ABSTRACT

Corresponding Author:
Mervyn Correia,
Resicom Elite,
Flat C-02 of Kadamba Depot Road,
Alto-Porvorim,
Bardez-403521, Goa.
E-mail: mcorreia@bsnl.in
 

ABSTRACT

AIMS AND OBJECTIVE

The main aim of this study was to assess the relief of symptoms and the healing of the anal fissure using the two techniques of lateral internal sphincterotomy and controlled intermittent anal dilatation.

MATERIALS AND METHODS

Thirty patients who were randomised into two groups underwent lateral internal sphincterotomy or controlled intermittent anal dilatation. Randomisation to treatment by either lateral internal sphincterotomy or controlled intermittent anal dilatation was done on the basis whether the patient’s registration number was odd or even. A total of 16 patients were treated by lateral internal sphincterotomy and 14 patients by controlled intermittent anal dilatation. All cases were done under general anaesthesia. The improvement in patient’s symptoms as well as healing of the fissure were recorded and the results were compared. No serious complications were observed in either group. Patients were followed up for six months post procedure.

RESULTS

No differences were observed with respect to immediate relief of pain, bleeding, mucous discharge, healing of the anal fissure, surgical complications and time off work. The post-operative symptoms in the form of pain, bleeding and constipation did not differ significantly between the two groups and were easily controlled with analgesic, stool softeners and sitz baths. The patients were also asked to hydrate themselves well and advised to have a diet rich in vegetables and fruit. Two months post-operatively, 16 patients in the lateral sphincterotomy group and 14 patients in the controlled intermittent anal dilatation group had healed completely and had no anal incontinence or other serious complications. At 6 months follow-up however 2 patients in the anal dilatation group complained of impaired control of flatus and faeces, although there was no soiling of the underwear. At the same point in time, one patient in the sphincterotomy group and 3 patients in the anal dilatation group had a recurrence. No statistical difference however existed in either treatment groups as regards to the relief of symptoms, the healing of the fissure and anal incontinence.

CONCLUSION

Lateral internal sphincterotomy is one of the most favoured procedures. The reason for this is the simplicity of the procedure, the minimal anaesthesia requirements and excellent results. Controlled intermittent anal dilatation applied with a standardised technique reduced anal canal resting pressure, cured symptoms and provided symptomatic healing that was equivalent to that of a lateral internal sphincterotomy. Since there were no findings of incontinence or situations which resulted in anal sphincter damage, we conclude that controlled intermittent anal dilatation is suitable for patients with chronic anal fissures because of its less invasive nature as compared to lateral sphincterotomy with equivalent efficacy and safety. In addition, the controlled intermittent anal dilatation method may be an alternative procedure in older and multiparous women who has a higher risk of incontinence.

KEYWORDS

Anal Fissure, Incontinence, Anal Dilatation, Lateral Internal Sphincterotomy.

INTRODUCTION

An anal fissure also called fissure-in-ano is a very painful condition that is frequently neglected and very often incorrectly treated. It is a longitudinal split in the anoderm of the distal anal canal, which extends proximally towards but

*Fisher exact test. NS= not significant.             

DISCUSSION

An anal fissure is a linear ulcer in the lower half of the anal canal, usually located in the posterior commissure in the midline. The majority of these will self-heal; however, some become deep and chronic and will not heal. The spasm of the internal sphincter is a well-accepted cause and occurs as a result of the trauma caused by the passage of a hard, scybalous and sometimes large and bulky stool which develops secondary to constipation.

When fissures are found laterally, tuberculosis, occult abscesses, leukemic infiltrates, carcinoma, Acquired Immunodeficiency Syndrome (AIDS) or inflammatory bowel disease should be considered as potential causes.⁽³⁾ Sexually transmitted infections that may affect the anorectal area are syphilis, herpes, chlamydia and human papilloma virus.

It is well-accepted that ischaemic events are effective in poor healing and recurrence of anal fissures.⁽⁴⁾ Blood supply to the anoderm at the posterior midline is significantly less. The reduced blood supply to the lesion is indicated by the absence of granulation tissue at the base of the fissure and a very slow growth of the anoderm even when the traditional conservative treatment eases the trauma due to hard stool.⁽⁵⁾ Studies have shown higher than normal resting anal canal pressures and reduced anal blood flow in the posterior midline. It is therefore believed that anal fissures are the result of anal sphincter hypertonia and subsequent mucosal ischaemia.⁽⁴⁾⁽⁶⁾

The most common symptoms in our patients were pain 100%, bleeding 93%, anal mucous discharge 100% and constipation 73%.

Surgery may be recommended if other treatment modalities have not worked. Surgical procedures are generally reserved for people with anal fissure who have tried medical therapy for at least one to three months and have not healed. It is not the first option in treatment. It is generally considered to be the most effective treatment for anal fissures with more than 90% of people experiencing good long-term results. However, it does carry a small risk of complications. In the patients with anal fissure, effective medical treatment, anal dilatation and lateral internal sphincterotomy decreases the anal canal resting pressure and helps to treat the pain. The decrease in the anal canal pressure and the cessation of pain after the effective treatment supported the ischaemic theory of Gibbons and the increase in anal sphincter tone has become a cause rather than the result of an anal fissure.⁽⁶⁾⁽⁷⁾

Division of internal sphincter fibres to relieve the sphincter spasm is presently considered the preferred therapy for chronic, recurrent and non-healing fissures.⁽⁸⁾ Lateral internal sphincterotomy is the preferred method of surgery for persons with chronic anal fissures and is generally used when medical therapy has failed.⁽⁹⁾

The procedure has been shown to be very effective with 96% of fissures healing at a median of 3 weeks in one trial.⁽¹⁰⁾ It is associated with a lower rate of side effects than older techniques, such as posterior internal sphincterotomy and anoplasty.⁽¹⁰⁾ It has also been shown to be superior to topical Glyceryl Trinitrate (GTN 0.2% ointment) in long-term healing of fissures with no difference in fecal continence.⁽¹¹⁾ The pain from the sphincterotomy is usually mild and is often less than the pain of the fissure itself. Patients often return to normal activity within one week. Excellent results have been reported by Arroyo et al with healing rates of 93-100% and negligible incontinence.⁽¹²⁾ Minor fecal incontinence and difficulty controlling flatulence are common side effects following surgery.⁽¹³⁾ Persistent minor fecal incontinence has been reported in 1.2% to 3.5% of patients; however, this does not appear to be significantly different to the rate of minor fecal incontinence experienced by patients treated with topical GTN.⁽⁹⁾

However, in a systematic review carried out by Garg P et al to analyse continence at 2 years or more after lateral internal sphincterotomy for chronic anal fissure, the long term risk of anal incontinence after lateral internal sphincterotomy was found to be quite significant.⁽¹⁴⁾ He had 324 studies screened, 22 (n=4512) were included in the study and he reported an overall continence disturbance rate was 14%. Most other studies however do not report such high figures.

Stretching of anal sphincter, the traditional Lord’s anal dilatation was described by Recamier in 1838. This was one of the most favoured and accepted methods of treating the anal fissures.⁽¹⁵⁾ The main reason of attraction to the procedure is its extreme simplicity. Since almost no instruments are needed for this procedure, it could be performed at the primary health centres or inadequately equipped hospitals situated at small townships.⁽⁵⁾ In the early 1990s, however, being a repeatable method anal dilation proved to be very effective and showed a very low incidence of side effects. Since then at least one controlled, randomised study has shown there to be a little difference in healing rates and complications between controlled anal dilation and lateral internal sphincterotomy,⁽⁷⁾ while another has again shown high success rates with anal dilation coupled with low incidence of side effects.⁽¹⁶⁾ The results of anal dilatation using a bivalve anoscope, also called as endoscopic dilatation are comparable with those of lateral sphincterotomy and can be achieved at a lower complication rate with only minor and temporary complications and performed by physicians with no specific surgical training.⁽¹⁷⁾

In our study, there was no significant difference between lateral internal sphincterotomy and controlled intermittent anal dilatation as far as improvement in patient symptomology and complications were concerned. Our results were similar to the study conducted by Yucel T et al. The manner in which the anal dilatation was done by us was more or less similar to the one conducted in their study. If the anal dilatation is done in an intermittent and controlled manner, and if a standardised technique is used, the resting anal pressures will reduce providing good symptomatic relief to the patient as well as having a negligible anal incontinence rate with results equivalent if not better than lateral internal sphincterotomy.