Letter to the Editor: Commentary on “The modified clipped ligation of intersphincteric fistula tract (clipped-LIFT) for high transsphincteric/suprasphincteric fistula”

Dear Editor, We read with great interest the recent study by Chen et al., which examined the outcomes of the modified clipped-ligation of intersphincteric fistula tract (LIFT) procedure in the treatment of complex anal fistulas[1]. Their work offers valuable insights into the efficacy and safety of this innovative technique, presenting a promising approach for managing challenging anorectal conditions. The authors are to be commended for their rigorous methodology and the encouraging results presented in the study. Despite these commendable strengths, we believe several aspects of the study merit further exploration to enhance the applicability and long-term impact of the modified clipped-LIFT procedure. First, the long-term impact on anal sphincter function remains underexplored. Although the study addresses postoperative complications and healing, it does not sufficiently investigate the potential long-term effects on anal sphincter function, which is critical for maintaining quality of life. Damage to the anal sphincter can lead to incontinence, particularly in complex fistula repairs[2]. Future studies should focus on assessing the impact of the modified clipped-LIFT procedure on anal sphincter function, utilizing anorectal manometry and electromyography to track changes before and after surgery. Long-term follow-up studies could reveal whether the procedure leads to functional impairment or any changes in sphincter integrity. Second, patient selection bias and preoperative evaluation warrant refinement. While the study controls for surgical variability by using a single experienced surgeon, it does not fully account for the diversity of patient characteristics. For example, the study does not offer a detailed preoperative evaluation of factors such as the complexity of the fistula, anal function, and the presence of anal canal stenosis, all of which may significantly influence surgical outcomes. We suggest that future research incorporate more comprehensive preoperative assessment protocols and establish more precise patient selection criteria, particularly in multicenter settings. This approach would allow for a more thorough evaluation of the procedure’s effectiveness across various clinical scenarios, thereby enhancing the generalizability of the findings. Third, magnetic resonance imaging (MRI) false-positive signals and clinical criteria for healing require further clarification. The study highlights that patients with mild high-signal areas on MRI were still classified as “healed” based on clinical evaluation. In traditional LIFT, high-signal areas often indicate a residual fistula[3]; however, in the modified clipped-LIFT procedure, the absorbable clips used during the procedure may induce localized granuloma formation and nonspecific inflammation during their degradation process. This “iatrogenic inflammatory signal” could be misinterpreted as a recurrence of the fistula, leading to unnecessary follow-up surgeries. We propose the development of a dedicated MRI scoring system for the modified clipped-LIFT procedure, akin to the modified Van Assche score, to distinguish between degradation-related inflammatory responses and true fistula recurrence. Such a system would enhance diagnostic accuracy and reduce unnecessary interventions. In conclusion, while Chen et al provide important evidence regarding the modified clipped-LIFT procedure, addressing the long-term effects on anal sphincter function, refining patient selection criteria, and improving the interpretation of MRI signals could further enhance the clinical application of this promising technique. We look forward to seeing these aspects explored in future research. This letter is reported in accordance with the TITAN Guidelines 2025[4]. Supplemental Digital Content, TITAN Guidelines 2025 available at: https://links.lww.com/JS9/H122