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Year : 2017  |  Volume : 30  |  Issue : 2  |  Page : 383-387

A comparativestudybetween lateral internal sphincterotomy(an alternative approach) and fissurectomy in the surgical management of chronic idiopathic anal fissure

Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission18-Apr-2016
Date of Acceptance26-Jun-2016
Date of Web Publication25-Sep-2017

Correspondence Address:
Ahmed E Ahmed Omara
Helwan, Cairo, 11722
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1110-2098.215440

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The objective of this study was to evaluate andcomparethe effectiveness of lateral internal sphincterotomy(LIS, an alternative approach) versus fissurectomy in the surgical management of chronic idiopathic anal fissure.
LIS(an alternative approach) versus fissurectomy in the management of chronic anal fissure is presented and its potential advantages are described.
Patients and methods
This is a prospective randomized study including 40patients presenting with chronic anal fissure (>2months). The patients were distributed randomly between two equal groups: groupA underwent LIS(an alternative approach), and groupB underwent fissurectomy. Both groups were evaluated for postoperative pain, postoperative fissure healing, and postoperative complications.
All patients in groupA were pain-free and without bleeding within 1week, whereas 65% in groupB were pain-free in the same period. Urinary retention was noted in one patient(5%) in groupA, whereas it was noted in two patients(10%) in groupB. Incontinence to flatus was noted in two patients(10%) in groupA, whereas it was noted in three patients(15%) in groupB. There was one patient(5%) with fissure recurrence in groupB but none in the LIS group. No patient in either group was affected with anal stenosis or perianal infections. All wounds healed within 4weeks in groupA, whereas 85% healed within the same period in groupB.
In the surgical treatment of chronic anal fissure not responding to conservative management, LIS may be the better treatment and, perhaps, the preferable surgical technique with fewer total complications(P<0.005).

Keywords: chronic anal fissure, fissurectomy, lateral internal sphincterotomy

How to cite this article:
El-Sibai O, Sabri A, Ahmed Omara AE. A comparativestudybetween lateral internal sphincterotomy(an alternative approach) and fissurectomy in the surgical management of chronic idiopathic anal fissure. Menoufia Med J 2017;30:383-7

How to cite this URL:
El-Sibai O, Sabri A, Ahmed Omara AE. A comparativestudybetween lateral internal sphincterotomy(an alternative approach) and fissurectomy in the surgical management of chronic idiopathic anal fissure. Menoufia Med J [serial online] 2017 [cited 2020 Jun 6];30:383-7. Available from: http://www.mmj.eg.net/text.asp?2017/30/2/383/215440

  Introduction Top

Anal fissure is a small spilt in the distal anoderm, and it most commonly occurs in the posterior midline of the anal canal. Anal fissure causes severe sharp pain on defecation, occasionally accompanied by a streak of blood on the outside of the stool or blood on toilet tissue[1]. Pain may persist for many hours after defecation, which is much distressing to patients. The pain of anal fissure causes proportionate worsening of quality of life[2]. Fissures are classified as acute or chronic; acute fissure usually heals spontaneously within 6weeks. Conversely, chronic anal fissure persists much longer, and it does not heal without intervention. The chronic anal fissures are wider and deeper than acute fissures. The edges of chronic anal fissures are often indurated, and there may be a skin tag distally and a hypertrophied papilla proximally[3],[4].

In 90% of patients, a typical anal fissure occurs in the posterior midline, and in the remaining 10% of patients it occurs in the anterior midline. Atypical anal fissure can occur anywhere in the anal canal, and these are associated with other diseases(Crohn's disease, HIV infection, cancer, syphilis, and tuberculosis). Anterior anal fissure occurs more commonly in women[5]. The aim of surgery is to reduce resting anal canal tone because of the internal anal sphincter, thereby increasing blood supply to the anoderm to improve healing. Surgical options include lateral sphincterotomy, fissurectomy, and advancement in flap procedures. In the past, anal dilatation and posterior sphincterotomy have been used, but there is little evidence to support their continued use. In patients with a low resting pressure, an anal advancement flap is a logical option. Surgery is referred for medical treatment failures or to meet immediate patient wishes[6]. Incontinence to flatus and fecal soiling are distressing complications of surgical techniques[7],[8],[9]. Surgical techniques that preserve the anal sphincters should reduce the possibility of postoperative fecal incontinence.

The purpose of this study was to compare the results of fissurectomy and lateral internal sphincterectomy(LIS), which is an alternative approach in terms of relief of symptoms, postoperative complications, and recurrence.

  Patients and Methods Top

The study was a prospective randomized controlled single-blind study that was started on December 2014 and completed on December 2015; the study continued for 1year and was approved by the Ethics Committee of the Faculty of Medicine of the University of Menoufia. An informed consent was obtained from all patients included in the study.

The study was conducted on 40patients with chronic idiopathic anal fissure. Chronicity was defined as history of pain lasting more than 2months and was physically evidenced by the presence of a sentinel pile at the distal margin of the fissure, heaped-up edges of the fissure, and visible sphincter fibers at the base of the fissure.

Exclusion criteria included prior anal surgery, any degree of fecal incontinence, and concomitant anal conditions requiring surgical treatment at the time of sphincterotomy–for example, hemorrhoids or fistula. No preoperative bowel preparation was required.

The patients were divided into two groups by systematic random sampling using the closed enveloped method.

GroupA: This group included 20patients who were subjected LIS(an alternative approach).

The operation was performed under spinal anesthesia technique with the patient in the prone jack-knife position and the buttocks strapped apart. The procedure starts by application of two fingers into the anus to allow a parks retractor to be admitted into the anal canal and opened slowly until the anal canal becomes taut.

Using the conventional diathermy, in the coagulation mode with power level set at 5, starting from the caudal border of the internal sphincter and proceeding cephalad, the internal sphincter along with its overlying anoderm is cut to the caudal border of the dentate line.

The right lateral position is usually chosen for this internal sphincterotomy to avoid the hemorrhoidal plexus at the left lateral position. However, in the absence of hemorrhoidal disease, either side could be chosen. The wound was left open. The completed LIS is demonstrated in [Figure1]. Neitherthe fissure nor the sentinel piles are excised, but hypertrophied anal papillae were excised when encountered. No anal packing is used. Patients were discharged 6h later after ensuring that there was no urine retention. Diclofenac potassium 75mg intramuscular injections(Cataflam; Novartis Pharma, Cairo, Egypt) were given before discharge on patient demand. Diclofenac potassium tablets 50mg were prescribed for home use when needed (Cataflam; Novartis Pharma).
Figure 1: Comparison between both groups as regards time elapsed for postoperative fissure healing.

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GroupB: This group included 20patients who were subjected to fissurectomy.

The operation will be performed under spinal anesthesia technique with the patient in the lithotomy position and the buttocks strapped apart. The procedure starts by dilatation of the anal canal to admit the speculum.

Using the conventional diathermy, in the coagulation method with power level set at level 5, excision of the fissure with the margin of healthy mucosa down to the level of internal sphincter and possibly excision of sentinel skin tags and polyps were carried out.

Patients were followed up in the outpatient clinic at the end of the first, second, and fourth postoperative weeks. Furthermore, patients were told that they would be followed up subsequently for 6months by telephone for the following: relief of pain, fissure healing, complication, and recurrence.

  Results Top

Forty patients with chronic anal fissure were studied. In all, 16patients were male and 24patients were female; the mean age was 38years, ranging from 19 to 65years. In 20patients, anal fissurectomy was performed under spinal anesthesia. In 20patients, LIS was done under spinal anesthesia.

All patients of groupLIS got rid of symptoms(pain and bleeding) within 7days of operation, whereas 65% of patients of group fissurectomy got rid of symptoms in the same period[Table1] and [Figure2].
Table 1: Time elapsed for postoperative pain relief in groups A and B

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Figure 2: Comparison between both groups as regards time elapsed for postoperative pain relief.

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With regardto the healing rate in the present study, there was a highly significant success with complete healing within 2weeks after treatment with LIS(an alternative approach): 100% compared with 30% with fissurectomy in the same period [Table2] and [Figure1].
Table 2: Time elapsed for postoperative fissure healing in groups A and B

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Urinary retention was noted in three patients(15%) in the 'fissurectomy' group and in one(5%) patient in the LIS group, which was transient and improved after warm sitz bath. Incontinence to flatus occurred in three(15%) patients in the 'fissurectomy' group and in two(10%) patients in the 'LIS' group. All three patients recovered from this complication within 2weeks of surgery, by conservative measures. There was one(5%) patient with anal fissure recurrence within 6months in the 'fissurectomy' group, but none in the 'LIS' group. Anal discharge was noted in eight patients(40%) in the LIS group and in six patients(30%) in the fissurectomy group. Bleeding spots were noted in one patient(5%) in the LIS group and in two patients(10%) in the fissurectomy group. Pruritis was noted in one patient(5%) in the LIS group and in five patients(25%) in the fissurectomy group. In either group no patient suffered from anal stenosis or perianal infections [Table3] and [Figure3].
Table 3: Incidence of postoperative complications in groups A and B

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Figure 3: Comparison between the complications in both groups.

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  Discussion Top

Anal fissure is a small tear in the anoderm extending from the anal verge to the dentate line. Atpresent, the exact etiology is uncertain, and anal mucosal ischemia secondary to sphincter hypertonia may be one possible cause; it has been accepted that it is responsible for poor healing and recurrence of anal fissure[10]. The posterior anal canal is more prone to develop ischemia as compared with other areas of the anal canal[11]. Fissure fails to heal when it occurs in that area. LIS produces a long-lasting fall of anal resting pressure[12], which restores mucosal perfusion resulting in healing, but the actual initiative mechanism is unknown, and the mechanism that transits from acute to chronic fissure remains obscure. Repeated passage of large(diameter) and hard fecal bolus may cause a defect in the anal lining, which heals poorly. The main aspect of our study is that it deals with a single procedure without any combination with other modalities, such as botulinum toxin injection, topical nitrate, and calcium channel blocker. There are various techniques for internal sphincterotomy, ranging from total sphincterotomy [13] to sphinterotomy limited to the dentate line, and a tailored approach, where the length of sphincterotomy is limited to the length of the fissure[14],[15]. We have adopted an alternative approach in this study.

The main point of difference between the present technique and other classic techniques is that the anoderm overlying the sphincterotomy is incised in the present technique and is preserved in the other classic techniques[16],[17]. The main reason for incising the anoderm along with the internal sphincter was to allow both the dentate line and the internal sphincter to be under the surgeon's direct vision throughout the procedure. Having both structures under direct vision allowed accurate and precise adjustment of the length of sphincterotomy in relation to the dentate line. In the classic open technique, although LIS is performed under direct vision, such visual correlation between both structures is absent[18]. None of the patients included developed permanent incontinence. The present technique may prove beneficial in avoiding some technical pitfalls of LIS–for example, the overextensive, the full-length, and the incomplete sphincterotomies[18]. Although a future anal endosonographic study is required to provide evidence to this suggestion, the results of the present technique in terms of recurrence and fecal continence seem to support it. Although unintentionally, incising the anoderm overlying the sphincterotomy offered two additional advantages. First, there was no dissection, that is, the anoderm was not lifted from the underlying internal sphincter and an intersphincteric plane was not developed, and, consequently, there was no dissection-induced bleeding. This, coupled with the use of diathermy, has rendered the present technique bloodless. This bloodlessness was extremely helpful in achieving fine adjustment of the length of sphincterotomy in relation to the dentate line and has, in part, contributed to the 1min operative time achieved with the present technique. Second, because the anodermal incision overlaid the full length of the sphincterotomy and because the procedure was bloodless, no complications requiring surgical intervention were encountered–that is, abscesses or fistulae[18]. Sentinel piles were not excised after explaining to the patient that this was not the fissure itself(a common belief of the lay people in our country). Patients were advised against the excision of sentinel piles on the basis that such excision will create a wound that will cause postoperative pain and will require a relatively long time to heal without influencing fissure healing positively[18]. More than two-thirds of the patients did not require analgesia at the time of discharge. Furthermore, more than 75% of the patients described their first postoperative defecation as painless and did not therefore require oral analgesics after defecation. Such findings suggest that the anodermal incision was not associated with either significant or prolonged postoperative pain. The alternative approach has achieved cure in all patients included. Furthermore, neither recurrences nor permanent fecal incontinence was encountered throughout the study period. Although longer follow-up durations are still required to draw more definite conclusions, however, the preliminary results seem encouraging. Whether these potential advantages would translate into an advantage for this approach over the currently applied techniques awaits the results of future prospective randomized studies comparing the present technique with other techniques.

Fissurectomy had been used as a separate technique in the treatment of chronic anal fissure with favorable result. Mousavi etal. [19] also compared the results of fissurectomy with LIS, and they reported fecal soiling in two(6.2%) patients and fissure recurrence in one(3.1%) patient of the fissurectomy group, whereas no recurrence of fissure and fecal soiling occurs in the LIS group. In other studies, fissurectomy has been combined with posterior midline sphincterotomy[20],[21]. The main disadvantage of fissurectomy with posterior midline sphincterotomy is 'keyhole' deformity, which may lead to fecal soiling, whereas after only fissurectomy this complication does not occur.

The main disadvantage of this study is that there is a risk of bias because of the single blinding.

  Conclusion Top

In the surgical treatment of chronic anal fissure not responding to conservative management, LIS(an alternative approach) may be the better treatment and, perhaps, the preferable surgical technique with fewer total complications.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure1], [Figure2], [Figure3]

  [Table1], [Table2], [Table3]


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