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Session: ePoster: Benign Anorectal 6 (Mon1015)

EP689 - Early Experience in Management of Complex High Transphincteric Fistula-in-Ano Disease: A Single Center Series

Monday, May 12, 2025
10:36 AM – 10:41 AM PT

    ePoster Presenter(s)

  • Joshua Zane, MD (he/him/his)

    General Surgery Resident
    Intermountain Health - Saint Joseph Hospital General Surgery
    Denver, CO, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no financial relationships with ineligible companies.

    • Senior Author(s)

  • NB

    Noelle Bertelson, MD, MPH, FACS, FASCRS

    Associate Program Director
    Intermountain Health - Saint Joseph Hospital General Surgery
    Denver, Colorado, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no financial relationships with ineligible companies.

All of the relevant financial relationships listed below have been mitigated.
Joshua Zane, MD: This individual has no financial relationships with ineligible companies.
Noelle Bertelson, MD, MPH, FACS, FASCRS: This individual has no financial relationships with ineligible companies.
Image or Table (Do Not add text here):

Purpose/Background: High transphincteric fistulas represent a subtype of anal fistula that requires complex management and repair due to high rates of recurrence. Both the ligation of intersphincteric tract (LIFT) and the endorectal mucosal advancement flap (ERF) procedures are used in treating this specific disease. However, neither has proven to be superior, leading to development of modifications of each procedure. Use of reinforcement material may be beneficial when there is higher complexity of disease. In the current series, we modify the LIFT and ERF procedures by incorporating extracellular matrix (ECM) into the repairs to reduce disease recurrence in complex high transphincteric fistulas.

Methods/Interventions: This is an IRB approved single institution retrospective case review of all patients who underwent complex LIFT and ERF repairs with ECM reinforcement between 2020-2024. Extracellular matrix was chosen based on clinical complexity of transphincteric disease at time of index procedure. Factors considered for complexity were initial abscess size >3cm, >4 months with a draining seton, depth of fistula tract >1cm, wide or branching tract within intersphincteric space, horseshoe abscess or fistula tract, prior recurrences, chronic immunosuppression and comorbidities. Repairs were reinforced by placing a sheet of ECM within the intersphincteric space between the ligated fistula tracts. Patients were followed in clinic for at minimum one visit to determine closure of fistula tract. The primary endpoint was 1-year fistula recurrence rate. Secondary endpoints included disease free interval, postoperative complications, and time to clinical closure of fistula tract.

Results/Outcomes: A total of 16 patients were included for review in this study. The median age was 43 with 10 (63%) male and 6 (38%) female. Race consisted of 11 (69%) Caucasian, 4 (25%) Hispanic, and 1 (6%) Other. While 11 (69%) of patients had commercial insurance, 4 (25%) had hospital charity services. There were 11 (69%) LIFT with ECM repairs, 4 (25%) ERF with ECM repairs, and 1 (6%) patient undergoing combination LIFT and ERF with ECM repair. A total of 3 (21%) patients had recurrence of disease. Of these patients, 2 had LIFT with ECM repairs with a 12-week median disease-free interval prior to recurrent disease. There was 1 ERF with ECM repair that reoccurred after 31 weeks. 1 patient undergoing combination LIFT and ERF repair with ECM had failure of their repair on postoperative day 10. 10 patients had clinical closure of disease including 8 LIFT with ECM repairs and 2 ERF with ECM repairs. Of these patients, the median time to clinical closure was observed as 7 weeks (7 weeks LIFT with ECM, 6 weeks ERF with ECM). Of note, 1 patient with a LIFT with ECM repair was lost to follow up and 1 patient with an ERF with ECM repair is under ongoing follow up clinical evaluation.

Conclusion/Discussion: The use of extracellular matrix in complex high intersphincteric fistulas may result in lower recurrence and faster healing rates. However, further investigation involving controlled comparisons is required to determine legitimacy of reinforced repair as well as which factors have greater contribution in complex disease.