anal incontinence 1 week postop No anal incontinence With discharge 1 week postop None .B.A.

TIME SCHEDULE October 2010 - Preparation of research materials Data collection Encoding of collected data November 2010 - ERC approval Encoding Collation and analysis of data Presentation of Results Writing of manuscript December 2010 - Final Report Presentation of results .

304(6831): 904-7 5 van Tets WF.al.S. Stitz RW.Cohen J.J. Apr 4 1992. Buie WD. The Riddle of Fistula-in-ano. Philips. Continence disorders after anal fistulotomy.A. Kilkenny J III. 5th ed. Orsay C. Springer_Verlag 11 Shanwani. 48: 1337-42 4 Hancock BD. Lippincott Williams & Wilkins p. Manila Philippines 3 Whiteford MH. Dis Colon Rectum 1994. 37: 1194-7. ABC of Colorectal diseases.SMX Convention Center Pasay. 2010. Metro Manila Philippines 2 Rojanasaku. Lunniss. Dis Colon Rectum 2010... Lunniss. A. Spinger-Verlag 2009 7 Matos D.References: 1 Rojanasakul.Dec 6-9. 6 Rojanasakul. Hyman N. 316 9 Rojanasakul A. 2009.J. Kuijpers HC. Medscape. Diamond Hotel. et al. MD et. PJ.53:39-42 12 Beals. Novel Surgical Correction of Intersphincteric Perianal Fistulas Preserves Anal Sphincter. Dis Colon Rectum 2005. PSCRS 1st National Convention. BMJ. Anal fissures and Fistulas.Dis Colon Rectum 1976. Ligation of Intersphincteric Fistula Tract (LIFT): A sphincter saving technique for fistula-in-ano.. Springer-Verlag 2010 10 Lunniss P. 25 July 2009. Published online. Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised).A M. Br J Surg 80:802-804 8 Corman ML (2004) Anal Fistula in-ano:Colon and Rectal Surgery. RKS (1993) Total Sphincter Conservation in fistula-in-ano: results of a new approach.com 13 Parks AG. LIFT 65th PCS Annual Convention 2009. PhD. Invited comment: LIFT procedure: a simplified technique for fistula-in-ano. LIFT procedure: a simplified technique for fistula-in-ano. Wikipedia . March 25-26. A. The treatment of high fistula-in-ano. Published online: 12 January 2010.19:487499 14 LIFT technique. Comments to the invited comment: LIFT procedure: a simplified technique for fistula-in-ano” by P.