A commentary on “The modified clipped ligation of intersphincteric fistula tract (clipped-LIFT) for high transsphincteric/suprasphincteric fistula: a proof-of-concept study”

Dear Editor, We read with great interest the proof-of-concept study by Chen et al on the modified clipped ligation of the intersphincteric fistula tract (clipped-LIFT) for high transsphincteric and suprasphincteric fistulas[1]. The authors are to be congratulated for addressing this difficult subset of anal fistulas and for reporting both clinical and radiological healing with a median follow-up of more than 2 years[1]. The higher one-stage healing rate observed with clipped-LIFT compared with suturing-LIFT in high fistulas is reassuring. We would like to offer a few comments that may help interpret these findings and inform future work. First, differences in disease stage between groups may have contributed to the apparent benefit of clipped-LIFT. The clipped-LIFT cohort included fewer patients presenting with abscess at baseline than the suturing-LIFT group (9.1% vs 33.8%)[1]. Acute sepsis and complex drainage pathways have previously been linked to lower LIFT success rates[2,3]. Although several variables were adjusted for, disease stage was not retained in the final model. Future analyses stratified by abscess versus chronic fistula and by key anatomic features – for example, deep posterior intersphincteric space involvement or horseshoe extension – could clarify how these factors modify outcomes after LIFT[2,4]. Second, one-stage healing is a pragmatic primary endpoint, but it does not capture the overall course of care. In this series, almost all patients ultimately achieved durable healing after salvage surgery and were followed for more than 3 years[1]. For patients with complex high fistulas, decisions between a technically demanding sphincter-preserving operation and staged procedures are often driven by cumulative time to wound closure, continence, and quality of life rather than single-procedure success alone[2,5]. Prospective comparisons of clipped-LIFT with other sphincter-preserving strategies might therefore incorporate time-to-healing curves, validated continence scores, and patient-reported outcome measures alongside surgical success. Third, the study provides valuable preliminary information on clip behavior in the intersphincteric space: complete or partial expulsion occurred in more than one quarter of clipped-LIFT cases and appeared to be associated with failure[1]. Although no serious adverse events were observed, systematic documentation of clip position, ideally with early postoperative imaging, could help elucidate mechanisms of migration and guide the design of LIFT-specific clips. Strengthening this technical aspect may further enhance the reliability of the procedure and support wider adoption in centers with different levels of colorectal expertise[4,5]. In summary, Chen et al have extended the armamentarium of sphincter-preserving surgery by adapting an established vascular closure device to the management of high anal fistulas[1]. Clarifying the impact of baseline sepsis and complex anatomy, broadening outcome assessment to include patient-centerd measures, and further defining clip performance may help to position clipped-LIFT within the growing range of sphincter-preserving options for high fistulas[2-5].