|Year : 2022 | Volume
| Issue : 2 | Page : 119-122
Therapeutic outcome of lateral internal sphincterotomy in the treatment of chronic anal fissures
Melvin Varghese, S Shaju, N Saran, MH Firoz Khan, S L. Shafy Ali Khan
Department of General Surgery, KIMSHEALTH Hospital, Thiruvananthapuram, Kerala, India
|Date of Submission||18-Nov-2022|
|Date of Decision||27-Nov-2022|
|Date of Acceptance||02-Dec-2022|
|Date of Web Publication||30-Jan-2023|
Dr. Melvin Varghese
Department of General Surgery, KIMSHEALTH Hospital, Thiruvananthapuram - 695 029, Kerala
Source of Support: None, Conflict of Interest: None
Introduction: Chronic anal fissure (CAF) is one of the most common proctologic conditions seen in surgery and is the most common cause of perianal pain. The surgical procedure of choice is lateral internal sphincterotomy (LIS) which usually provides a permanent cure for CAF. The fear of causing incontinence restricts many surgeons from performing LIS for managing CAF. The objective of our study is to evaluate the outcome of LIS in treating CAF in terms of fissure healing and reduction in resting anal pressure (RAP), as well as the incidence of anal incontinence following the procedure. Materials and Methods: A prospective study was conducted among 43 patients with CAF who underwent LIS. Anal manometry of the patients was done and results were noted preoperatively as well as at 6 weeks postoperatively. Patients were followed up and symptom relief, healing of fissure and incontinence to flatus or stool if present were noted on post-operative day, 1 week after surgery and 6 weeks after surgery. Results: Fissure healed in all 43 patients who underwent LIS in our institute. Hence, we observed a 100% healing rate following the procedure. RAP was found to be raised in all patients with CAF who required surgical treatment with a mean pre-operative RAP of 86.6 mmHg (normal 40–60 mmHg.). There was a significant reduction in RAP after the LIS surgery with a P < 0.001. The mean post-operative RAP was 53.16 mmHg which is in the normal range. Only one patient (2.3%) developed post-operative anal incontinence in our study. He was also managed conservatively with no permanent incontinence. Conclusions: We conclude that LIS is the surgical treatment of choice for CAFs, as it gave a 100% healing rate with a very low incidence of post-operative anal incontinence and other complications.
Keywords: Chronic fissure in ano, faecal incontinence, lateral internal sphincterotomy
|How to cite this article:|
Varghese M, Shaju S, Saran N, Firoz Khan M H, Ali Khan S L. Therapeutic outcome of lateral internal sphincterotomy in the treatment of chronic anal fissures. Kerala Surg J 2022;28:119-22
|How to cite this URL:|
Varghese M, Shaju S, Saran N, Firoz Khan M H, Ali Khan S L. Therapeutic outcome of lateral internal sphincterotomy in the treatment of chronic anal fissures. Kerala Surg J [serial online] 2022 [cited 2023 Mar 24];28:119-22. Available from: http://www.keralasurgj.com/text.asp?2022/28/2/119/368598
| Introduction|| |
An anal fissure is one of the most common conditions encountered in the general surgery outpatient department. It is defined as a vertical tear in the anal mucosa that is lined with squamous epithelium, which causes moderate-to-severe pain during and after defecation along with streaks of fresh blood., The pain can sometimes become excruciating and it may significantly reduce the patient's quality of life. Anal fissures can be acute or chronic. Chronic anal fissure (CAF) is considered when it fails to heal and remains symptomatic even after 6–8 weeks of conservative management.,
Hard stool and high resting anal pressure (RAP) are generally accepted as the major causative factors for the disease. Hard stool causes tear in the anoderm when the patient strains to defecate which causes pain resulting in spasm of the internal anal sphincter which increases the RAP. High RAP results in decreased blood supply to the anoderm and the ischemia causes further tearing as well as impairs the healing of the existing fissure. This cycle of pain, spasm and ischaemia contribute to the development of a non-healing wound that becomes a chronic fissure.,,,
The treatment of CAF is hence focussed on breaking this vicious cycle of pain, spasm and ischaemia. Conservative management should be tried initially which includes laxatives to avoid hard stools, analgesics to reduce the pain, local ointments such as lignocaine or glyceryl trinitrate and injection of botulinum toxin which relaxes the internal sphincter and reduces RAP.,,,
Surgical therapy is usually reserved for patients who fail to respond to medical therapy and those patients with recurrent fissures or the ones with other associated anorectal pathologies needing surgical management. Many surgical procedures are defined for the treatment of CAF. The most popular procedures are manual anal dilatation, sphincterotomy, fissurectomy and posterior anal flap.,
Lateral internal sphincterotomy (LIS) is considered the gold standard procedure in the surgical management of CAF as it addresses the problem almost permanently with faster healing of fissures and a very low recurrence rate.,,, Although a decrease in anal sphincteric pressure is the desired outcome of the procedure, it can result in an incompetent anal sphincter complex resulting in anal incontinence. Thus, the amount of decrease in anal sphincteric pressure after LIS is critical. The fear of causing incontinence restricts many surgeons from performing LIS for managing CAF.,
This study is aimed at evaluating the outcome of LIS in the surgical management of CAFs in terms of fissure healing as well as in terms of a decrease in RAP. This study also evaluated the incidence of anal incontinence following LIS.
| Materials and Methods|| |
This was a prospective, observational study conducted at our tertiary care centre from November 2019 to June 2021, on all the patients above 18 years with CAF admitted under the department of general surgery and underwent LIS. The aim of the study was to study the outcome of LIS in the treatment of CAF in terms of fissure healing and decrease in RAP after the procedure, as well as the rate of faecal incontinence developed following the procedure
The sample size was calculated as
A = 1.000
B = (Zα + Zβ)2 = 7.849
C = (E/S [Δ])2 = 0.250
N = AB/C = 31.40
Accordingly, the sample size required for this study was 40
Patients were complicated with cancer, inflammatory bowel disease, dermatitis, poor general condition, history of anal trauma, previous anal surgery or diagnosis of any neurological diseases and those above the age of 80 years or <18 years were excluded.
All patients satisfying the inclusion criteria were enrolled in the study after obtaining written informed consent. A detailed explanation of the associated risks and benefits of participating in the study and a description of the study protocol was given to all the patients. The presenting history and the clinical examination findings of the primary investigator and other investigators were noted. The RAP and squeeze pressure of the study population were measured using MSM ProMedico Sphinctometer (MSM Promedico GmbH, Germany) before surgery. All the patients underwent LIS by open technique under spinal anaesthesia. Postoperatively, healing of the fissures and anal continence for flatus and stool were noted at immediate post-operative period, after 1 week of procedure and after 6 weeks. Anal manometry was repeated on the 6th week post-operative follow-up visit and the RAP and SP values were also noted.
All the data collected were coded and entered into a Microsoft Excel sheet which was re-checked and analysed using SPSS statistical software version 22 (IBM, New Delhi). Quantitative variables were summarised using mean and standard deviation if normally distributed and using median and interquartile range when not normally distributed. Categorical variables were represented using frequency and percentage. Pearson's Chi-square test and Fisher's exact test were used for comparing categorical variables between groups. MannWhitney test and Kruskal–Wallis test were used for comparing continuous variables between groups. Wilcoxon signed-rank test was used for comparing variables preoperatively and postoperatively. A P < 0.05 was considered statistically significant.
| Results|| |
Forty-three subjects who underwent LIS in our hospital for the treatment of CAF and satisfied the inclusion and exclusion criteria were included in the study. We found 14 (32.6%) patients belonged to the age group of 31–35 years followed by 41–45 years of age group which had 10 (23.3%) patients. Seventy per cent of the patients who underwent LIS were between 31 and 45 years of age. The majority (55.8%) of the patients were male.
Mean pre-operative RAP was found to be 86.86 ± 17.04 mmHg with a median value of 84 mmHg. The mean pre-operative SP was found to be 127.28 ± 33.14 mmHg with a median value of 122 mmHg. Postoperatively, mean RAP decreased to 53.16 ± 5.35 mmHg with a median value of 54 mmHg and SP decreased to 118.42 ± 20.57 mmHg with a median value of 123 mmHg [Table 1].
Incontinence was seen in none of the patients in the immediate post-operative period, whereas 1 (2.3%) patient had incontinence to liquids and flatus at 2 weeks and 6 weeks post-operative follow-up visits [Figure 1]. He was managed with dietary modifications and was asymptomatic 2 months after surgery.
Four (9.3%) patients had minor complications other than incontinence. Three patients had persisting pain which was managed with analgesics and one patient developed hypotension in the post-operative period. All four of them recovered well with conservative management and were asymptomatic at 6 weeks post-operative follow-up. Fissures healed in all 43 (100%) patients who underwent LIS at the 6-week post-operative follow-up visit.
There was a significant decrease in RAP after the LIS surgery with a P < 0.001. SP also decreased after the procedure but it was not statistically significant. The mean pre-operative RAP is 86.6 mmHg. The mean post-operative RAP is 53.16 mmHg which is in the normal range of 40–60 mmHg [Table 2].
Improvement in resting anal sphincter pressure after surgery had no statistically significant association with age, sex, incontinence or other complications following the surgery.
Complications were found to be higher among 41–45 years age group and female but these were not statistically significant. Patients who developed the complications had a significantly higher mean pre-operative squeeze pressure. There were no statistically significant differences in mean pre-operative and post-operative resting anal sphincter pressure and mean post-operative squeeze pressure between patients with and without complications.
| Discussion|| |
In our study, we found that fissures healed in all the patients who underwent LIS in our institute for CAF during the study period. All previous studies showed a fissure healing rate of more than 90% after LIS. Acar et al. found that fissure healing of 94.7% at 8 weeks after LIS. Hassan et al. also reported a similar result of complete healing of fissures in 96.7% at 6 weeks follow-up. Similar high healing rates were shown in multiple meta-analyses also conducted recently., On a detailed review of these studies, we could note that the post-operative sphincter tone was high for the patients who had unhealed fissures. Hence, the failure of LIS in the minority of patients after the surgery in these studies can be attributed to either improper technique or inadequate division of the internal sphincter.
We also found that all patients with CAF, who required surgical procedures, had elevated RAP preoperatively compared to the normal population. There was a significant reduction in RAP after surgery and the post-operative manometric study showed normal RAP in all patients who underwent LIS.
Peker et al. conducted a manometric study in 41 patients who underwent LIS. They also reported a high RAP in CAF patients preoperatively which significantly reduced after LIS. Mean pre-operative and post-operative RAP values were slightly lower as per their study compared to our values. This can be attributed to the difference in population characteristics as well as the technique of measurement of RAP.
We also found that only one patient developed incontinence following LIS in our study. The patient had incontinence to flatus and liquids at 1 week. He was managed conservatively with lifestyle and dietary modifications and he became asymptomatic 2 months after the procedure. None of our patients developed incontinence to solid stool at any stage of the study.
The majority of the studies reported LIS to be safe with <5% incontinence rate,,, whereas few authors like Garg et al. have reported an alarmingly high incontinence rate. They reported 14% anal incontinence following LIS. According to them, 9% had incontinence to flatus alone, 6% to fluids and 0.83% had incontinence to even a solid stool.
Even large meta-analyses give contradicting reports on the subject of post-operative anal incontinence after LIS. Ebinger et al. reported 9% post-operative incontinence and they suggested a reconsideration of LIS in CAF management. On the contrary, Nelson et al. reported a low incontinence rate of 3.4%–4.4%.
The majority of the patients (70%) who required surgery for RAP were between 31 and 45 years of age. This is consistent with the previous literature., The number of males who required surgery was more than the number of females but there was no statistically significant difference. Men and women are hence almost equally affected by CAF as per our study. Patients who developed the complications had a significantly higher mean pre-operative squeeze pressure. This is a new finding and needs to be further evaluated. Improvement in RAP had no statistically significant association with age, sex, incontinence or other complications.
The main strength of our study is that it was a prospective study and we have considered symptomatic relief, signs of fissure healing as well as anal manometric parameters for evaluating the outcome of the surgery.
The limitation of this study is the lack of a long-term follow-up of at least 1 or 2 years to analyse the long-term outcome and complications of the surgery. Furthermore, the study was done in a tertiary care private hospital and only 43 patients were evaluated. This sample may not be an exact representation of the general population. A multicentre study with a higher sample size may offer a better clinical implication.
| Conclusions|| |
We conclude that LIS is the surgical treatment of choice for CAFs, as it gave a 100% healing rate with a very low incidence of post-operative anal incontinence and other complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]