A Comparison of Different Surgical Treatments for Complex Anal Fistula: Flap Procedures, LIFT, TROPIS, or FiLaC

Abstract

Introduction: Chronic paraproctitis is a common proctological pathology predominantly affects younger population and leads to deteriorated quality of life (QoL). Fistula-in-ano could be simple or complex. A complex fistula is difficult to treat due to higher recurrence rates and incontinence associated with surgery, especially in female patients. There are variety of surgical approaches, which have been developed for the eradication of complex fistulas with differences in postop results in long-term follow-up.

Materials and Methods: Retrospective analysis of cases of complex perianal fistulas operated on at the Clinic of Surgery of Alexandrovska University Hospital, comparing the most modern and well-established methods for fistula closure—flap techniques, LIFT, TROPIS, and FiLaC, has been conducted. The markers examined were primary: recurrences and degree of incontinence at follow-up, and secondary: technical complexity of the procedure, operative time, postoperative pain and recovery, cost.

Results: For the period from 2007 to 2025, 168 patients with perianal fistulas were operated on—64% were male and 36% were female, at an average age of 36 years. The applied techniques were: lay-open—45%; flap—22%; LIFT—24%; TROPIS—6%; FiLaC—3%. The follow-up period varied from 3 months to 72 months. The recurrence rate varied from 4% to 33%, with the data for the FiLaC method not being relevant due to the recent introduction of the technique. The LIFT procedure showed the highest level of success, but here, together with the flap methods, the technical implementation was the most difficult. Mild incontinence was observed with the flap and LIFT techniques, which spontaneously resolved within 3 months. The operating time was the shortest with the laser method and there was no significant difference in postoperative pain and recovery period amongst the different approaches. The FiLaC method required payment for consumables, unlike the other techniques.

Discussion: There are a significant number of new therapies to address the problem of complex perianal fistula. Sphincter-preserving procedures have the presumption of healing the fistula with no/or minimal risk to continence. As far as the current results of multiple studies of varying strength and quality of design are concerned, confirmed by the results of our study, several combined techniques based on draining Seton (pulling/loose Seton; EAS-preserving Seton after repositioning; Seton repositioning around the EAS, combined with a mucosal/+ submucosa and superficial fibers flap from the IAS), the LIFT technique, the FiLaC method, as well as the TROPIS technique are currently considered feasible therapies for complex anal fistulas, of course under certain conditions, given the complex morphological variations of complex fistulas. Regardless of the twelve currently applied (with variable frequency and modifiable nature) surgical methods available in world surgical practice, the realistically achieved level of success varies on average from 60% to 80% with long-term follow-up, and we must strive not to go, in our results, below the upper limit of this level.