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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 5  |  Issue : 1  |  Page : 20-24

Re-evaluation of lateral subcutaneous sphincterotomy in treating anal fissure


1 Department of Surgery; Faculty of Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
2 Department of Surgery; King Abdulaziz University, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
3 Department of Surgery, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
4 Department of Surgery, Ummul Qura University, Makkah, Saudi Arabia

Date of Web Publication13-Mar-2015

Correspondence Address:
AMA Kensarah
Department of Surgery, Faculty of Medicine, King Abdulaziz University, King Abdulaziz University Hospital, P.O. Box 80215, Jeddah - 21589
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.153144

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  Abstract 

Background: Anal fissure is a common disease and has a myriad of treatment options. The aim of this study was to re-evaluate lateral subcutaneous sphincterotomy in the treatment of anal fissure.
Patients and Methods: We retrospectively studied143 patients with chronic anal fissure at King Abdulaziz University Hospital between March 1995 and April 2011, to determine the outcome of lateral subcutaneous sphincterotomy. These patients were studied using file data, operative notes, post operative course, OPD follow up. Variables studied were age, sex, nationality, History of previous surgery, recurrence, open or closed sphincterotomy, healing of wound, duration of healing [weeks], post op pain, post op bleeding, incontinence of flatus, liquid or solid stool, length of incontinence, duration of surgery, and weather admitted or treated as a day case.
Results: In our study the youngest patient was 18 years old and the oldest 67 years old with mean age 42.5 years. Majority were females 65% and males 35%. Saudis were 52.4% and non Saudis were 47.5%. 55.4% of patients had previous surgery. Recurrence occurred in 5.4% of patients. 42.3% underwent closed surgery and 57.7% open surgery. Duration of operation was minimum 4 minutes and maximum 25 minutes with mean duration of 14.5 minutes. 11.9% of patients needed admission while 88.1% were treated as day case. Healing occurred in 72.8% while 27.2% did not have healing of wounds. Majority of wound healed in one week-57.6% and 18.4 had healing in two weeks while longest healing occurred in 52 weeks. Longest follow up was 180 weeks. Post op pain occurred in 50% of cases and no pain in 50% of cases. Post op bleeding occurred in 23.9% of patients. There was no incontinence in 80.4% of cases while 14.1 % of patients had incontinence of flatus, 4.3% of liquid stools 1% incontinence of solid stool. Length of incontinence was one to sixteen weeks. In 16.3% cases incontinence was resolved and in 3.2% cases it did not resolve. 73.9% of patients expressed satisfaction of treatment while 17.3% were partially satisfied and 8.6% patients were not satisfied with the treatment.
Conclusion: Lateral sphincterotomy is a safe, effective treatment of anal fissure and evolving as a gold standard treatment for chronic anal fissure.

Keywords: Anal fissure, incontinence, lateral sphincterotomy


How to cite this article:
Kensarah A, Zaidi N H, Al Daqal S M, Shaheen H M, Johari A, Altaf A, Khogeer H, Sibiani A R. Re-evaluation of lateral subcutaneous sphincterotomy in treating anal fissure . Arch Int Surg 2015;5:20-4

How to cite this URL:
Kensarah A, Zaidi N H, Al Daqal S M, Shaheen H M, Johari A, Altaf A, Khogeer H, Sibiani A R. Re-evaluation of lateral subcutaneous sphincterotomy in treating anal fissure . Arch Int Surg [serial online] 2015 [cited 2024 Mar 19];5:20-4. Available from: https://www.archintsurg.org/text.asp?2015/5/1/20/153144


  Introduction Top


Anal fissure is an ulcer in the mucosa of anal canal between anal verge and dentate line which commonly occurs in midline posteriorly. Acute anal fissure have sharp edges and are well-demarcated but if they persist longer than 4 weeks, then they are called chronic anal fissure which are characterized by indurated margins, hypertrophied anal papilla, visible sphincter fibers at fissure base, and sentinel piles. [1] Injury to anal mucosa by hard stool appears to be initiating event in the development of anal fissure. Internal anal sphincter hypertonia is implicated in development of anal fissure. [2] Anal manometery has shown hypertonia of internal anal sphincter in chronic anal fissure. [3],[4] Poor perfusion at posterior commissure of anal canal has been demonstrated by postmortem inferior rectal artery angiography. [5] Doppler laser flow studies have demonstrated poor anodermal blood flow at the fissure site. [6] Anal fissure presents with anal pain, rectal bleeding, and constipation. Symptomatic fissure require treatment although more than 90% of fissure heal spontaneously. Conservative treatment is the usual treatment in form of dietary fiber-like Psyllium, methylcellulose, Guar gum, laxative or stool softners, sitz bath, and increased water intake. Non-surgical management of anal fissure has advantage of maintaining of structural integrity of internal anal sphincter, repeatability of treatment, and possibility of using combination of therapeutic agents.

Medical treatment in the form of topical nitroglycerine ointment helps in relaxation of internal anal sphincter [7] and promote healing by lowering intra-anal pressure and increasing blood flow. [8] Comparison of transdermal nitroglycerin patch in a randomized study with topical nitroglycerin 0.2% showed same effect in pain relief and healing of fissure. [9] Other agents like Diltiazem 2% and Nifedipine 0.3% which are calcium channel blocker have healing rates of 65% to 95%. [10],[11] Injection of botulinum toxin into internal sphincter produces healing rates from 60% to 80% after single injection and recurrences can be managed by repeating injection. [12] Lateral internal sphincterotomy is considered as treatment of choice for anal fissure management. It produces faster pain relief, with healing rates from 75% to 95% than fissurectomy or posterior midline sphincterotomy. [13] We present our series of patients who underwent Lateral internal anal sphincterotomy for the treatment of chronic anal fissure.


  Patients and Methods Top


We retrospectively studied 143 patients with chronic anal fissure at King Abdulaziz University Hospital between March 1995 and April 2011, to determine the outcome of lateral subcutaneous sphincterotomy. These patients were studied using file data, operative notes, post-operative course, and surgical outpatient department (SOPD) follow-up. Variables studied were age, sex, nationality, previous surgery for chronic anal fissure, recurrence, open or closed sphincterotomy, healing of wound, duration of healing [weeks], post-operative pain, post-operative bleeding, incontinence of flatus, liquid or solid stool, length of incontinence, duration of surgery, and weather admitted or treated as a day case and patient's satisfaction. Pre-operative preparation like relief of constipation with high fiber diet, use of laxatives and enema on the night prior to surgery and on the morning of surgery helps to achieve good results. Precise surgical technique and gentle handing of tissues helps to achieve faster healing and reduction of recurrence. Post-operative pain control, use of sitz bath, high fiber diet and laxatives are essential for a good result in the prevention of recurrence. The outcome of surgery is influenced by pre- and post-operative preparation of the patient. Therefore, you should briefly describe the measures you usually take in order to get a good outcome.


  Results Top


In our study, the age ranged from 18 to 67 years with mean age 31.63 ± 9.2 years. Majority were females (65%) and males 35%. Saudis were 52.4% and non-Saudis were 47.5%. Also, 55.4% of patients had previous surgery for chronic anal fissure. Among our 143 patients, recurrence occurred in 5.4% of patients. And, 42.3% underwent closed surgery and 57.7% open surgery. Duration of operation ranged 4-25 minutes with mean of 14.5 minutes. Also, 11.9% of patients needed admission due to stabilizing of their comorbid conditions like blood sugar and blood pressure control, one of them was on warfarin which needed to be switched to heparin. Two of the patients had post-operative bleeding so they were admitted to surgical wards, while 88.1% were treated as day case. Healing occurred in 72.8% while 27.2% did not have healing of wounds in 6 weeks. One patient's wound did not heal even after 1 year because he was later diagnosed as a case of Crohn's disease. Majority of wound healed in 1 week-57.6% and 18.4 had healing in 2 weeks while longest healing occurred in 52 weeks. Longest follow-up was 180 weeks. Post-operative pain occurred in 50% of cases which was assessed on a visual analogue scale of one to ten and no pain in 50% of cases on the same scale where zero was assigned as no pain. Post-operative bleeding occurred in 23.9% of patients. There was no incontinence in 80.4% of cases while 14.1% of patients had incontinence of flatus, 4.3% of liquid stools, 1% incontinence of solid stool. Length of incontinence was 1-16 weeks. In 16.3% cases, incontinence was resolved and in 3.2% cases it did not resolve. And, 73.9% of patients expressed satisfaction of treatment while 17.3% were partially satisfied and 8.6% patients were not satisfied with the treatment. Three of the patients were not happy because of longer healing time as they took five5 weeks for their wound to heal. Two had incontinence of stool, so they were not satisfied. One was not satisfied because of -operative bleeding while two patients were not satisfied because of sitz bath which they told us that it is old-fashioned treatment and causing much inconvenience to their daily routine [Figure 1], [Figure 2], [Figure 3], [Figure 4].
Figure 1: Age and sex distribution

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Figure 2: Nationality

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Figure 3: Sphincterotomy details

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Figure 4: Outcome of Sphincterotomy

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  Discussion Top


Anal fissure is commonly found in the midline posteriorly as hard stool causes abrasions on mucosa posteriorly due to curve of rectum over sacrum and anorectal angle. There is poor perfusion of blood in midline posteriorly which has been shown by inferior rectal arteriography, and spasm of anal sphincter which further reduces blood supply to midline posteriorly and only 10% of females and 1% of males have fissure located in anterior midline. [14],[15] Various modalities of treatment of anal fissure are available with different success rates. Meta-analysis of different studies done by Nelson et al. showed that glycerin trinitrate has overall response rate of 55%, botox injection has response rate of 65%, while surgery in the form of lateral sphincterotomy is 85%. [16] Posterior sphincterotomy is now no longer performed due to key hole deformity which causes mucosal discharge in one-third of patients. Sphinterotomy emerged as standard treatment of anal fissure. There are certain principles which should be followed like, sphincterotomy should be away from fissure site so that gap of sphincter be filled by intact mucosa, full thickess of sphincter must be divided, upper third of sphincter must remain intact for continence, and the length of sphincterotomy should be tailored to the length of anal fissure. Lateral internal sphincterotomy appears to be gold standard against all treatment for anal fissure.

In our study, youngest patient was 18 years old and oldest 67 years old with mean age 42.5 years and this comparable with findings of Melange et al. who reported mean age 45 years. [17] Majority were females 65% and males 35% while Nahas et al. reported male to female ratio 2.3:1. [18] Saudis were 52.4% and non-Saudis were 47.5%. And, 55.4% of patients had previous surgery. Recurrence occurred in 5.4% of patients. And, 42.3% underwent closed surgery which was promoted by Notaras et al., [19] by introducing knife blade at anal verge between anal mucosa and internal anal sphincter and cutting laterally toward internal anal sphincter and 57.7% open surgery which was described by Hoffman and Goligher, [20] by passing the blade between internal and external sphincter and cutting medially. Also, 88.1% of our patients were treated as day case while Wiley et al. had all patients operated as day case. [21] Healing occurred in 72.8% while 27.2% did not have healing of wounds in 6 weeks. One patient's wound did not heal even after 1 year. This patient was later diagnosed as a case of Crohn's disease. Wiley et al. reported healing in 96% of cases but our results of healing are comparable to Hananel et al. who reported 73.2% healing in 1 month. [22] Majority of wounds in our study healed in one week-57.6% and 18.4 had healing in 2 weeks while longest healing occurred in 52 weeks. Delayed healing in one patient was attributed to Crohn's disease while others was due to comorbid condition like poor diabetic control and poor personal hygiene. Longest follow-up was 180 weeks. Post-operative pain occurred in 50% of cases and no pain in 50% of cases. Post-operative pain was found more in patients who had excision of sentinel tag along with lateral sphincterotomy as well as in those with concomitant hemorrhoid excision. Post-operative bleeding occurred in 23.9% of patients. Garcea et al. reported post-operative bleeding in 18.5% of cases. [23] There was no incontinence in 80.4% of cases in our study, incontinence occurred in 19.6% of cases which is similar to study of Lewis et al. who reported incontinence in 17% of cases. [24] In our study, 14.1% of patients had incontinence of flatus, 4.3% of liquid stools which is similar to study of Garcea et al. who reported incontinence of liquid stool in 3.4% of cases, and 1.7% incontinence of feces, while our study has 1% incontinence of solid stool. Length of incontinence was 1-16 weeks. In 16.3% cases, incontinence was resolved; and in 3.2% cases, it did not resolve. In one case, incontinence did not resolve because patient had Crohn's disease while other had sphincterotomy in recurrent anal fissure. Moreover, 73.9% of patients expressed satisfaction of treatment while 17.3% were partially satisfied and 8.6% patients were not satisfied with the treatment Three of the patients were not happy because of longer healing time as they took 5 weeks for their wound to heal. Two had incontinence of stool, so they were not satisfied. One was not satisfied because of post-operative bleeding while two patients were not satisfied because of sitz bath which they told us that it is old-fashioned treatment and causing much inconvenience to their daily routine. Our results are similar to Nyam et al. who reported 3% of his patients not satisfied with the treatment. [25]

To minimize the rates of incontinence and recurrence, meticulous pre-operative preparations required high-fiber diet and good personal hygiene. Operative technique should be meticulous, and certain principles are to be followed like, do not perform sphincterotomy if fissure is not visualized under anesthesia. Caution should be applied while performing sphincterotomy in patients with diarrhea, irritable bowel syndrome, diabetics, Crohn's disease. Avoid multiple procedures like hemorrhoidectomy, fissurectomy, or fistula surgery with sphincterotomy. Avoid posterior sphincterotomy as it would result in key hole deformity. Post-operative diet modification like plenty of fruits, vegetables should be incorporated in diet. Good personal hygiene plays important role in faster healing and prevention of recurrence.


  Conclusion Top


Lateral sphincterotomy is a safe, effective treatment of anal fissure and evolving as a gold standard treatment for chronic anal fissure.

 
  References Top

1.
Nelson R. Non surgical therapy for anal fissure. In: The Cochrane Library, Issue 3, 2009. Chichester: John Wiley & Sons, Ltd. Search date; 2006:18.  Back to cited text no. 1
    
2.
Gibbons CP, Read NW. Anal hypertonia in fissures: Cause or effect? Br J Surg 1986;73:443-5.  Back to cited text no. 2
    
3.
Farouk R, Duthie GS, MacGregor AB, Bartolo DC. Sustained internal sphincter hypertonia in patients with chronic anal fissure. Dis Colon Rectum 1994;37:424-9.  Back to cited text no. 3
    
4.
Schouten WR, Briel JW, Auwerda JJ. Relationship between anal pressure and anodermal blood flow. The vascular pathogenesis of anal fissures. Dis Colon Rectum 1994;37: 664-9.  Back to cited text no. 4
    
5.
Klosterhalfen B, Vogel P, Rixen H, Mittermayer C. Topography of the inferior rectal artery: A possible cause of chronic, primary anal fissure. Dis Colon Rectum 1989;32:43-52.  Back to cited text no. 5
    
6.
Schouten WR, Briel JW, Auwerda JJ, De Graaf EJ. Ischaemic nature of anal fissure. Br J Surg 1996;83:63-5.  Back to cited text no. 6
    
7.
O'Kelly T, Brading A, Mortensen N. Nerve mediated relaxation of the human internal anal sphincter: The role of nitric oxide. Gut 1993;34:689-93.  Back to cited text no. 7
    
8.
Kua KB, Kocher HM, Kelkar A, Patel AG. Effect of topical glyceryl trinitrate on anodermal blood flow in patients with chronic anal fissures. ANZ J Surg 2001;71:548-50.  Back to cited text no. 8
    
9.
Zuberi BF, Rajput MR, Abro H, Shaikh SA. A randomized trial of glyceryl trinitrate ointment and nitroglycerin patch in healing of anal fissures. Int J Colorectal Dis 2000;15: 243-5.  Back to cited text no. 9
    
10.
Kocher HM, Steward M, Leather AJ, Cullen PT. Randomized clinical trial assessing the side-effects of glyceryl trinitrate and diltiazem hydrochloride in the treatment of chronic anal fissure. Br J Surg 2002;89:413-7.  Back to cited text no. 10
    
11.
Perrotti P, Bove A, Antropoli C, Molino D, Antropoli M, Balzano A, et al. Topical nifedipine with lidocaine ointment vs. active control for treatment of chronic anal fissure: Results of a prospective, randomized, double-blind study. Dis Colon Rectum 2002;45:1468-75.  Back to cited text no. 11
    
12.
Jost WH, Schrank B. Repeat botulinum toxin injections in anal fissure: In patients with relapse and after insufficient effect of first treatment. Dig Dis Sci 1999;44:1588-9.  Back to cited text no. 12
    
13.
Nelson R. Operative procedures for fissure-in-ano. Cochrane Database Syst Rev 2004:CD002199  Back to cited text no. 13
    
14.
Brisinda G, Cadeddu F, Brandara F, Brisinda D, Maria G. Treating chronic anal fissure with botulinum neurotoxin. Nat Clin Pract Gastroenterol Hepatol 2004;1:82-9.  Back to cited text no. 14
    
15.
Lund JN, Scholefield JH. Aetiology and treatment of anal fissure. Br J Surg 1996;83:1335-44.  Back to cited text no. 15
    
16.
Nelson R. Non surgical therapy for anal fissure. Cochrane Database Syst Rev 2006;18:CD003431.  Back to cited text no. 16
    
17.
Melange M, Colin JF, Van-Wymersch T, Vanhevverzwyn R. Anal fissure: Correlation between symptoms and manometry before and after surgery. Int J Clorectal Dis 1992;7:108-11.  Back to cited text no. 17
    
18.
Nahas SC, Sobrado Júnior CW, Araujo SE, Aisaka AA, Habr-Gama A, Pinotti HW. Chronic anal fissure: Results of the surgical treatment of 220 patients. Rev Hosp Clin Fac Med Sao Paulo 1997;52:246-9.  Back to cited text no. 18
    
19.
Notaras MJ. Lateral subcutaneous sphincterotomy for anal fissure - a new technique. Proc R Soc Med 1969;62:713.  Back to cited text no. 19
    
20.
Boulos PB, Araujo JG. Adequate internal sphincterotomy for chronic anal fissure: Subcutaneous or open technique? Br J Surg 1984;71:360-2.  Back to cited text no. 20
    
21.
Wiley M, Day P, Rieger N, Stephens J, Moore J. Open vs. closed lateral internal sphincterotomy for idiopathic fissure-in-ano: A prospective, randomized, controlled trial. Dis Colon Rectum 2004;47:847-52.  Back to cited text no. 21
    
22.
Hananel N, Gordon PH. Lateral internal sphincterotomy for fissure-in-ano--revisited. Dis Colon Rectum 1997;40:597-602.  Back to cited text no. 22
    
23.
Garcea G, Sutton C, Mansoori S, Lloyd T, Thomas M. Results following conservative lateral sphincteromy for the treatment of chronic anal fissures. Colorectal Dis 2003;5:311-4.  Back to cited text no. 23
    
24.
Lewis TH, Corman ML, Prager ED, Robertson WG. Long-term results of open and closed sphincterotomy for anal fissure. Dis Colon Rectum 1988;31:368-71.  Back to cited text no. 24
    
25.
Nyam DC, Pemberton JH. Long-term results of lateral internal sphincterotomy for chronic anal fissure with particular reference to incidence of fecal incontinence. Dis Colon Rectum 1999;42:1306-10.  Back to cited text no. 25
    


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