|Year : 2021 | Volume
| Issue : 1 | Page : 9-13
A comparative study to see the outcome in patients suffering from fissure-in-ano following modified closed lateral internal sphincterotomy, closed lateral internal sphincterotomy, and fissurectomy
Sivaji Sankar Ghose1, Mili Das Chowdhury2, MY Dharmamer3
1 Department of Surgery, Naval Hospital Powai, Mumbai, Maharashtra, India
2 Department of Obstretics and Gynaecology, Naval Hospital Powai, Mumbai, Maharashtra, India
3 Department of Anaesthesia, Naval Hospital Powai, Mumbai, Maharashtra, India
|Date of Submission||30-Sep-2020|
|Date of Decision||21-Nov-2020|
|Date of Acceptance||23-Mar-2021|
|Date of Web Publication||02-Jul-2021|
Mili Das Chowdhury
Department of Obstretics and Gynaecology, Naval Hospital Powai, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: The present study was undertaken to evaluate the comparative results of “Modified Closed Lateral Internal Sphincterotomy (LIS), Closed LIS, and Fissurectomy” technique in treating fissure-in-ano in terms of relief of symptoms, healing of wound, postoperative hospital stay, recurrence rate, and postoperative complications.
Materials and Methods: A total of 120 cases with definite history of fissure and clinically diagnosed cases of fissure-in-ano were selected for the study. A final diagnosis was made after proctoscopic examination under anesthesia during operation. The type of procedure which was to be undertaken was done by letting patient pick up slips randomly where the name of the procedure was written. Total 120 slips were made with 40 slips of each procedure written in them. Postoperative period was closely monitored, and all the cases were meticulously followed for a variable period of time.
Results: In the present study, 68% of the patients were male and 32% were female. It was more prevalent in the age group of 18–40 years. Forty patients underwent modified closed LIS, 40 underwent closed LIS, and remaining 40 patients underwent fissurectomy. Postoperative pain, operative time, duration of hospital stay, and recurrence rate were compared.
Conclusion: Fissure-in-ano is a very painful condition and may cripple the daily activity of the patient. Encouragingly, high success rates were achieved in our patients with the modified closed LIS technique.
Keywords: Closed lateral internal sphincterotomy, fissurectomy, fissure-in-ano, modified closed lateral internal sphincterotomy, posterior, proctoscopy, recurrence
|How to cite this article:|
Ghose SS, Chowdhury MD, Dharmamer M Y. A comparative study to see the outcome in patients suffering from fissure-in-ano following modified closed lateral internal sphincterotomy, closed lateral internal sphincterotomy, and fissurectomy. J Curr Res Sci Med 2021;7:9-13
|How to cite this URL:|
Ghose SS, Chowdhury MD, Dharmamer M Y. A comparative study to see the outcome in patients suffering from fissure-in-ano following modified closed lateral internal sphincterotomy, closed lateral internal sphincterotomy, and fissurectomy. J Curr Res Sci Med [serial online] 2021 [cited 2022 May 19];7:9-13. Available from: https://www.jcrsmed.org/text.asp?2021/7/1/9/320507
| Introduction|| |
Anal canal is a muscular tube of 3–4 cm. The lining is cuboidal columnar mucosa in upper part and stratified squamous in the lower part in relation to the dentate line. The upper part of anal canal is endodermal in origin and the lower third is ectodermal. It is a structure of great surgical importance in maintaining continence and has a rich vascularity and neural nerve distribution. Fissure-in-ano is a linear ulcer of the lower half of the anal canal, usually located in the posterior commissure in the mid line. In the general population, the frequency of anal fissure is around 1 in 350. These lesions involve the anal tissue. The location of the fissures may vary and an anterior midline fissure is seen more often in women (25%), while the majority occur in a posterior midline. Characteristic-associated findings may be sentinel piles externally with an enlarged anal papilla internally. Anal fissures lead to serious complications such as severe pain, bleeding per rectum internal anal sphincter spasm results in decreased blood flow and reduced healing. Fissure-in-ano involves the highly sensitive squamous epithelium and hence is a painful condition. The pain may be such that patient may avoid defecation with resulting hard stools further compounding the problem. The underlying anal fissure pathophysiology is multifactorial and includes anodermal ischemia, inflammation, chronic constipation, infection, and hypertonicity of the smooth muscles of internal anal sphincter.
Due to effect of hormonal impact, anal fissures are more common in females during pregnancy. Anal fissure may occur in an acute form where it is very painful after defecation and bright red anal bleeding may occur while in chronic fissure, the pain severity is lower but the discomfort and burning sensation is constant after passing the stool.
| Materials and Methods|| |
After obtaining institutional ethical committee approval and written informed consent from all the patients, this study was conducted on 120 patients who presented with definite history of painful defecation, bleeding per rectum, and irritation in the anal region after defaecation and clinically been diagnosed as fissure-in-ano attending at Naval Hospital Powai, Mumbai, Maharashtra during a period from August 3, 2015, to February 2, 2019. A detailed history was taken from all selected patients. Thorough clinical examination. The diagnosis was made on the basis of the history, clinical examination, presence of pain, bleeding, and discharge per rectum. The final diagnosis was made after proctoscopic examination under anesthesia.The study involved all patients of both sexes between the ages of 18 and 70 suffering from fissure-in-ano. Patients were exempted if they had some other anorectal operation and if they had a history of previous sphincterotomy or anal dilatation. Other criterion for exclusion included fissures related to inflammatory or malignant bowel disease. The type of procedure which was to be undertaken was done randomly by letting patient picking up slips where the name of procedure was written. Total 120 slips were made with 40 slips of each procedure written in them.
All the patients were provided light diet and two enemas, one in bedtime and another on the morning of surgery. All the patients were operated under general or spinal anesthesia.
In long-standing chronic cases with much induration, complete excision was done. An elliptical incision deepened down to the internal sphincter was done with knife and cleanly excised along with any sentinel piles if present. The sphincteric fibers immediately deep to the fissure was divided in only two cases. Hemostasis was achieved by packing with gauze soaked with povidine-iodine ointment and secured with T bandage.
Lateral internal sphicterotomy operation
Careful palpation of the intersphincteric groove with the index finger is the mainstay of the procedure. After the internal and external sphincters have been identified, a no. 11 blade is inserted through the intersphincteric plane and advanced cephalad to the level of the dentate line. Then, the sharp edge of the blade is turned toward the anal canal and the incision is made medially, controlled by the index finger. A gauze soaked with povidine-iodine solution is inserted in the incision and secured with T bandage.
Modified closed lateral internal sphincterotomy
The left index finger is inserted into the anal canal in the closed method in order to palpate the internal sphincter and feel the intersphincteric groove. A 1 cm incision is made between the inner and outer sphincters in the groove. A curved artery forceps is introduced into the wound from the lateral margin of the incision and the tip of the forceps is forwarded horizontally toward the anal canal guided by the left index finger inside the anal canal and is delivered out from the medial margin of the wound plucking out fibers of the internal sphincter. The internal sphincter is divided under vision using a knife or electro cautery. The wound is closed with 1 or 2 interrupted 2-0 Vicryl. A small dressing is then applied [Figure 1].
|Figure 1: Stepwise procedure of modified closed lateral internal sphincterotomy|
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In fissurectomy and closed lateral internal sphincterotomy (LIS), parenteral antibiotics were continued for 3 days. In modified closed LIS, single dose of parenteral antibiotics was given followed by oral antibiotics. Stool softeners and analgesics were given to all the patients. Fissurectomy patients were discharged after 6–7 days due to the requirement of regular postoperative dressings. Patients undergoing closed LIS were discharged after 2–3 days. Patients undergoing the modified closed LIS were discharged the next day or after 1 day.
The data were collected for comparison depending on the age-wise prevalence of the disease in the civilian naval community, postoperative pain, requirement of antibiotics, healing, duration of hospital stay, and recurrence if any.
The collected data were presented in number of patients and analyzed statistically using the SPSS version 20.0 (Statistical Package for the Social Sciences, IBM, India). Differences among variables of the three groups were analyzed using Chi-square test. P < 0.05 was considered statistically significant for all measures.
| Results|| |
The present study was conducted at NH Powai among naval civilian dockyard population attending the Surgical outpatient department from August 2015 to February 2019 with the complaints of painful defaecation, constipation, and per rectal fresh painful bleeding.
After proper diagnosis, three types of surgeries were undertaken – fissurectomy, Closed LIS, and Modified Closed Lateral Sphincterotomy. The patients were selected randomly according to the slips picked up by them in the outpatient department when surgery was considered for them.
The data were collected for comparison depending on age-wise prevalence of the disease, postoperative recovery rate, per operative blood loss, postoperative pain, etc.
Among 120 cases, 85 cases (70.8%) were in the age group of 18–40 and out of which 59 (49.1%) were male and 26 (21.6%) were female. In the 40–60-year age group, 24 patients (20%) were male and 10 were female (8.3%). In the age group, 60–70 years, only one (0.008%) male was diagnosed and operated for fissure-in-ano [Table 1].
Of 84 male patients, thirty underwent modified closed LIS (35.7%), thirty patients (35.7%) underwent closed LIS, and 24 patients (28.5%) underwent fissurectomy surgery. Out of the 36 female patients, 10 patients (27.7%) had modified closed LIS, 10 patients (27.7%) had closed LIS, and 16 patients (44.4%) underwent fissurectomy operation. Overall, 33.3% patients had modified closed LIS operation [Table 2].
In the forty patients who underwent fissurectomy procedure, the average blood loss was 20–30 ml and the operative time was about 15–20 min. The average blood loss in both the closed LIS and modified closed LIS method was <5 ml. The closed LIS procedure took about 5–6 min to perform compared to the average of 9–10 min required for the modified closed LIS method [Table 3].
|Table 3: Cases depending upon intra operative blood loss and operative time|
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Severe-to-moderate pain persisted in the forty Fissurectomy cases for 4–5 days necessitating frequent analgesia which was gradually tapered down along with frequent sitz bath. In the closed LIS group, severe pain lasted for about 3–4 days requiring strong analgesics and could be tapered down by the 3rd day along with frequent sitz bath and dressing. In the modified closed LIS group, the pain lasted for maximum of 1–2 days and analgesics were required for the 1st and 2nd postoperative days, following which no analgesics were required and without the requirement of frequent sitz bath and dressing [Table 4].
|Table 4: Distribution of cases depending on postoperative pain and requirement of analgesics|
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In the Fissurectomy group, the minimum duration of hospital stay was 6–7 days because of the requirement of frequent dressing, parenteral antibiotics, and analgesics. The average duration of hospital stay in the closed LIS group was 2–3 days compared to 1–2 days hospital stay for the modified closed LIS group [Table 5].
|Table 5: Distribution of cases depending on the duration of hospital stays|
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Only one male patient (0.8%) who underwent fissurectomy in this study had a recurrence during the period of follow-up. He later underwent modified closed LIS surgery and was asyptomatic on follow up. The rest of the patients (99.2%) did not have incontinence, nonhealing ulcers, or recurrence of their symptoms during the period of this study and were highly satisfied with the outcomes after surgery.
| Discussion|| |
There are several ways to treat fissure-in–ano, but LIS remains the gold standard so far. Boyer first proposed treatment of anal fissures by sphincterotomy in 1818. This procedure has been used with increasing frequency since Eisenhammer introduced LIS in 1959, and it is now considered the treatment of choice for fissure-in-ano. This present study has compared fissurectomy, closed LIS, and a modified closed technique of LIS developed and performed by this author.
Most of the fissures were found in the young and middle age group in this study, with 70.8% of patients in the group aged between 18 and 40 years and 29.1% of patients in the group aged between 40 and 50 years. Only one patient was in the age group between 60 and 70 years. In this study, men outnumbered women, with a ratio of 2:1. These findings are comparable with previous studies., Nahas et al. recorded that 70% of their CAF patients were males, and 30% were females, with a ratio of 2.3:1. Melange et al. recorded that 55.2% of their anal fissure patients were males, and 47.8% were females, with a ratio of 1.15:1. Patients most commonly experienced pain during defecation, accompanied by subsequent rectal bleeding. Most of the patients (94%) had anal fissures posterior to the midline. Other positions that have been seen were anterior midline (6%), i.e., at 12 o'clock position. A number of previous studies of anal fissures have established the posterior midline to be the most common location. In this study, although induration was present in only 24 patients, sentinel piles were present in 86% of patients.
Comparing the complication levels of closed LIS and modified closed LIS procedures, both approaches have been shown to be equally successful in treating fissures. No instance of incontinence or soiling was observed, and the majority of patients reported rapid healing and symptom resolution. Pernikoff et al. stated that their rate of complication in the open compared to closed sphincterotomy was relatively higher. Mousavi et al. also had better results with LIS compared to fissurectomy. Kortbeek et al. also stated that closed sphincterotomy with less postoperative complications is successful in the treatment of fissure-in-ano. No case of delayed or absent healing was observed in both the modified closed LIS group and the closed LIS group. Only one recurrence of anal fissure was noted on long-term follow-up in the study. No cases of incontinence to stool or flatus were noted on long-term follow-up in the study.
Garcia-Aguilar et al. indicated in a long-term study that closed lateral sphincterotomy is advantageous to open lateral sphincterotomy, since it brings a similar proportion of cure with little control impairment and noted that both techniques were equally efficient, but the closed group was highly satisfied. Kortbeek et al. actively support closed-lateral sphincterotomy. In the current study, visual analog pain scale of 1–10 points was used to quantify subjective pain of the patients. In the modified closed sphincterotomy group, the mean pain level on the visual analog scale was considerably lower 24 h after the procedure than in the closed LIS and fissurectomy group. There was a statistical significant difference between these three groups in the length of hospital stay. The average stay period in the modified closed LIS group was 2 days, in the closed LIS group was 4 days and in the fissurectomy group 6 days. These findings are correlated with the study done by Mousavi et al. and Kortbeek et al.. In their study, they suggested that closed LIS for anal fissure is successful and may result in substantially less postoperative pain, shortened postoperative stay at the hospital compared to fissurectomy, and open LIS.
| Conclusion|| |
The closed LIS and the modified closed LIS procedures do not vary substantially in terms of postoperative complications occurrence. In the modified closed LIS technique, postoperative pain was less than in the closed LIS technique and the fissurectomy surgery. Healing was faster in the modified closed LIS group with a shorter mean length of stay than in the closed LIS group, even more so when compared to the fissurectomy group, along with a decreased operating cost stress. There was a statistically significant difference between the mean pain level on the visual analog scale after the procedure at 12 h and 24 h and the length of hospital stay in the three groups. Modified closed LIS is the recommended treatment for anal fissure and it can be successfully and safely done with lower risks and lower cost burden for the patient.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]