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Segmental Lateral Internal Sphincterotomy: a New Technique for Treatment of Chronic Anal Fissure - Clinical Outcome and Review of Literature

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Segmental Lateral Internal Sphincterotomy: a New Technique for Treatment of Chronic Anal Fissure - Clinical Outcome and Review of Literature DOI: 10.17354/SUR/2016/24 Original Article Segmental Lateral Internal Sphincterotomy: A New Technique for Treatment of Chronic Anal Fissure - Clinical Outcome and Review of Literature Rajiv K Sonarkar1, Satish D Deshmukh2, Murtuza A Akhtar3, Ridhima Bindlish4 1Assistant Professor, Department of Surgery, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, Maharashtra, India, 2Associate Professor, Department of Surgery, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, Maharashtra, India, 3Professor and Head, Department of Surgery, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, Maharashtra, India, 4Junior Resident, Department of Surgery, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, Maharashtra, India Abstract Introduction: Lateral internal sphincterotomy is an effective treatment for fissure in ano but carries a definite risk of incontinence. In trail to avoid this complication and to study the clinical outcomes such as the symptomatic relief, early postoperative wound healing, safety, and efficacy after segmental internal sphincterotomy, it was used to treat chronic anal fissure. Materials and Methods: This is hospital-based, cohort study was conducted at the NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, Maharashtra, India. This study was undertaken on 62 patients (35 male and 27 female, with mean age 38 years) with chronic fissure in ano from March 2012 to March 2015. Surgical intervention, i.e., lateral internal segmental sphincterotomy done in two segments under direct vision under spinal anesthesia. Post-operative course with early and long-term result was recorded. Mean follow-up was 32 weeks (ranging from 2 to 48 weeks). Results and Discussion: In all patients, the technique was done under spinal anesthesia. The fissure and anal wound were healed within 4 weeks. The pain was reduced at postoperative day 1 in all patients. There were no early complications; one male patient had an infection at anal wound site at the 4th post-operative week which was managed conservatively. No transient or any persistent degree of incontinence occurred in these patients group. Conclusion: Segmental lateral internal sphincterotomy is a safe, easy, and effective procedure and not associated with risk of incontinence for the treatment of chronic anal fissure. Keywords: Anal incontinence, Fissure in ano, Segmental lateral internal sphincterotomy INTRODUCTION muscle fibers at the base of the cutaneous defect.1 Anal fissure is a common disorder which affects all age issure in ano is a painful linear ulcer situated in groups with an equal incidence in both genders 90% Fthe anal canal and extending from just below the are situated posteriorly and 10% anteriorly.2 The exact dentate line to the margin of the anus.1 The chronic anal etiological factors are unknown but trauma caused by fissure was defined by duration of symptoms longer than fecal mass, diarrhea, water stream from bidet toilets, 3 months, the presence of induration at fissure edges, constant vibration in bikers, and hypertonicity of the sentinel pile, hypertrophied anal papillae, and circular internal sphincter are thought to be initiating factors.3-5 The presenting symptoms of fissure in ano are pain Access this article online during defecation and hours onward, bleeding while defecation with hard stool. Lock and Thomson reported Month of Submission : 02-2016 that once the fissure develops chronicity, it was unlike Month of Peer Review : 03-2016 that spontaneous healing will occur.1 Lateral internal Month of Acceptance : 04-2016 sphincterotomy is the treatment of choice for chronic anal Month of Publishing : 05-2016 www.surgeryijss.com fissure. This procedure, however, has been associated with the development of the period of transient post-operative Corresponding Author: Dr. Rajiv K Sonarkar, Department of General Surgery, NKP Salve Institute of Medical Sciences and Research Centre, Digdoh Hills, Hingna Road, Nagpur - 440 019, Maharashtra, India. Phone: +91-9422142779. E-mail: [email protected]. 30 IJSS Journal of Surgery | May-June 2016 | Volume 2 | Issue 3 Sonarkar, et al.: Segmental Lateral Internal Sphincterotomy: A New Technique for Treatment of Chronic Anal Fissure - Clinical Outcome and Review of Literature impairment of anal continence in 30% of the patient anal verge, i.e. sentinel piles in 90% cases and bleeding which can become permanent in 10% in a systemic review during defecation in 75% cases. All of these were of randomized surgical trials.6,7 To avoid this side effect, associated with h/o constipation off and on and passage segmental lateral internal sphincterotomy was used for of hard stool. No h/o anal incontinence was found in the treatment of chronic anal fissure in this study. these patients. All patients have received conservative/ medical treatment (stool softener, analgesic, lidocaine, Rationale diltiazem, 0.2% glyceryl trinitrate) and presented with Segmental internal sphincterotomy is a new technical persistent fissure. procedure for treatment of chronic anal fissure. By doing this study, we come to know its effectiveness, safety, Steps of Segmental Internal Sphincterotomy and clinical outcomes such as immediate post-operative All patients underwent the procedure under spinal relief from pain, no bleeding, two short incisions so early anesthesia and in lithotomy position. Internal sphincter healing of the wound and no anal incontinence which is palpated by per rectal examination and stabilized over known with conventional lateral sphincterotomy. middle and index finger. Two small incisions made (given at either 3/9 0’ clock position) with the help of MATERIALS AND METHODS electrocautery. First, small incision (a-b) extends from the anal verge points a to b midway between the anal The protocol was approved by the Local Ethics verge and dentate line. Second, small incision (a’-b’) Committee, and written informed consent was obtained extends from the midway point between the anal verge from each patient after the nature of the procedure was to dentate line a’ and dentate line point b’. With the explained. This is tertiary care hospital-based, cohort help of mosquito artery forceps, internal sphincter study was undertaken in the Department of Surgery, NKP brought in visualization and divided into direct vision Salve Medical College and Research Centre, Digdoh Hills, by electrocautery. The internal sphincter is divided into Nagpur, Maharashtra, India. All 62 patients (median age two segments from anoderm up to dentate line but not 38 years; range, 15-60 years) with chronic anal fissure in the same line. The two segments are equal in length have been enrolled in this study from March 2012 to and parallel with about 1 cm in between them. Good March 2015. Among patients, 27 (43.54%) were female hemostasis is achieved using diathermy. The wounds are and 35 (56.45%) were male. All patients clinically left open to heal with secondary intention. Antibiotics diagnosed as chronic anal fissure was defined by the were given perioperatively in all patients (Figure 1). duration of symptoms longer than 3 months, (c/o pain and bleeding while defecation) presence of induration RESULTS at fissure edges, sentinel piles, circular muscle fibers at the base of the cutaneous defect, and spasm at anal Between March 2012 and March 2015, a series of sphincter. A typical fissure associated with fistula in ano, 62 segmental lateral internal sphincterotomy were perianal/anal infection, inflammatory bowel disease, performed for chronic anal fissure and patients were immunocompromised patients, and malignancy (local/ follow-up for 1 year in our institute. The main presenting systemic) were excluded from the study. Exclusion complaint in this group of patients was pain during criteria also were previous sphincterotomy or anal defecation and hours afterward. The pain was significantly dilatation and suspicious of malignant fissure or ulcer. reduced in all patients in the first post-operative day The fissure was found posterior in 47 patients, anterior while symptoms such as bleeding and irritation were in 8 patients, and both in 7 patients. The most common reduced in most patients in the second post-operative symptoms were painful defecation in all cases (100%). day. No patient reported incontinence to solid/liquid Second most common symptoms were growth over stool and flatus during follow-up on direct questioning. a b c Figure 1: Diagrammatic and operative illustration of surgical technique IJSS Journal of Surgery | May-June 2016 | Volume 2 | Issue 3 31 Sonarkar, et al.: Segmental Lateral Internal Sphincterotomy: A New Technique for Treatment of Chronic Anal Fissure - Clinical Outcome and Review of Literature The operation time ranged from 10 to 15 min (mean The most recent theories on the etiopathogenesis of 12.5 min). The main hospital stay was 1 day. During anal fissures have focused on increased tonicity of the follow-up on the 6th week, one patient complained of pus internal anal sphincter, which contains smooth muscle discharge through wound suggestive of infection over the fibers whose contraction is controlled by neural influences wound which was managed conservatively. No fissure and myogenic mechanism. Factor for internal sphincter relapse was observed during the follow-up period. Anal hypertonia are not well understood, but a significant role fissure and sphincterotomy wound show complete healing in perpetrating the muscle spasm is played by the trauma within 4 weeks
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