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 (ranging from 2 to 4 weeks). To evaluate caused by the passage of hard stool on the mucosa. Spasm symptoms of incontinence, a simple questionnaire was of sphincter not only promotes constipation (thus setting used which was based on information from the patient up a vicious cycle) but also leads to compression of the about the type of incontinence (for solid or liquid or flatus terminal arterioles supplying the mucosa of the anal canal. alone) and possible effect on lifestyle (Table 1). Items were Impaired blood flow in this already poorly perfused area each allocated a numerical value based on our perceived prevents fissure healing.7 estimation of the severity of particular symptoms, ranging from 1 to 3, with a possible maximum score of 10, this Since the introduction of posterior internal sphincterotomy questionnaire was given in each patient before and after by Eisenhammer, in 1951, the chronic anal fissure has the operation at 2, 6, 24, and 48 weeks. Wexner continence been managed with surgery11 lateral sphincterotomy grading scale (Table 2) was also used in each patient popularized by Notaras (in 1969) has until now been the before and after the operation at 2, 6, 24, and 48 weeks mainstay of treatment of chronic anal fissure.12 Despite also, for assessment of the severity of incontinence and lateral internal sphincterotomy is highly efficacious and lifestyle. Patients’ satisfaction in our series was 98%. No succeeds in curing chronic anal fissure in more than anal incontinence was reported in this patients group after 90% of patients with high satisfaction, carries a risk of segmental lateral sphincterotomy in follow-up. postoperative impairment of continence. Incontinence is the main complication feared by most surgeons for both DISCUSSION kind of treatments (present in 20% of cases with anal dilatation and 20-28% of cases treated by surgery).7 The In this study, the most common presenting symptoms incidence is not well documented and varies between 0% were painful defecation in all cases(100%) and with and 35% for flatus, 0% and 21% for liquid, and 0% and rectal bleeding in 70% cases corresponding to 100% and 5% for solid stool.13 From previous studies, we believed 80% and also 98.8% and 71.4% in other study. This study that incontinence follows lateral sphincterotomy due to favored the reports that anal fissure is common in middle the gutter formation at the site of sphincter division. The age and on posterior midline of anus.10 gutter allows the rectal contents to pass through it in spite of internal anal sphincter contraction.14 The incontinence Table 1: Simple questionnaire for evaluation of after lateral internal sphincterotomy is usually in the incontinence8 form of flatus incontinence because flatus is easy to pass 15 Did the patient experienced Daily Weekly Rarely Never through this gutter. One study reported that perianal Accidental bowel leakage of 3 2 1 0 injection of autologous fat treated the anal incontinence 16 gas or mucous well. We think this due to the obliteration of anal gutter Accidental bowel leakage of 3 2 1 0 by the injected fat. To prevent this gutter formation, with liquid stool our technique, internal sphincterotomy done in two short Accidental bowel leakage of 3 2 1 0 incisions and not in the same continuity producing. solid stool 1. Good relief of sphincter hypertonia leading to good Deterioration of life (yes/no) fissure healing Never (no episodes of past month), Rarely (1 episode of past month), Weekly (1 or >1 2. Two short incisions healed rapidly by the second episodes a week), Daily (1 episode a day), Deterioration of life Yes: 1; No: 0, Maximum intention score=10 complete incontinence 3. Without gutter formation avoiding anal incontinence.

8 Table 2: Wexner continence grading scale No incontinence or failure of fissure healing was reported Type of incontinence Never Rarely Sometimes Usually Always in this study which treated by segmental lateral internal Solid 0 1 2 3 4 sphincterotomy. Liquid 0 1 2 3 4 Gas 0 1 2 3 4 Wears pads 0 1 2 3 4 CONCLUSION Lifestyle alteration 0 1 2 3 4 Never: 0, Rarely: 1/month, Usually <1/day; Segmental lateral internal sphincterotomy is a safe, >1/week, Always: >1/day; 0 perfect; 20 complete incontinence easy, and effective procedure and not associated with

32 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 risk of incontinence for the treatment of chronic anal follow-up of multicenter, randomized, controlled trail. Dis fissure. Till date, similar type of study was undertaken Colon Rectum 2007;50:442-8. on 50 patients by Lasheen et al., in Zagazig, Egypt. This 8. Liratzopoulos N, Efremidou EI, Papageorgiou MS, may be the second one (62 patients and continuing) as Kouklakis G, Moschos J, Manolas KJ, et al. Lateral per literature, having matching result regarding a new subcutaneous internal sphincterotomy in the treatment of chronic anal fissure: Our experience. J Gastrointestin Liver surgical technique for treatment of chronic anal fissure. Dis 2006;15:143-7. Still, we need more evaluation studies on long run about 9. Lasheen AE, Morsy MM, Fiad AA. Segmental internal its efficacy and complications. sphincterotomy - A new technique for treatment of chronic anal fissure. J Gastrointest Surg 2011;15:2271-4. REFERENCES 10. Hyman N. Incontinence after lateral internal sphincterotomy: A prospective study and quality of life assessment. Dis Colon Rectum 2004;47:35-8. 1. Gorden PH. Fissure in ano. Principal and Practise of Surgery 11. Eisenhammer S. The evaluation of the internal anal for Colon, Rectum and Anus. 3rd ed. Ch. 9. London: Taylor sphincterotomy operation with special reference to anal & Francis; 2007. p. 167, 173, 119. fissure. Surg Gynecol Obstet 1959;109:583-90. 2. Dykes SL, Madoff RD. Bening anorectal: Anal fissure. 12. Notaras MJ. Lateral subcutaneous sphincterotomy for anal In: Wolff BG, Fleshman JW, Beck DE, Pemberton JH, fissure - A new technique. Proc R Soc Med 1969;62:713. Wexner SD, editors. The ASCRS Textbook of Colon and 13. Nelson R. Non surgical therapy for anal fissure. Cochrane Rectal Surgery. New York: Springer; 2007. p. 178-91. Database Syst Rev 2006:CD003431. 3. Brisinda G, Cadeddu F, Brandara F, Brisinda D, Maria G. 14. Mentes BB, Güner MK, Leventoglu S, Akyürek N. Treating chronic anal fissure with botulinum neurotoxin. Fine-tuning of the extent of lateral internal sphincterotomy: Nat Clin Pract Gastroenterol Hepatol 2004;1:82-9. Spasm-controlled vs. up to the fissure apex. Dis Colon 4. Elía Guedea M, Gracia Solanas JA, Royo Dachary P, Rectum 2008;51:128-33. Ramírez Rodríguez JM, Aguilella Diago V, Martínez 15. Garcia-Granero E, Sanahuja A, Garcia-Botello SA, Díez M. Prevalence of anal diseases after Scopinaro’s Faiz O, Esclapez P, Espi A, et al. The ideal lateral internal biliopancreatic bypass for super-obese patients. Cir Esp sphincterotomy; clinical and endosonographic evaluation 2008;84:132-7. following open and closedinternal anal sphincterotomy. 5. Sauper T, Lanthaler M, Biebl M, Weiss H, Nehoda H. Colorectal Dis 2009;11:502-7. Impaired anal sphincter function in professional cyclists. 16. Shafik A. Perianal injection of autologous fat for treatment of Wien Klin Wochenschr 2007;119:170-3. sphincteric incontinence. Dis Colon Rectum 1995;38:583-7. 6. Hyman N. Incontinence after lateral internal sphincterotomy: A prospective study and quality of life assessment. Dis Colon Rectum 2004;47:35-8. How to cite this article: Sonarkar RK, Deshmukh SD, Akhtar MA, 7. Brown CJ, Dubreuil D, Santoro L, Liu MO, Conneor BI, Bindlish R. Segmental Lateral Internal Sphincterotomy: A New Mcleod RS. Lateral internal sphincterotomy is superior to Technique for Treatment of Chronic Anal Fissure - Clinical Outcome topical nitroglycerin for healing chronoc anal fissure and and Review of Literature. IJSS Journal of Surgery 2016;2(3):30-33. does not compromise long - Term fecal continence: Six year Source of Support: Nil, Conflict of Interest: None declared.

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