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The Ligation of the Intersphincteric Fistula Tract Procedure for Anal Fistula : A Mixed Bag of Results
肛瘺括約肌間瘺束手術的結紮術： 結果喜憂參半

Sirany, Anne-Marie E. M.D.Nygaard, Rachel M. Ph.D.Morken, Jeffrey J. M.D.
安妮-瑪麗 E. 醫學博士 SiranyNygaard， Rachel M. 博士傑弗里·莫肯 （Jeffrey J. M.D.）

Abstract   抽象

BACKGROUND:   背景：

The ligation of the intersphincteric fistula tract procedure, a sphincter-preserving technique, aims to obtain complete, durable healing, while preserving fecal continence in the treatment of transsphincteric anal fistulas.
括約肌間瘺束結紮手術是一種保留括約肌的技術，旨在獲得完全、持久的癒合，同時在治療經括約肌肛瘺時保持大便失禁。

OBJECTIVE:   目的：

This was a systematic review to evaluate the outcomes of the originally described (classic) ligation of the intersphincteric fistula tract procedure and the identified technical variations of the procedure.
這是一項系統評價，旨在評估最初描述的括約肌間瘺束結紮手術的（經典）結局以及已確定的手術技術差異。

DATA SOURCES:   資料來源：

PubMed, Web of Science, and the archive of Diseases of the Colon & Rectum were searched with the terms “ligation of intersphincteric fistula” and “ligation of intersphincteric fistula tract.”
PubMed、Web of Science 和結腸和直腸疾病檔案通過術語「括約肌間瘺的結紮」和“括約肌間瘺道的結紮”進行檢索。

STUDY SELECTION:   研究選擇：

Original, English-language studies reporting the primary healing rate for each technical variation of the ligation of the intersphincteric fistula tract procedure were included. Studies were excluded when the technique used was unclear or when primary healing rate was reported in a pooled manner including outcomes from multiple technical variations of the ligation of the intersphincteric fistula tract procedure.
納入了報告括約肌間瘺束手術結紮的每種技術變化的初級癒合率的原始英文研究。當使用的技術不明確或以匯總方式報告初次癒合率時，包括括約肌間瘺管結紮手術的多種技術變化的結果，研究被排除在外。

INTERVENTION:   介入：

Outcomes associated with all of the technical variations of the ligation of the intersphincteric fistula tract procedure were investigated.
調查了與括約肌間瘺管手術結紮的所有技術變化相關的結果。

MAIN OUTCOME MEASURES:   主要結局指標：

The main outcome measured was primary healing rate. Secondary outcome measures included time to healing, changes in continence, and risk factors for failure.
測量的主要結局是原發性癒合率。次要結局指標包括癒合時間、節制變化和失敗的危險因素。

RESULTS:   結果：

In all, 26 studies met criteria for review, including 1 randomized controlled trial and 25 cohort/case series. Seven technical variations of the ligation of the intersphincteric fistula tract procedure were identified and classified according to the surgical technique. Primary healing rates ranged from 47% to 95%.
總共有 26 項研究符合綜述標準，包括 1 項隨機對照試驗和 25 項佇列/病例系列。根據手術技術確定了括約肌間瘺束手術結紮的 7 種技術變異並進行分類。原發性治癒率為 47% 至 95%。

LIMITATIONS:   局限性：

The levels of evidence available in the published works are relatively low, as indicated by the Oxford Center for Evidence-Based Medicine evidence levels.
正如牛津循證醫學中心證據水準所表明的那樣，已發表作品中可用的證據水平相對較低。

CONCLUSIONS:   結論：

The ligation of the intersphincteric fistula tract procedure is a promising treatment option for transsphincteric fistulas, with reasonable success rates and minimal impact on continence. The true efficacy of the procedure is unknown because of the number of technical variations and the pooled results reported in the literature.
括約肌間瘺束結紮手術是經括約肌瘺的一種很有前途的治療選擇，成功率合理，對節制的影響最小。由於文獻中報導的技術變異數量和匯總結果，該程式的真正療效尚不清楚。

An anal fistula is a persistent tract that develops between the anal canal and perianal skin, resulting in intermittent swelling, pain, and purulent drainage.
肛瘺是在肛管和肛周皮膚之間形成的持久性束，導致間歇性腫脹、疼痛和膿性引流。 The most common etiology is a cryptoglandular infection after drainage of a perianal abscess,
最常見的病因是肛周膿腫引流后的隱腺感染， , whereas other causes include Crohn’s disease, trauma, radiation, or malignancy.
而其他原因包括克羅恩病、外傷、放射線或惡性腫瘤。 Anal fistulas are classified by their anatomic relationship to the anal sphincter musculature: superficial, intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric.
肛瘺根據其與肛門括約肌的解剖關係進行分類：淺表、括約肌間、跨括約肌、括約肌上和括約肌外。 They can also be classified as simple or complex. Complex fistulas include high transsphincteric (>30% external sphincter involvement), suprasphincteric, or extrasphincteric fistulas; other types are horseshoe fistulas, recurrent fistulas, and, in women, anterior fistulas. Complex fistulas can be associated with multiple tracts, pre-existing incontinence, IBD, radiation, or malignancy.
它們也可以分為簡單或複雜。複雜瘺管包括高位經括約肌（>30% 外括約肌受累）、括約肌上或括約肌外瘺;其他類型包括馬蹄瘺、復發性瘺管和女性前瘺。複雜瘺管可能與多條尿束、預先存在的尿失禁、IBD、放射或惡性腫瘤有關。 , For surgeons, complex fistulas pose a particular treatment problem, because no single surgical technique has demonstrated a high success rate while preserving sphincter function.
對於外科醫生來說，複雜瘺管是一個特殊的治療問題，因為沒有一種手術技術在保留括約肌功能的同時顯示出高成功率。
Transsphincteric fistulas typically do not heal spontaneously nor are they amenable to any form of medical management. They are believed to persist, in part, because of the entrance of fecal material into the internal opening within the anal canal.
經括約肌瘺通常不會自發癒合，也不適合任何形式的藥物治療。據信，它們之所以持續存在，部分原因是糞便物質進入了肛管內的內部開口。 This, combined with intermittent compression of the intersphincteric portion of the tract between the sphincters, creates a septic focus.
這與括約肌之間束括約肌間部分的間歇性壓迫相結合，形成了敗血症病灶。 , , The treatment for anal fistulas is surgery; the goal is complete, durable healing with preservation of fecal continence.
肛瘺的治療方法是手術;目標是在保持大便失禁的情況下實現完全、持久的癒合。 , , Surgical techniques are composed of 2 broad categories, including sphincter-preserving procedures, such as fibrin glue injection, fistula plug, and rectal advancement flap, and sphincter-sacrificing procedures, such as cutting seton, fistulotomy, and fistulectomy. In general, sphincter-sacrificing procedures have high success rates but are associated with high rates of fecal incontinence. In contrast, sphincter-preserving procedures have more modest success rates but are associated with a relatively minimal risk of changes in continence.
手術技術包括 2 大類，包括保留括約肌的手術，例如纖維蛋白膠注射、瘺管塞和直腸前移皮瓣，以及括約肌犧牲手術，例如切割掛線、瘺管切開術和瘺管切除術。一般來說，犧牲括約肌手術的成功率高，但大便失禁的發生率高。相比之下，保留括約肌手術的成功率較低，但尿失禁變化的風險相對較小。
The ligation of the intersphincteric fistula tract (LIFT) procedure was first reported in 2007 as a sphincter-preserving procedure, primarily indicated for transsphincteric fistulas.
括約肌間瘺管結紮術 （LIFT） 手術於 2007 年首次報導，作為保留括約肌的手術，主要用於經括約肌瘺管。 Rojanasakul et al  Rojanasakul 等人 proposed that ligation and excision of the intersphincteric portion of the fistula tract would close the internal opening, as well as eliminate the intersphincteric septic nidus. The sphincter muscle is not divided, so the impact on continence was projected to be negligible. In a series of 18 patients, they reported a success rate of 94% with no changes in continence.
提出結紮和切除瘺管的括約肌間部分將關閉內部開口，並消除括約肌間敗血病灶。括約肌沒有分裂，因此預計對節制的影響可以忽略不計。在一項包含18名患者的系列研究中，他們報告的成功率為94%，尿失禁沒有變化。 Given these promising initial outcomes, the LIFT procedure has increased in popularity.
鑒於這些有希望的初步結果，LIFT 手術越來越受歡迎。
Numerous studies have since been published on the LIFT procedure, with success rates varying from 47% to 95%.
此後發表了許多關於 LIFT 手術的研究，成功率從 47% 到 95% 不等。 , , A major limitation of the literature is the inclusion of several technical variations of the LIFT procedure, with little direct comparison of these variations with the original LIFT procedure. Several systematic reviews evaluated the cumulative data since the introduction of the LIFT procedure; however, they reported pooled success rates, which included all of the technical variations of the LIFT procedure.
文獻的一個主要局限性是納入了 LIFT 手術的幾種技術變體，幾乎沒有將這些變體與原始 LIFT 手術進行直接比較。幾項系統評價評估了自引入 LIFT 手術以來的累積數據;然而，他們報告了匯總成功率，其中包括 LIFT 手術的所有技術變化。 , , , Therefore, the true efficacy of the originally described LIFT procedure (classic LIFT) and of its technical variations is not clearly known. In addition, specific risk factors affecting success have not been clearly identified; we do not know the impact, if any, of preoperative imaging or routine draining seton placement.
因此，最初描述的 LIFT 手術（經典 LIFT）及其技術變化的真正療效尚不清楚。此外，影響成功的具體風險因素尚未明確確定;我們不知道術前影像學檢查或常規引流掛線放置的影響（如果有的話）。
The goals of this review were to identify the individual success rates of the original LIFT procedure and its technical variations, assess the impact of the LIFT procedure on continence, and identify any risk factors for failure of the LIFT procedure.
本綜述的目的是確定原始 LIFT 手術的個體成功率及其技術變化，評估 LIFT 手術對節制的影響，並確定 LIFT 手術失敗的任何危險因素。

MATERIALS AND METHODS   材料和方法

A systematic review was conducted according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses group.
根據系統評價和薈萃分析首選報告專案小組的指南進行了系統評價。 ,

Search Strategy   檢索策略

A comprehensive literature search of PubMed, Web of Science, and archive search of Diseases of the Colon & Rectum , as well as a directed search of all embedded references in reviewed articles, was conducted to identify English-language primary publications related to the LIFT procedure. No timeframe limit was imposed on the search; however, the LIFT procedure was first reported in the literature in 2007. Key search terms included “ligation of intersphincteric fistula tract” and “ligation of intersphincteric fistula.”
對 PubMed、Web of Science 和 Diseases of the Colon & Rectum 的檔案檢索，以及對審查文章中所有嵌入的參考文獻進行了定向檢索，以確定與 LIFT 手術相關的英文主要出版物。搜索沒有時間限制;然而，LIFT 手術於 2007 年首次在文獻中報導。主要檢索詞包括 「ligation of sphincteric fistula tract」 和 “ligation of sphincteric fistula”。

Selection Criteria   納入排除標準

Studies reporting a primary healing rate with clear details of the LIFT procedure were included for analysis. Studies were excluded if they failed to report a primary healing rate or reported only a pooled primary healing rate (including the healing rate from multiple technical variations of the LIFT). When studies reported extended outcomes from an already-described patient cohort, only the original study was included for review. Corresponding authors were contacted to clarify the procedural technique when it was unclear; when appropriate, these studies were included for further review. Review articles, case reports, abstracts that later led to full publication, letters, editorials, and comments were excluded from further review.
納入報告了 LIFT 手術明確細節的初級癒合率的研究以供分析。如果研究未能報告原發性癒合率或僅報告匯總的原發性癒合率（包括 LIFT 多種技術變體的治癒率），則排除這些研究。當研究報告了已描述的患者佇列的擴展結局時，僅納入原始研究以供審查。當程式技術不清楚時，聯繫了通訊作者以澄清程序技術;在適當的情況下，這些研究被納入以供進一步評價。綜述文章、病例報告、後來導致完整發表的摘要、信件、社論和評論被排除在進一步審查之外。

Study Selection   研究選擇

A 2-step process was used to identify relevant studies. All of the abstracts were initially reviewed for potential inclusion by 2 independent reviewers (A-M.E.S. and J.J.M.). The selected articles were then reviewed independently by the 2 reviewers, categorized as meeting or not meeting inclusion/exclusion criteria, and scored according to the level of evidence. The quality of level of evidence was characterized for each study using the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence system.
採用 2 步過程來確定相關研究。所有摘要最初由 2 位獨立評價員 （A-M.E.S. 和 J.J.M.） 進行審查，以納入。然後由 2 位評價員獨立評價選定的文章，分類為符合或不符合納入/排除標準，並根據證據水平進行評分。使用牛津循證醫學中心 2011 年證據水平系統對每項研究的證據質量進行表徵。 Any discrepancies were resolved by discussion with a third reviewer (R.M.N.).
通過與第三位評價員 （R.M.N.） 討論解決任何差異。

Data Extraction and Outcomes
數據提取和結果

The details of the operative technique were carefully reviewed in each publication. Review of the operative technique resulted in identification of 6 technical variations on the originally described LIFT procedure (classic LIFT): LIFT without excision of the intersphincteric tract, the LIFT-plus, the LIFT-plus with intraoperative seton placement, the LIFT-plus with advancement flap, the LIFT-plug, and the BioLIFT.
每篇出版物都仔細審查了手術技術的細節。對手術技術的審查導致確定了最初描述的 LIFT 手術（經典 LIFT）的 6 個技術變化：不切除括約肌束的 LIFT、LIFT-plus、術中掛線放置的 LIFT-plus、帶前進皮瓣的 LIFT-plus、LIFT 插頭和 BioLIFT。
The classic LIFT, as originally described by Rojanasakul et al,
經典的 LIFT，正如 Rojanasakul 等人最初描述的那樣， is performed with the patient in the prone jackknife position under regional anesthesia. The internal opening is identified by injecting water through the external opening or by probing the fistula tract. A curvilinear incision is made in the intersphincteric plane over the site of the fistula tract. Meticulous dissection with scissors and electrocautery is used to identify the intersphincteric tract; exposure is facilitated by the use of retractors. The intersphincteric tract is hooked with a right-angled clamp and is then ligated close to the internal sphincter with polyglactic 3/0 sutures. The tract is divided distal to the point of ligation. The remnant of the intersphincteric tract, or possibly the infected gland, is removed and sent for histopathologic analysis. Water is injected through the external opening to confirm that the correct tract was divided. The fistula tract is curetted. The external opening is drained through an additional incision. The intersphincteric wound is loosely closed with interrupted polyglactic 3/0 sutures.
在區域麻醉下，患者處於俯臥折刀位置進行。通過通過外部開口注入水或探查瘺管來識別內部開口。在瘺管部位上方的括約肌間平面上做一個曲線切口。用剪刀和電烙術細緻解剖以識別括約肌間束;使用牽開器有助於暴露。括約肌間束用直角夾鉤住，然後用多乳膠 3/0 縫合線在靠近括約肌內的地方結紮。該束在結紮點的遠端分開。去除括約肌間束的殘餘部分，或可能的感染腺體，並送去進行組織病理學分析。通過外部開口注入水，以確認劃分了正確的通道。瘺管被刮除。外部開口通過一個額外的切口排出。括約肌間傷口用間斷的多乳膠 3/0 縫合鬆散地閉合。
The main outcome evaluated was successful treatment of the fistula (primary healing), defined clinically as complete healing of both the surgical intersphincteric wound and the original external opening of the fistula. Secondary outcomes included any changes in continence and risk factors for failure of the procedure. Other recorded data included study design, number of patients, percentage of transsphincteric fistula, preoperative imaging, preoperative seton use, preoperative and postoperative continence evaluation technique, changes in continence, risk factors for failure of the procedure, follow-up duration, time to healing, and secondary interventions. A meta-analysis was not included in this review because of the limited published reports regarding each of the technical variations of the LIFT.
評估的主要結局是瘺管的成功治療（一期癒合），臨床定義為手術括約肌傷口和瘺管原始外部開口完全癒合。次要結局包括尿失禁的任何變化和手術失敗的危險因素。其他記錄的數據包括研究設計、患者人數、經括約肌瘺的百分比、術前影像學、術前掛線使用、術前和術后失禁評估技術、節制變化、手術失敗的危險因素、隨訪時間、癒合時間和二次干預。由於關於 LIFT 每種技術變化的已發表報告有限，因此本綜述未納入薈萃分析。

RESULTS   結果

The literature search strategy identified 133 articles for review ( Fig. 1). After careful review, a total of 26 studies were included for analysis ( Fig. 1 and Table 1). The search identified a single randomized controlled trial
文獻檢索策略確定了 133 篇文章進行綜述（ 圖 1）。經過仔細審查，共納入 26 項研究進行分析（ 圖 1 和表 1）。檢索確定了一項隨機對照試驗; all of the other studies were prospective or retrospective cohort/case series. Published variations of the LIFT, including the classic LIFT procedure, were identified and classified according to the surgical technique described: the classic LIFT,
;所有其他研究均為前瞻性或回顧性佇列/病例系列研究。已發表的 LIFT 變體，包括經典的 LIFT 手術，根據所描述的手術技術進行識別和分類：經典的 LIFT， , the LIFT without excision of the intersphincteric tract,
不切除括約肌間束的 LIFT， the LIFT-plus,  LIFT-plus、 , the LIFT-plus with intraoperative seton placement,
LIFT-plus 術中掛線放置， the LIFT-plus with advancement flap,
帶前進擋板的 LIFT-plus， the LIFT-plug,  LIFT 插頭， and the BioLIFT.  和 BioLIFT。 ,
Table 1. Studies included in review undefined

Table 1. Studies included in review
表 1.納入綜述的研究

Table 1. Studies included in review undefined

Table 1. Studies included in review
表 1.納入綜述的研究

undefined undefined

Figure 1   圖 1

Systematic review flow diagram.
系統評價流程圖。

Classic LIFT   經典 LIFT

A total of 12 studies, including 352 patients, described outcomes associated with the classic LIFT procedure ( Table 2).
共有 12 項研究，包括 352 名患者，描述了與經典 LIFT 手術相關的結果（ 表 2）。 , The healing rate ranged from 61.0% to 94.4%. When reported, the time to healing ranged from 4 to 8 weeks; follow-up duration ranged from 3 to 13 months. One patient reported postoperative fecal incontinence; however, the authors did not describe any further clinical follow-up or impact of the change on quality of life.
治癒率從 61.0% 到 94.4% 不等。據報導，癒合時間從 4 到 8 周不等;隨訪時間從 3 個月到 13 個月不等。1 例患者報告術后大便失禁;然而，作者沒有描述任何進一步的臨床隨訪或變化對生活質量的影響。 BMI was noted to be a risk factor for recurrence after both the classic LIFT and the LIFT-plus.
BMI 被認為是經典 LIFT 和 LIFT-plus 後復發的危險因素。 In another study, fistula tract length of ≥3 cm was identified as a risk factor for failure of the classic LIFT.
在另一項研究中，瘺管長度為 ≥3 cm 被確定為經典 LIFT 失敗的危險因素。
Table 2. Classic LIFT undefined

Table 2. Classic LIFT   表 2.經典 LIFT

Table 2. Classic LIFT undefined

Table 2. Classic LIFT   表 2.經典 LIFT

LIFT Without Excision   無需切除的 LIFT

In this slight variation from the classic LIFT, the intersphincteric portion of the tract is ligated and divided but not excised. A total of 5 studies, including 130 patients, reported on this variation ( Table 3).
與傳統 LIFT 的這種細微變化中，束的括約肌間部分被結紮和分裂，但未切除。共有 5 項研究，包括 130 名患者，報告了這種變化（ 表 3）。 The healing rate ranged from 47.0% to 94.2%. The time to healing neared 4 weeks but was reported in only 2 of the 5 studies.
癒合率從 47.0% 到 94.2% 不等。癒合時間接近 4 周，但 5 項研究中只有 2 項報告了治愈時間。 , Follow-up ranged from 3.0 to 19.2 months, but most studies reported a relatively short follow-up duration of 3.0 to 5.0 months.
隨訪時間從 3.0 個月到 19.2 個月不等，但大多數研究報告的隨訪持續時間相對較短，為 3.0 至 5.0 個月。 , , No changes in continence were reported. In a single randomized controlled study,
未報告尿失禁的變化。在一項隨機對照研究中， this variation was compared with an advancement flap: the healing rate was 68% for the LIFT without excision versus 85% for the advancement flap.
將這種變化與前進皮瓣進行了比較：無切除的 LIFT 的癒合率為 68%，而前進皮瓣的癒合率為 85%。
Table 3. LIFT without excision undefined

Table 3. LIFT without excision
表 3.無需切除的 LIFT

Table 3. LIFT without excision undefined

Table 3. LIFT without excision
表 3.無需切除的 LIFT

LIFT-Plus   LIFT-Plus 提升

The LIFT-plus procedure combines the classic LIFT with the coring out of the fistula tract from the external opening of the fistula tract to the lateral border of the external sphincter.
LIFT-plus 手術將經典的 LIFT 與從瘺管外開口到外括約肌外緣的瘺管取芯相結合。 A total of 4 prospective studies, including 104 patients, focused on this technical variation ( Table 4).
共有 4 項前瞻性研究，包括 104 名患者，專注於這種技術差異（ 表 4）。 , The healing rate ranged from 76.5% to 85.0%. The time to healing ranged from 4 to 7 weeks. Follow-up duration ranged from 5.0 to 19.5 months. As noted above, BMI was noted to be a risk factor for recurrence after both the classic LIFT and the LIFT-plus procedures.
治癒率從 76.5% 到 85.0% 不等。癒合時間從 4 到 7 周不等。隨訪時間從 5.0 個月到 19.5 個月不等。如上所述，BMI 被認為是經典 LIFT 和 LIFT-plus 手術后復發的危險因素。 No changes in continence were reported.
未報告尿失禁的變化。
Table 4. LIFT-plus undefined

Table 4. LIFT-plus   表 4.LIFT-plus 電梯

Table 4. LIFT-plus undefined

Table 4. LIFT-plus   表 4.LIFT-plus 電梯

LIFT-Plus With Intraoperative Seton
LIFT-Plus 術中掛線

This recently described variation of the LIFT-plus procedure includes the ligation of the internal sphincter side of the intersphincteric portion of the fistula tract but adds a seton placed through the LIFT incision site out through the cored-out external opening of the fistula tract,
最近描述的 LIFT-plus 手術的變體包括結紮瘺管括約肌間部分的內括約肌側，但增加了一個通過 LIFT 切口部位通過瘺管的內核外部開口向外放置的掛線， which is then removed at 3 postoperative weeks. The proposed benefit of the seton is to minimize the potential impact of any residual local sepsis in the intersphincteric space, which could compromise the closure of the internal opening of the fistula. The healing rate was 95% in 20 patients ( Table 5). Median follow-up duration was 18 months; median time to healing was 7 weeks. Continence was evaluated preoperatively and postoperatively with both anal manometry and the Fecal Incontinence Severity Index, with no changes found.
然後在術后 3 周將其取出。掛線的擬議好處是最大限度地減少括約肌間隙中任何殘留的局部膿毒症的潛在影響，這可能會損害瘺管內部開口的閉合。20 名患者的癒合率為 95%（表 5）。中位隨訪時間為 18 個月;中位癒合時間為 7 周。術前和術后用肛門測壓和大便失禁嚴重程度指數評估尿失禁，未發現變化。
Table 5. Other technical variations of the LIFT procedure undefined

Table 5. Other technical variations of the LIFT procedure
表 5.LIFT 手術的其他技術變化

Table 5. Other technical variations of the LIFT procedure undefined

Table 5. Other technical variations of the LIFT procedure
表 5.LIFT 手術的其他技術變化

LIFT-Plus With Flap   帶翻蓋的 LIFT-Plus

This variation adds a transanal advancement flap repair to the LIFT-plus procedure ( Table 5).
這種變化在 LIFT-plus 手術中增加了經肛門前移皮瓣修復術（ 表 5）。 The healing rate was 51% in 41 patients, with a median follow-up duration of 15 months. No patient characteristics or fistula factors predicted failure of the procedure. One patient had a worse postoperative Fecal Incontinence Severity Index score but did not experience any change in continence overall.
41 例患者的癒合率為 51%，中位隨訪時間為 15 個月。沒有患者特徵或瘺管因素預測手術失敗。1 例患者術后大便失禁嚴重程度指數評分較差，但總體失禁無任何變化。

LIFT-Plug   LIFT-插頭

In this variation, an anal fistula plug is added to the LIFT procedure. The plug is secured to the external sphincter and fills the external portion of the tract distal to the external sphincter.
在這種變體中，LIFT 手術中增加了一個肛瘺栓。栓子固定在外括約肌上，並填充外括約肌遠端的束外部。 A single prospective study described 21 patients with transsphincteric fistulas who underwent the LIFT-plug procedure for initial fistula repair ( Table 5).
一項前瞻性研究描述了 21 名經括約肌瘺患者，他們接受了 LIFT 塞手術進行初始瘺管修復（ 表 5）。 The healing rate was 95%. Median time to healing was 2 weeks for the external anal fistula opening and 4 weeks for the intersphincteric surgical incision. Median follow-up duration was 14 months. No fecal incontinence was reported, but 1 patient experienced infrequent incontinence for gas (Wexner Incontinence Score of 1).
治癒率為 95%。肛瘺外瘺開口的中位癒合時間為 2 周，括約肌間手術切口的中位癒合時間為 4 周。中位隨訪時間為 14 個月。未見大便失禁報告，但 1 例患者出現不頻繁的氣體失禁 （Wexner 失禁評分為 1）。

BioLIFT   生物升降機

The BioLIFT procedure interposes a bioprosthetic mesh between the ligated ends of the intersphincteric portion of the fistula tract. A total of 2 studies, encompassing 44 patients, focused on this variation ( Table 5).
BioLIFT 手術在瘺管括約肌間部分的結紮端之間插入生物假體網片。共有 2 項研究，包括 44 名患者，專注於這種變化（ 表 5）。 , Ellis  埃利斯 initially reported on 31 patients, with a healing rate of 94.0% and no incontinence. Median follow-up duration was 15 months. In a smaller study by Tan and Lee,
最初報導了 31 例患者，癒合率為 94.0%，無尿失禁。中位隨訪時間為 15 個月。在 Tan 和 Lee 的一項較小的研究中， involving only 13 patients, the healing rate was 68.8% with no changes in continence; median follow-up duration was 6.5 months. Preoperative and postoperative manometry measurements did not significantly change.
僅涉及 13 例患者，癒合率為 68.8%，大小便失禁無變化;中位隨訪時間為 6.5 個月。術前和術后測壓測量值沒有顯著變化。

Classic LIFT in Patients With Crohn’s Disease
克羅恩病患者的經典 LIFT

In 2013, Gingold et al
2013 年，Gingold 等人 evaluated the classic LIFT procedure in 15 patients with Crohn’s disease. The healing rate was 60% at 2.0 months; mean follow-up duration was 11.2 months ( Table 5). At 6.0 months, 1 patient had a recurrence of the original fistula. At 12.0 months, of the 9 patients whose procedure was successful, 3 developed a novel fistula. The authors reported midline fistulas and shorter fistula tracts to be associated with failure. No changes in continence were reported.
在 15 名克羅恩病患者中評估了經典的 LIFT 手術。2.0 個月時癒合率為 60%;平均隨訪時間為 11.2 個月 （ 表 5）。在 6.0 個月時，1 例患者原始瘺管復發。在 12.0 個月時，在手術成功的 9 例患者中，有 3 例出現了新型瘺管。作者報告了中線瘺管和較短的瘺管束與失敗有關。未報告尿失禁的變化。

DISCUSSION   討論

When surgically treating complex anal fistulas, the primary goal is to achieve complete, durable healing while preserving continence. However, with current surgical options, reaching this goal remains a struggle. To date, 4 other reviews
在手術治療複雜的肛瘺時，主要目標是在保持節制的同時實現完全、持久的癒合。然而，使用目前的手術選擇，實現這一目標仍然是一項艱巨的任務。迄今為止，其他 4 條評論 , , , have addressed the LIFT procedure; however, all 4 pooled outcomes for all of the technical variations and reported success rates for the LIFT procedure as if it were a single technique being performed in a consistent manner. In reality, at least 6 different technical variations of the originally described LIFT procedure (what we call the classic LIFT) have been identified in the literature, and only 1 of them has been directly compared with the original procedure.
解決了 LIFT 程式;然而，所有 4 個合併了所有技術變化的結果，並報告了 LIFT 手術的成功率，就好像它是以一致的方式進行的單一技術一樣。實際上，文獻中已經確定了最初描述的 LIFT 手術（我們稱之為經典 LIFT）的至少 6 種不同的技術變體，其中只有 1 種與原始手術進行了直接比較。 Therefore, it has been difficult to ascertain the true efficacy of the classic LIFT or any of its technical variations. In our systematic review of the existing literature, we paid specific attention to the technical details of the operative procedures reported. A total of 26 studies ( Table 1) reported a clear procedural technique and primary healing rate. We found significant heterogeneity in the procedural techniques reported, wide variety in the results, and a lack of long-term follow-up.
因此，很難確定經典 LIFT 或其任何技術變體的真正功效。在我們對現有文獻的系統評價中，我們特別關注了所報導的手術程序的技術細節。共有 26 項研究 （ 表 1） 報告了明確的手術技術和初級癒合率。我們發現報告的手術技術存在顯著異質性，結果差異很大，並且缺乏長期隨訪。
Introduced in 2007, the classic LIFT procedure strives to achieve the success rates of sphincter-sacrificing procedures while preserving continence. Rojanasakul et al
經典的 LIFT 手術於 2007 年推出，致力於在保持節制的同時實現括約肌犧牲手術的成功率。Rojanasakul 等人 initially reported a 94% healing rate; subsequent studies reported rates ranging from 47% to 95%.
最初報告的治癒率為 94%;隨後的研究報告的發生率從 47% 到 95% 不等。 , The procedural techniques that appeared most frequently in the literature were the classic LIFT ( Table 2), the LIFT without excision of the intersphincteric tract ( Table 3), and the LIFT-plus ( Table 4). Those 3 techniques were described in a total of 20 studies, including 586 patients. The healing rate ranged from 61.0% to 94.4% for the classic LIFT, 47.0% to 94.2% for the LIFT without excision, and 76.5% to 85.0% for the LIFT-plus. Overall, such healing rates outperform those of other sphincter-preserving procedures (10% to 67% for fibrin glue,
文獻中最常出現的手術技術是經典的 LIFT（ 表 2）、不切除括約肌束的 LIFT（ 表 3）和 LIFT-plus（ 表 4）。共有 20 項研究描述了這 3 種技術，包括 586 名患者。經典 LIFT 的癒合率為 61.0% 至 94.4%，無切除的 LIFT 為 47.0% 至 94.2%，LIFT-plus 為 76.5% 至 85.0%。總體而言，這種癒合率優於其他保留括約肌的手術（纖維蛋白膠為 10% 至 67%， <50% for fistula plug,
瘺管塞 <50%， and 25% to 95% for advancement flap
25% 到 95% 用於前進皮瓣) but fall short of those reported for sphincter-sacrificing procedures, such as fistulotomy (92% to 97%).
），但低於括約肌犧牲手術（如瘺管切開術）的報導（92%-97%）。 , Given that no additional statistical analysis was performed and the limited published reports of each technical variation, it is difficult to recommend one technique over the others.
鑒於沒有進行額外的統計分析，並且每種技術變化的公開報告有限，因此很難推薦一種技術優於其他技術。
All of the studies in our review included a standard definition of success for the procedure, determined clinically as complete healing of both the original external opening of the fistula and the surgical site. Nonetheless, the definition of failure and recurrence has not been universally agreed on. Tan et al
我們綜述中的所有研究都包括手術成功的標準定義，臨床上確定為瘺管的原始外部開口和手術部位完全癒合。儘管如此，失敗和復發的定義尚未得到普遍認可。Tan 等人 reported on 3 patterns of failure and recurrence after the classic LIFT procedure. They found that, after all of the successful LIFT procedures, time to healing occurred within 12 weeks, and the type of failure can direct subsequent treatment options.
報告了經典 LIFT 手術后的 3 種失敗和復發模式。他們發現，在所有成功的 LIFT 手術之後，癒合時間發生在 12 周內，失敗的類型可以指導後續的治療方案。
Few authors have reported on risk factors for failure of the classic LIFT procedure or its variations, thereby limiting the ability of surgeons to tailor the specific choice of a surgical procedure to a given patient’s risk profile. Limited studies with small cohorts have suggested that BMI
很少有作者報導經典 LIFT 手術失敗或其變體的危險因素，從而限制了外科醫生根據給定患者的風險狀況定製外科手術具體選擇的能力。針對小佇列的有限研究表明，BMI and fistula tract length
和瘺管長度 may lead to increased rates of failure after the LIFT procedure. Abcarian et al
可能導致 LIFT 手術後失敗率增加。Abcarian 等人 demonstrated a trend toward decreasing success rates as the number of previous attempts at fistula repair increased, whereas others
隨著先前嘗試修復瘺管的次數增加，成功率呈下降趨勢，而其他人 , have found no correlation between previous attempts at fistula repair and success or failure of the LIFT procedure. However, a large-scale, prospective study examining risk factors is needed.
發現先前的瘺管修復嘗試與 LIFT 手術的成功或失敗之間沒有相關性。然而，需要一項大規模的前瞻性研究來檢查危險因素。
Similar to other sphincter-preserving procedures, the LIFT procedure appears to have minimal impact on fecal continence. Various studies of advancement flap repairs have reported rates of incontinence ranging from 0% to 35%.
與其他保留括約肌的手術類似，LIFT 手術似乎對大便失禁的影響很小。各種關於前移皮瓣修復術的研究報告了尿失禁的發生率從 0% 到 35% 不等。 Fibrin glue and fistula plug studies have reported low rates of fecal incontinence.
纖維蛋白膠和瘺管栓研究報導了大便失禁的發生率較低。 Of the 26 studies included in our review, including more than 800 patients, only 2 patients had reported changes in continence after their procedure.
在我們綜述納入的 26 項研究中，包括 800 多名患者，只有 2 名患者報告了手術后尿失禁的變化。 , The impact on continence appears to be minimal, but only half of the studies included a formal evaluation of continence.
對尿失禁的影響似乎很小，但只有一半的研究包括對尿失禁的正式評估。 , , , , , , , , , , Therefore, we may not yet have a completely accurate rate of fecal continence changes after this procedure.
因此，我們可能還沒有完全準確的該程式後大便失禁變化率。
Our review revealed very few reported complications associated with any of the variations of the classic LIFT procedure. Only 13 complications were reported in 6 studies.
我們的綜述顯示，與經典 LIFT 手術的任何變體相關的併發症報告很少。6 項研究僅報告了 13 例併發症。 , , , The complications were relatively minor, including anal fissure, anal pain, vaginal fungal infection, minor bleeding, superficial surgical site infection, and external hemorrhoidal thrombosis. Overall, the classic LIFT procedure and its technical variations appear to be safe.
併發症相對較輕，包括肛裂、肛門疼痛、陰道真菌感染、輕微出血、淺表手術部位感染和外痔血栓形成。總體而言，經典的 LIFT 手術及其技術變體似乎是安全的。
The treatment of anal fistula in patients with Crohn’s disease poses particular problems. In such patients, achieving complete, durable healing while preserving continence can be more complex. Wounds may not heal, especially in the setting of proctitis, and these patients are more prone to diarrhea, thereby predisposing them to continence issues.
克羅恩病患者肛瘺的治療存在特殊問題。對於此類患者，在保持節制的同時實現完全、持久的癒合可能更加複雜。傷口可能無法癒合，尤其是在直腸炎的情況下，這些患者更容易出現腹瀉，從而使他們容易出現失禁問題。 Gingold et al  Gingold 等人 ( Table 5) specifically evaluated the use of the classic LIFT in 15 patients with Crohn’s disease. The healing rate was 60% at 2 months and 53% at 12 months. There was a 20% incidence of new fistula formation after successful LIFT. None of the patients developed incontinence. The majority of the perianal wounds that patients experienced were able to heal even in the presence of proctitis. Despite the small study size and relatively short follow-up, Gingold et al
（ 表 5）專門評估了 15 名克羅恩病患者使用經典 LIFT。2 個月時愈合率為 60%，12 個月時癒合率為 53%。成功 LIFT 後新瘺管形成的發生率為 20%。沒有患者出現尿失禁。即使在直腸炎的情況下，患者經歷的大多數肛周傷口也能夠癒合。儘管研究規模小且隨訪時間相對較短，但 Gingold 等人 demonstrated that the classic LIFT procedure is safe in patients with Crohn’s disease. Although several other studies in our review included patients with Crohn’s disease, they did not perform a subset analysis.
證明經典的 LIFT 手術對克羅恩病患者是安全的。儘管我們綜述中的其他幾項研究納入了克羅恩病患者，但它們沒有進行亞組分析。 , ,
The strengths of our review consist of the large number of total patients (more than 800) including 26 studies, our focused analysis of the 6 identified technical variations of the classic LIFT, and the attention to key risk factors for failure. Our review was limited by the inability to make any definitive conclusions based on the data available in the literature. In addition, we excluded 4 studies from our review that have been cited elsewhere, because they reported pooled healing rates of the variations, so we were unable to analyze them in the same manner as the included studies.
我們綜述的優勢在於患者總數眾多（超過 800 人），包括 26 項研究，我們對經典 LIFT 的 6 種已確定的技術變化的重點分析，以及對失敗的關鍵風險因素的關注。由於無法根據文獻中可用的數據得出任何明確的結論，我們的綜述受到限制。此外，我們從綜述中排除了 4 項已在其他地方引用的研究，因為它們報告了變異的合併癒合率，因此我們無法以與納入研究相同的方式分析它們。
Future research should elucidate preoperative and intraoperative factors impacting the success of the LIFT procedure and its variants. The routine use of a preoperative draining seton has been somewhat controversial. Draining setons have been used as a means to control sepsis, ensure adequate drainage, and promote maturation of a fibrous fistula tract.
未來的研究應闡明影響 LIFT 手術及其變體成功的術前和術中因素。術前引流掛線的常規使用一直存在一些爭議。引流 seton 已被用作控制膿毒症、確保充分引流和促進纖維瘺束成熟的一種手段。 Four studies included in this review did not use preoperative setons,
本綜述中納入的 4 項研究未使用術前掛線， , , , with primary healing rates similar to studies using setons, ranging from 81% to 95%. Preoperative imaging with endoanal ultrasound or MRI has been advocated by some authors.
原發性癒合率與使用 Seton 的研究相似，範圍為 81% 至 95%。一些作者提倡術前使用肛門內超聲或 MRI 進行影像學檢查。 Roughly half of the publications included in our review used preoperative imaging,
我們綜述中納入的出版物中大約有一半使用了術前成像， , , , , , , , , , whereas most relied on clinical and intraoperative examination to delineate fistula anatomy. Eliminating routine preoperative seton placement and imaging, if shown to be of no advantage, would provide patients and the health system alike significant cost savings and decrease the time it takes for a patient to achieve relief from the problem.
而大多數依靠臨床和術中檢查來描繪瘺管解剖結構。如果證明沒有優勢，則取消常規的術前掛線放置和成像將為患者和衛生系統節省大量成本，並減少患者緩解問題所需的時間。
Future research should also be directed at larger patient populations using a standardized procedure with adequate follow-up, eventually directly comparing the classic LIFT with its technical variations and identification of risk factors for failure. We advocate the use of a standardized classification of failures, as originally described by Tan et al,
未來的研究還應針對更大的患者群體，使用標準化程式和充分的隨訪，最終直接將經典 LIFT 與其技術變化進行比較，並確定失敗的危險因素。我們提倡使用標準化的失敗分類，正如 Tan 等人最初描述的那樣， to aid in further understanding this procedure. Ideally, further research on this procedure and its technical variations would allow the surgeon to tailor the choice of surgical procedure based on patient factors.
以幫助進一步瞭解此過程。理想情況下，對該程式及其技術變化的進一步研究將使外科醫生能夠根據患者因素定製外科手術的選擇。

CONCLUSION   結論

The LIFT procedure appears to be a promising treatment option for patients with transsphincteric anal fistulas, providing reasonable success rates with minimal impact on continence and few complications. However, the true efficacy of the procedure remains unknown given the number of variations and the pooled results that are too often reported in the literature.
LIFT 手術似乎是經括約肌肛瘺患者的一種有前途的治療選擇，提供合理的成功率，對尿失禁的影響最小，併發症很少。然而，鑒於文獻中經常報導的變異數量和匯總結果，該程式的真正療效仍然未知。

ACKNOWLEDGMENTS   確認

The authors thank David M. Radosevich, Ph.D., R.N., for his help with interpretation of the data and Mary E. Knatterud, Ph.D., for her editing assistance, both from the University of Minnesota Department of Surgery. They also thank Mary R. Kwaan, M.D., M.P.H., from the University of Minnesota, and Scott Steele, M.D., from Madigan Army Medical Center, for their helpful comments in earlier drafts of this review.
作者感謝明尼蘇達大學外科系的 David M. Radosevich 博士、註冊護士對數據的解釋説明，以及 Mary E. Knatterud 博士的編輯説明。他們還感謝來自明尼蘇達大學的 Mary R. Kwaan（醫學博士、公共衛生碩士）和來自 Madigan Army Medical Center 的 Scott Steele（醫學博士）在本綜述的早期草稿中提出的有益評論。

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