EP1082 - A Successful Multimodal Surgical Approach with Diversion and Bio-LIFT for Chronic, Complex Transsphincteric Anal Fistula: A Case Report

Purpose/Background: Complex anal fistulas involving multiple tracts and a large internal opening pose significant challenges, with high recurrence risk and potential sphincter damage. This report describes a staged, multimodal approach using fecal diversion, Bio-LIFT, and biologic adjuncts for durable healing in a chronic branching transsphincteric fistula.

Methods/Interventions: After an estimated 12-15 simple incision and drainage procedures performed internationally for abscess treatment without fistula control, a 55-year-old man developed a chronic multifocal transsphincteric fistula. His disease had evolved into a complex chronic branching network involving bilateral ischiorectal fossae and the deep postanal space with large bilateral branches that did not coalesce before penetrating the internal sphincter, and a single internal opening at the posterior dentate line.

Between December 2023 and March 2024, the patient required multiple examinations under anesthesia (EUA) with abscess drainage, fistulotomy, and seton placement to gain control. In May 2024, a laparoscopic loop descending colostomy was determined necessary to optimize conditions prior to definitive repair.

In December 2024, a combined approach included bilateral posterior Bio-LIFT (biologic ligation of the intersphincteric fistula tract), submucosal advancement flap, autologous platelet-rich plasma (PRP) application, application of acellular matrix grafts, and selective subcutaneous fistulotomy. A 6 month period of healing and EUA confirming fistula healing preceded colostomy reversal with concurrent parastomal hernia repair in July 2025.

Results/Outcomes: The patient has healed well from his open colostomy reversal. He remains perfectly continent and recurrence-free.

Conclusion/Discussion: Management of complex anal fistulas requires strategies that maximize healing while preserving sphincter function. The LIFT procedure, particularly its biologic modification (Bio-LIFT), has shown promising results in complex cases, with reported primary healing rates of 35-75% and low incontinence risk (1-3). Diversion, while not universally required, can optimize tissue healing in particularly risky or extensive repairs.

Adjunctive biologic therapies, such as platelet-rich plasma (PRP), may also improve healing odds compared to controls, according to recent meta-analyses (4,5). Similarly, acellular matrix grafts have emerged as valuable tools in soft tissue reconstruction, although data remains limited mostly to small series for this off-label use (6).

Temporary fecal diversion has been shown to reduce bacterial contamination, facilitate wound healing, and protect complex reconstructive repairs, particularly in large or recurrent fistulas. Diversion also decreases postoperative sepsis risk and recurrence in extensive or high trans-sphincteric tracts (7-9). This case demonstrates how a staged, multimodal approach incorporating fecal diversion, Bio-LIFT, and biologic adjuncts can optimize outcomes in extremely complex fistulas resulting in healing tissues while preserving continence.

Figure 1.
Setons in place demonstrating complex branching network involving bilateral ischioanal fossae


Figure 2
Conclusion of bilateral posterior BioLIFT procedure with submucosal advancement flap, autologous platelet-rich plasma application, multiple acellular matrix grafts, and selective subcutaneous fistulotomy