Full Length versus Partial Length Lateral Internal Sphincterotomy for the Treatment of Chronic Anal Fissure

Full Length versus Partial Length Lateral Internal Sphincterotomy for the Treatment of Chronic Anal Fissure

Hatem ElGohary, MD, MRCS

Department of General Surgery, Faculty of Medicine, Helwan University, Ain Helwan, Egypt

Background and aim: Surgical treatment with lateral internal sphincterotomy (LIS) remains the principal treatment for chronic resistant cases with high degree of success despite persistence or recurrence of anal fissures. The incidence of these unfavorable outcomes has been reported to be related mostly to the height of the sphincterotomy. The aim of this study was to evaluate the effectiveness and safety of full length LIS compared to partial length LIS.

Patients and methods: Between May 2008 and June 2014, we surgically treated 80 patients with chronic anal fissure. Group A had partial length LIS and group B had full length LIS. All the patients were continent preoperative and postoperative data were recorded regarding pain, bleeding, infection, recurrence and postoperative incontinence.

Results: None of our patients in both groups had permanent incontinence to flatus or stools. Temporary incontinence to stool and flatus occurred in 9 patients with full length LIS group and only in 3 patients in the partial length LIS.

Conclusion: Full length LIS is a safe effective procedure for the treatment of resistant chronic anal fissure.

Key words: Anal fissure, lateral internal sphincterotomy, fissurectomy, incontinence, full length lateral

internal sphincterotomy.

Introduction

Anal fissure is one of the most common proctologic disorders which appear on distal part of anal canal causing severe pain and bleeding during and after defecation.1  Although it may affect people of all ages, mainly young and middle aged patients suffer from the disease, which is distributed to both genders in the same ratio.2  Solid stools and high anal sphincter pressures have usually been accepted reasons for etiology.3

Treatment options are varying from local medical applications to surgical sphincterotomy. The object in anal fissure treatment is to dissolve or at least to reduce the spasm in anal sphincter.4  Surgical treatment remains to be the principal treatment for chronic resistant cases.5

Initial experience with the posterior sphincterotomy was unsatisfactory; the main weakness of this procedure was a significant rate of recurrences and anal incontinence and a long period required for the wound to heal.6

Many  of  these  drawbacks  were  overcome  by the adoption of subcutaneous lateral internal sphincterotomy (LIS).7,8  This procedure achieves a high degree of success despite persistence or recurrence of anal fissures.9-12 The incidence of these unfavorable outcomes has been reported to be related mostly to the height of the sphincterotomy, thus raising the question of the

ideal length of the sphincteral section.13,14

In this study, we describe the technique and results of full length lateral internal sphincterotomy (LIS) combined with fissurectomy compared to partial length lateral internal sphincterotomy with fissurectomy.

Patients and methods

A prospective randomized study was conducted at Ain Shams University students hospital and Dar El Shefa hospital – Ministry of Health in Egypt between May 2008 and June 2014. All patients were asked to provide written consent prior to enrollment, after explanation of the associated risks and benefits and description of the study protocol.

We treated 80 patients for chronic anal fissure who were nonresponders to medical therapy (glyceryl trinitrate 0.2% paste twice a day for 3 weeks) by LIS combined with fissurectomy. No patient showed deficit of continence preoperatively. Patients were divided into group A included 40 patient who underwent partial length LIS corresponding to the length of fissure, and group B included 40 patients who underwent full length LIS.

The following data were recorded for each patient: age, sex, site of the fissure, mode of presentation and preoperative continence to stool and flatus. Patients   were   followed   up   postoperative   in

outpatient clinic for six months and the following data were recorded: postoperative continence to flatus and stools, patient satisfaction according to the extent of relieve of symptoms and minor and

major  complications.  Postoperative  continence to flatus and stools was assessed using Wexner continence grading scale. (Table 1).

Table 1: Wexner continence grading scale15

Frequency

Never, 0; rarely, <1/month; sometimes, <1/week, >1/month;

usually, <1/day, >1/week; always, >1/day.  0, perfect; 20, complete incontinence.

A chronic anal fissure was defined as a lesion that presented with indurated edges, sentinel pile, hypertrophied anal papillae, and the presence of circular muscle fibers at the base of the cutaneous defect.

Patients were excluded if they had any previous pelvic or perineal surgeries or if they have any de- gree of preoperative incontinence.

Surgery:

All patients were operated on by the same sur- geon under spinal anesthesia, in lithotomy posi- tion with a tape retracting the gluteal region lat- erally. The perineal region was prepared with a disinfectant solution (Betadine) and draped in the usual fashion.

Digital per rectal examination was initiated to exclude any other ano-rectal pathology, then proctoscopy was done to visualize the fissure and the inter-sphincteric space was entered through a 1 cm long transverse radial incision in 3 o’clock position. The full length  and thickness of the internal anal sphincter was identified through a mosquito forceps when left index finger was placed in anal canal.

Hypertrophied anal papillae and sentinel pile were

routinely removed with the fissure.

In group A partial length of internal sphincter was transected corresponding to the length of the fissure.

In group B Full length of internal sphincter was transected.

Hemostasiswasachievedwithagauzepadandelectro cauteryandtheincisionwasleftopen.Allpatientswere given soft foods at postoperative sixth hour. They were   later   discharged   with   recommendation for regular betadine wash after defecation with prescription  for  regular oral  analgesic (NSAIDs e.g, Cataflam 50mg twice daily for three days), osmotic laxative agent e.g. Lactulose three times daily for a week and instructions to consume a high-fiber diet.

First follow-up was conducted on the postopera- tive seventh day, second was in the fourth week, and then continued monthly. Mean follow-up peri- od was six months.

Results

Among eighty patients having a chronic anal fis- sure, 57.5% were female and 42.5% were male, with  the  male  to  female  ratio  being  1:  1.35 (Table 1). Their age ranged from 20-50 years; with a mean age of 36.34±7.16 in group A and mean age of 34.25±6.76 in group B. The peak in- cidence age of patients with a chronic anal fissure was recorded in the age group from 20 to 30 years (43.7%), while there was a lower incidence in the age in group 41 to 50 years (16%) (Table 2). 75% of our patients suffered preoperatively from chronic constipation.

Table 2: Sex distribution

P-value

0.956

Table 3: Age distribution

The  fissure was  on  the   posterior   midline   in

63     patients, anterior in 5 and both anterior and

posterior in 12 patients (Table 3).

66.25% of our patients presented with anal pain and

bleeding during and after defecation and 22.5% complained from anal pain only, 8.75% of patients complained from anal swelling (Sentinel pile) and

2.5% complained from pruritus ani (Table 4).

Table 4: Site of fissure

Table 4: Mode of presentation

Group1

Group2

Symptom

Partial

length LIS (n=40)

Full length LIS (n=40)

Total No. of

patients

Percentage        P value

Pain only                              8 (20.0%)         10 (25.0%)               18                  22.5%              0.592

Pain and bleeding                25 (62.5%)        28 (70.0%)               53                 66.25%             0.478

Swelling (sentinel pile)            2 (5%)            5 (12.5%)                7                   8.75%              0.235

Pruritus ani                           0 (0.0%)           2 (5.0%)                 2                   2.5%               0.152

The results of postoperative complications in our study were as following (Table 5): The incidence of complications was 55% in group A while only

30% in group B (P Value < 0.05). Ten patients (25%) in group A complained from prolonged postoperative pain while two patients (5%) from group B complained from prolonged postoperative pain  (P  Value  <0.05).  Pain  was  reported  as a complication if the patient needed to take analgesics more than three days postoperative in the oral, intravenous or intramuscular form.

Bleeding was reported in four patients (10%) from group A while no patients were reported in group B (P Value < 0.05).

Two patients (5%) in group A had infection while one patient (2.5%) had infection in group B (P

Value >0.05).

Temporary incontinence to flatus and stools were

recorded in group A with incidence of 5% and

2.5% respectively while it was recorded higher in group B with 15% and 7.5% respectively (P Value

> 0.05). Wexner score for these patients ranged from 7 to 4 during 1, 4 and 8 weeks postoperative. None of our patients in both groups had permanent incontinence to flatus or stools. The recurrence was in the form of appearance of anal fissure at the same site of the old fissure or at different site and it was 7.5% (3 patients) in group A and 0% in group B (P Value > 0.05). None of our patients in this study showed failure of fissure healing after 3 months during their follow up visits.

Table 5: Postoperative complications

Complications

No. of

Group A                         Group B No. of

P Value

patients      Percentage

patients    Percentage

Pain                                                                      10            25.0%             2               5%          0.012

Bleeding                                                                 4             10.0%             0               0%          0.040

Infection                                                                2              5.0%              1              2.5%         0.556

Temporary incontinence to flatus (not more than 3

months)

Temporary incontinence to stool (not more than 3 months)

2              5.0%              6              15%         0.136

1              2.5%              3              7.5%         0.304

Permanent incontinence to flatus                              0              0.0%              0                                                                            0%                                 NA Permanent incontinence to stool                               0              0.0%              0                                                                            0%                                 NA Recurrence                                                             3              7.5%              0                                                                            0%           0.077

Total                                                                     22            55.0%             12             30%         0.023

NA: Not applicable

Discussion

An occasional sudden expulsive hard fecal mass in chronic constipated patients has long been considered as the main cause of anal fissure.16

We reported 75% of our patients to have chronic constipation; Tocchi et al reported only 40% of their patients having chronic constipation while the rest had normal bowel habit or even diarrhea.17

In this study 57.5% of patients were females and the peak incidence of age was in the third decade (43.7%) with mean of 35.3±6.96. In a study done by Hamid H, Sarhan, only 22% were females and the peak incidence of age was in the fourth decade of life (55%).18

The most common site for anal fissure is the posterior midline,19 78.75% of our patients had anal fissure located posteriorly while 21.25% had it anteriorly and both anteriorly and posteriorly.

Among surgeons, there is still a debate about how much of the internal sphincter that should be divided.20  Division of short segment of the internal sphincter make the patient more prone to complications such as: Prolonged postoperative pain, bleeding and persistence or recurrence of the anal fissure.

The present study showed lower complications rate  in  the  full  length LIS  group  than  in  the partial length LIS group with 30% and 55% respectively. The full length division of internal sphincter enhances early healing, and consequent intramuscular linear fibrosis prevents permanent incontinence.17

In this study, postoperative pain and bleeding reduced significantly with full length LIS than in patients with partial length LIS. In a study done by Pujahari, pain was significantly reduced by doing bilateral LIS with pain score of 12 out of 100 compared to 57 in unilateral LIS on average dose of NSAIDs.21

Despite that full length division of the internal sphincter have a higher incidence of temporary incontinence to flatus and stools, but still have better long-term results than partial length internal sphincterotomy. In a study done by Kensarah et al doing partial length LIS, 14.1% patients had incontinence of flatus, 4.3% of liquid stools, and

1% incontinence of solid stools.22

Conclusion

The full length lateral internal sphincterotomy with fissurectomy is a safe and  effective procedure for the treatment of chronic anal fissure with acceptable long-term results in the previously continent  patients.  Further  studies  should  be done to include patients with previous pelvic and perineal surgeries.

References

1.   Utzig  MJ,  Kroesen  AJ,  Buhr  HJ:  Concepts in  pathogenesis  and  treatment  of  chronic anal fissure a review of the literature. Am J Gastroenterol 2003; 98: 968–974.

2.   Tsunoda A, Kashiwagura Y, Hirose K, Sasaki T, Kano N: Quality of life in patients with chronic anal fissure after topical treatment with diltiazem. World J Gastrointest Surg 2012;

27: 251-255.