|Year : 2016 | Volume
| Issue : 3 | Page : 570-574
Extent of division of the internal anal sphincter in chronic anal fissure
Samir M. H. Kohla, Ahmed Fawzy, Ahmed S Goda
Department of General Surgery, Menoufia University Hospitals, Menoufia University, Shebin El Kom, Egypt
|Date of Submission||21-Jun-2015|
|Date of Acceptance||13-Sep-2015|
|Date of Web Publication||23-Jan-2017|
Ahmed S Goda
Shohada, Menoufia Governorate, 32958
Source of Support: None, Conflict of Interest: None
The aim of this study was to compare the results of lateral internal anal sphincterotomy up to the dentate line or up to the apex of the anal fissure.
Troublesome fecal incontinence following a lateral internal sphincterotomy is often attributed to faulty surgical technique. However, it may be associated with coexisting occult sphincter defects. Whether continence is related to the extent of sphincterotomy remains debatable.
Patients and methods
This prospective randomized study included 48 patients suffering from chronic anal fissures in the period between October 2013 and March 2015. They were admitted to the Department of Surgery of Menoufia University and Al-Helal insurance hospitals. This study included 24 patients who underwent traditional lateral internal sphincterotomy (up to the dentate line) and 24 patients who underwent conservative lateral internal anal sphincterotomy (up to the height of the fissure apex or just below it). All patients were evaluated with respect to operative time and postoperative complications. The results were documented and statistically analyzed.
The mean time required for relief of pain postoperatively after conventional lateral sphincterotomy (LS) operation was 2.1 ± 2.6 days and that after conservative LS was 3.7 ± 3.5 days. Early transient incontinence was reported in 9/24 (37.5%) patients in the conventional LS group and 2/24 (4.2%) patients in the conservative LS group. Wounds healed within 6 weeks in 16/24 (66.7%) patients of the conventional LS group and in 22/24 (95.8%) patients of the conservative LS group.
On the basis of this study, we conclude that the conservative LS operation has several advantages over the conventional LS operation in the treatment of chronic anal fissures.
Keywords: chronic anal fissure, dentate line, internal anal sphincterotomy
|How to cite this article:|
Kohla SM, Fawzy A, Goda AS. Extent of division of the internal anal sphincter in chronic anal fissure. Menoufia Med J 2016;29:570-4
|How to cite this URL:|
Kohla SM, Fawzy A, Goda AS. Extent of division of the internal anal sphincter in chronic anal fissure. Menoufia Med J [serial online] 2016 [cited 2020 Apr 9];29:570-4. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/570/198712
| Introduction|| |
An anal fissure is a painful cut or crack in the distal anal canal. The acute form of the disease responds readily to nonsurgical methods such as dietary bran supplements, warm sitz baths, and/or topically applied local anesthetic creams  . However, nonsurgical methods rarely promote healing of a chronic anal fissure, characterized by a deep, intractable ulcer, with the internal anal sphincter being visible in its base. The characteristic skin tag and anal papilla are also regarded as indicators of poor response to conservative therapy  . Therefore, surgical treatment is almost uniformly recommended for such fissures in the chronic state, with lateral internal anal sphincterotomy being the time-honored treatment. Lateral internal anal sphincterotomy lowers the pressure exerted by the internal anal sphincter, restores normal perfusion of the anoderm, and leads to relief of pain and healing of the fissure  . Recent innovations in nonsurgical alternatives include the administration of topical nitrates (glyceryl trinitrate or isosorbide dinitrate) or botulinum toxin injections targeted at relaxation of the internal anal sphincter. In spite of the initial excitement over such treatments, randomized trials have revealed that topical glyceryl trinitrate is inferior to both botulinum toxin  and lateral internal anal sphincterotomy  in providing symptomatic relief and fissure healing. We have also shown that botulinum toxin injection is inferior to lateral internal anal sphincterotomy in the treatment of chronic anal fissure  . Lateral internal anal sphincterotomy remains the gold-standard treatment for chronic anal fissure; therefore, the aim of this study was to compare the results of lateral internal anal sphincterotomy up to the dentate line and up to the apex of the anal fissure.
| Patients and methods|| |
The study was approved by the Ethical Committee of the Faculty of Medicine, Menoufia University and informed patient consent was obtained. This prospective randomized study included 48 patients suffering from chronic anal fissure in the period between October 2013 and March 2015. They were admitted to the Department of Surgery of Menoufia University and Al-Helal insurance hospitals.
Chronic anal fissure was considered to be present if the patients presented with a history of anal pain during defecation for at least 2 months that had failed to resolve, presence of sentinel piles, hypertrophied anal papilla, fibrosis, indurations, or exposed internal fibers in the fissure base  .
Inclusion criteria were as follows: presence of chronic anal fissures not responding to medical treatment and increased resting anal pressure.
Exclusion criteria were as follows: a history of fecal incontinence, previous anal sphincter injury or surgery, concurrent fistula or hemorrhoids, recent obstetric delivery, inflammatory bowel disease, diabetes or other endocrinal disorders, and patients using calcium channel blockers and oral sublingual nitrite. Severely depilated patients not fit for surgery were also excluded.
All patients were subjected to careful history analysis, clinical examination, and laboratory investigation.
Preoperative written consent was obtained from all patients. Preoperative preparation in the form of rectal enemas for cleaning the colon was carried out. Prophylactic antibiotics in the form of third generation cephalosporin were administered 2 h before operation.
Group A included 24 patients, and this group underwent conventional lateral sphincterotomy (LS). After adequate lubrication of the anal canal, the retractor was positioned and the intersphincteric groove was identified. A blade knife (No. 11) was inserted between the internal and the external sphincter. The tip of the blade was angled medially pointing just above the dentate line, and the internal sphincter was divided; when the knife was seen beneath the intact mucosa, it was withdrawn. Digital pressure was applied to ensure hemostasis.
Group B included 24 patients, and this group underwent conservative LS. The internal sphincter was divided to the proximal level of the fissure. Hemostasis was checked. Sitz bath was provided postoperatively for 1 week.
All patients were re-examined on postoperative days 1 and 7, and then after 1 month, 3 months, and every 6 months for 1 year. They were asked to come immediately if they developed symptoms. The parameters investigated were time of relief of pain (days), postoperative anal incontinence, and healing rate. Complete healing was defined as completely epithelialized scar or no sign of fissure. Anal incontinence was determined according to the Pescatori scoring system  .
Statistical analysis of data in this study was performed using SPSS (version 19 SPSS Inc., Chicago, Illinois, USA). For continuous variables, descriptive statistics were calculated and were reported as mean ± SD. Categorical variables were described using frequency distributions. The Student's t-test for paired samples was used to detect differences in the means of continuous variables, and the χ2 test was used in cases with low expected frequencies (P < 0.05 was considered to be significant).
| Results|| |
The present study included 48 patients who presented with chronic anal fissures. They were classified into two groups - A and B. Group A included 24 patients with a mean age of 40.9 ± 3.7 years (24-61). They were treated by conventional LS. Group B included 24 patients with a mean age of 42.1 ± 5.2 years (23-63); they were treated by conservative LS ([Table 1]).
|Table 1 Comparison between both age and sex in conventional and conservative lateral sphincterotomy groups |
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The time required for relief of pain postoperatively was 2.1 + 2.6 days in the conventional group, which was shorter compared with the controlled sphincterotomy group of 3.7 ± 3.5 days ([Table 2]).
|Table 2 Time required for relief of pain postoperatively in both conventional and conservative lateral sphincterotomy groups |
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Sixteen patients in group A had complete healing of fissure within 4-6 weeks, which was characterized by re-epithelialization of the anal canal with no further episodes of pain or bleeding. Among all, seven patients had delayed healing (>6 weeks) and one patient had recurrence. Twenty-two patients in group B had complete healing of fissure within 4-6 weeks, and only two patients had delayed healing (6 weeks); the difference was statistically significant ([Table 3]).
|Table 3 Postoperative healing time in both conventional and conservative lateral sphincterotomy groups |
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Continence and recurrence
None of the patients in both groups developed incontinence of stool. Eight patients in group A reported diminished ability to differentiate between flatus and liquid stool. This was transient in two patients but continued in the last six patients. Only two patients in group B suffered from transit soiling, which improved completely after complete healing of the wound; the difference was statistically significant ([Table 4]).
|Table 4 Continence and recurrence in both conventional and conservative lateral sphincterotomy groups |
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| Discussion|| |
Chronic anal fissure is a common anorectal disease affecting all ages and is often associated with the underlying hypertonic internal sphincter  .
Chronic anal fissure is often associated with anatomical anal stenosis, resulting from a fibrotic internal sphincter, in conjunction with functional anal stenosis caused by IS spasm  .
Incontinence found in patients who have been treated surgically for anal fissure is usually attributed to the treatment, but whether it is attributed to sphincter abnormalities associated with the condition remains speculative  .
The cardinal symptom of anal fissure is pain in the anus during and after defecation. The pain is very agonizing to the patient; it is described as a sharp, cutting, or tearing sensation during and after passage of stool. Subsequently, the pain may be less severe and may be described as a burning discomfort that may persist from a few minutes to several hours. Bleeding is very common with fissure but is not invariably present. The blood is bright red and usually scant in amount. In addition, pruritus ani may accompany in up to 50% of cases  .
In this study, the mean age of the patients ranged from 24 to 61 years in the conventional group, whereas in the conservative group it ranged from 23 to 63 years, with a P value of 0.3623, which indicates that there is no statistically significant difference.
In addition, the male/female ratio in the conventional group was 13/11, whereas in the conservative group it was 14/14, with a P value of 0.666, which indicates that there is no statistically significant difference.
The clinical parameters with P values more than 0.05 indicated lack of statistically significant differences.
Therefore, we considered age, sex, and clinical parameters as fixed values in this study.
Whether the extent of internal sphincterotomy should be confined to the upper limit of the fissure (conservative division) or to the dentate line (conventional sphincterotomy) remains debatable. Performing a shorter sphincterotomy corresponding to the length of the fissure reduces the risk of anal incontinence  .
Furthermore, a more conservative division could lead to an equivalent healing rate by the time of outpatient follow-up (mean = 6.9 weeks)  .
It has been reported that the closed internal sphincterotomy technique had less postoperative pain and less postoperative incontinence, but the healing time of the fissure was the same compared with the open technique  .
The results of a recent meta-analysis demonstrated that incontinence rates after sphincterotomy by both techniques to be equally efficacious. However, one advantage of the open technique in this study was that the internal sphincter was cut under direct visualization  .
Other studies have concluded that incontinence due to lateral internal sphincterotomy does not recover after long-term follow-up and appears to be an independent cause of fecal incontinence, especially when the puborectal sling has lost its ability to compensate for continence  .
This study revealed that the recurrence rate after conventional sphincterotomy was 4.2% (one patient), whereas after conservative sphincterotomy the recurrence rate was 8.3% (two patient), with a P value of 0.555, showing no statistically significant difference.
Rotholtz et al.  proved that conservative division of the internal anal sphincter results in adequate fissure healing and a much lower incontinence rate (2.17%) compared with conventional division of the internal anal sphincter (10-35%).
Our study proved that conservative division of the internal anal sphincter results in adequate fissure healing compared with conventional LS.
In contrast to lateral internal anal sphincterotomy in males, division of the internal anal sphincter in most females tends to be more extensive than intended. This is probably related to their shorter anal canal. Females who have had two or more previous vaginal deliveries should be warned about possible long-term flatus incontinence  .
Care should be exercised especially in the presence of previous obstetric trauma, particularly in the presence of external sphincter defects, as internal anal sphincter division may further compromise sphincter function  .
In our study, none of the patients in both groups developed incontinence of stools, but early and late transient incontinence occurred in some patients.
Early transient incontinence in the conventional sphincterotomy group occurred in nine (37.5%) patients, whereas in the conservative sphincterotomy group it occurred in two (4.2%) patients, with a P value of 0.01, showing a statistically significant difference.
Late transient incontinence in the conventional sphincterotomy group occurred in two (4.2%) patients, whereas in the conservative sphincterotomy group none of the patients had late transient incontinence (0), with a P value of 0.153, showing no statistically significant difference.
Moreover, according to the incontinence score, the conventional sphincterotomy group and the conservative sphincterotomy group had statistically significant differences in results, with the conservative sphincterotomy group having lower incontinence rates, both early and late, compared with the conventional sphincterotomy group.
| Conclusion|| |
Conservative LS (up to the apex of the fissure) provided faster anal fissure healing, and it was less associated with a significant postoperative alteration in anal continence, whereas conventional LS (up to the dentate line) provided faster pain relief only. Surgeons need to be certain of the extent of sphincterotomy to perform, and patients should be informed about the advantages and disadvantages of both treatment choices. Future studies are needed for further details and patient selection criteria to determine the individual, ideal extent of sphincterotomy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]