Presidential address. Lateral subcutaneous internal anal sphincterotomy for anal fissure

Comparison of skin incisions used for open lateral internal sphincterotomies--radial versus circumferential incisions: a retrospective cohort study

INTRODUCTION

Lateral internal sphincterotomy (LIS) is a safe and effective surgical treatment, commonly used in patients with chronic anal fissures (CAFs). Although LIS is a simple surgical technique, it may cause several complications. Open LIS is usually performed through an incision made in the intersphincteric groove; radial or circumferential incisions, used according to the surgeon's preference. However, differences in clinical outcomes and wound healing, based on type of skin incision, are unclear. We investigated incision site wound healing and other clinical outcomes, after open LIS, according to the type of skin incision employed.

METHODS

We retrospectively reviewed the data of the electronic medical records of 602 patients who underwent open LIS for CAFs between March 2005 and February 2010 at Yang Hospital, Seoul, Korea.

RESULTS

Of the 602 patients, 298 patients received radial incisions and 304 received circumferential incisions. Circumferential incisions of the anus reduced the wound healing time compared to radial incisions (19.1 vs. 24.0 days, p < 0.001). There were no significant differences between the groups in wound complications such as perianal abscess, fistula, or cellulitis. Clinical outcomes including recurrence, persistence of fissures, and continence problems were also similar between the groups.

CONCLUSIONS

Our study shows that circumferential skin incisions, during LIS, are associated with shorter healing times than radial incisions.

Evaluation of healing and complications after lateral internal sphincterotomy for chronic anal fissure: marginal suture of incision vs. open left incision: prospective, randomized, controlled study

PURPOSE

Internal sphincterotomy remains the standard for treatment of anal fissure, but it is associated with risks of infection, bleeding, and incontinence. Recent studies have suggested that the complications after lateral internal sphincterotomy are related to surgical technique. This study was designed to assess the incidence of early and late complications after lateral internal sphincterotomy with marginal sutured incision. Fissure healing, pain, and complications were compared in patients undergoing a procedure involving three interrupted marginal sutures after open lateral internal sphincterotomy procedure.

METHODS

Ninety patients of chronic anal fissure were randomly assigned to two groups. Both groups received open lateral internal sphincterotomy via standardized method. The incisions of the patients in Group 1 (n=45) were sutured marginally with three interrupted sutures using 2-0 chromic catgut, whereas the incisions of the patients in Group 2 (n=45) were left open. The patients were assessed at 12 weeks postoperatively by an independent observer.

RESULTS

The fissure-healing rate was not significantly different in both groups (95 and 93.1 percent, respectively). The pain score was slightly higher in Group 2, and it was statistically significant. Four cases of bleeding and two abscesses were observed in Group 2. These complications were not observed in Group 1. One case of incontinence was observed at the beginning in Group 1 and four in Group 2, but the incontinence was transient in both cases.

CONCLUSIONS

Marginal sutures of incision after lateral internal sphincterotomy may be beneficial to reduce complications related to early wound healing.

Aetiology and treatment of anal fissure

Anal fissure is a common problem that causes significant morbidity in a young and otherwise healthy population. Treatment has remained largely unchanged for over 150 years and the pathogenesis of this condition is not yet fully explained. Acute fissure should be treated conservatively with dietary modification. Chronic fissures do not respond to conservative treatment. The current recommended surgical treatment for chronic fissure is lateral internal sphincterotomy. However, there is a disturbance of continence in a sizeable proportion of those undergoing this procedure. As yet there is no proven non-surgical treatment for chronic fissure. Although local injection of botulinum toxin and the topical application of nitrates show early promise, further controlled trials are needed.

Patient selection and treatment modalities for chronic anal fissure

BACKGROUND

Incontinence of feces or flatus is a serious complication of lateral internal sphincterotomy with a incidence of 0-35%. Multiple cofactors may predispose to fecal incontinence.

METHODS

Review of 27 reported series of internal sphincterotomy and analysis of 34 consecutive cases of fecal incontinence seen by the author were carried out. Reports of the effect of topical nitroglycerin or botulinum toxin on the anal sphincter are discussed and supplemented by the author's experience.

RESULTS

Reported postoperative incidence of incontinence to feces or flatus is remarkably variable (0-35%). Multiple factors (eg, multiparity, age, constipation, and previous surgery) were identified in each of the author's cases of incontinence. Pharmacologic sphincterotomy reliably relieves sphincter spasm and may promote healing.

CONCLUSIONS

Reappraisal of current standard treatment of anal fissure is warranted. Many preexisting, possibly predisposing, factors should be considered when deciding on treatment. Pharmacological sphincterotomy requires further clinical study. New nonsurgical modalities should be included in the treatment algorithm.

Performing internal sphincterotomy with other anorectal procedures

PURPOSE

A study was conducted to compare the outcome of combined anorectal procedures involving lateral internal sphincterotomy with lateral internal sphincterotomy alone to determine if the former results in increased complications.

METHODS

Complications and anal function of 57 patients who underwent lateral internal sphincterotomy for chronic anal fissure in conjunction with another anorectal procedure (combined group) between April 1989 and June 1992 were compared with 57 other age- and sex-matched patients who underwent lateral internal sphincterotomy alone (control group).

RESULTS

There was no statistical difference in the incidence of incontinence in the combined group (8.7 percent) and the control group (7 percent). None of the cases in either group had permanent incontinence. There were also no statistical differences in the incidence of postoperative bleeding, pruritus ani, mucus discharge, abscess formation, fistulation, and rates of fissure recurrence.

CONCLUSIONS

Additional anorectal procedures performed at the same time as internal sphincterotomy do not increase the incidence of postoperative complications.

Practice parameters for the management of anal fissure. The Standards Task Force American Society of Colon and Rectal Surgeons

It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Anal fissure and stenosis

Fissure in ano is a simple condition that causes considerable discomfort. The acute forms should be treated by conservative nonsurgical regimens initially. If the patient finds the symptoms intolerable, or if the fissure demonstrates signs of chronicity, then lateral subcutaneous sphincterotomy is recommended as an ideal simple surgical procedure that has the advantages of a low complication rate and low morbidity. It is easily performed under local anesthesia and does not require hospitalization. It is gratifyingly satisfying for both the patient and surgeon. Certain types of anal stenosis, especially those following hemorrhoidectomy, are successfully managed by lateral sphincterotomy combined with postoperative anal dilatation. This approach avoids the more complicated plastic anal procedures that have been used in the past.

Long-term results of open and closed sphincterotomy for anal fissure

Three hundred fifty patients who underwent open or closed lateral internal anal sphincterotomy for acute or chronic anal fissure between January 1981 and June 1985 were reviewed. Minimum follow-up was 14 months (mean, 37 months). No patient underwent an additional procedure at the time of sphincterotomy. Twenty-one failed to heal or developed a recurrence in the interval (6 percent). Five of these individuals were found subsequently to have Crohn's disease. Excluding these patients, the incidence of nonhealing was 4.6 percent. Eight patients (2.3 percent) developed postoperative infections requiring drainage, one half of which were associated with fistulas. Sixty patients (17 percent) complained of incontinence for flatus or feces. For two thirds, this was transient. There was no statistically significant difference in rate of healing or morbidity when comparing the open with the closed method.

[Functional pathomechanisms of anal fissure]

In a prospective consecutive study of 40 patients with anal fissure we analysed the anal sphincter function at rest and rectal distension. Healthy persons with comparable age and sex distribution were controls. The anal pressures were registered with thin water perfused catheters (2 ml/min). Our patients with anal fissure showed significant elevation of anal pressures at rest along the whole length of anal canal. During rectal distension only the distal part of anal sphincter (up to a level of 2 cm from the anocutaneous line) showed a spasm with reduced relaxation. Our results are useful for operative therapy, since lateral internal sphincterotomy corresponds very well to functional pathomechanism of anal fissure.

Morbidity of internal sphincterotomy for anal fissure and stenosis

Internal sphincterotomy is thought by most surgeons to have minimal complications. We retrospectively reviewed 306 patients following internal sphincterotomy to determine the incidence of any complications. Major complications (requiring reoperation) caused by fistula, bleeding, abscess, or unhealed wounds occurred in ten patients (3 percent). Minor complications caused by pruritus, persistent wound, pain, bleeding, abscess, discharge, urgency, impaction, or defects of continence occurred in 110 patients (36 percent). Complications were lowest for closed sphincterotomy (20 percent) and highest for open sphincterotomy alone (55 percent). All patients were cured of anal fissure or stenosis. Long-term follow-up (average 4.3 years) revealed a 22 percent incidence of persistent minor complications. Defects in continence caused 15 percent of total long-term morbidity. Minor complications occur frequently after internal sphincterotomy for anal fissure and stenosis. Closed sphincterotomy has the lowest complication rate. Long-term minor defects in continence occur in a significant number of patients.

Keyhole deformity. Fact and fiction

The purpose of this paper is to show whether there is a keyhole deformity, its surgical significance, and how often it occurred following surgery for ulcer-in-ano. To do this, a retrospective study, over a 16-year period, of all patients admitted to the Ferguson Clinic with chief complaints of anal incontinence was undertaken. Of this group of patients, seven were identified as having questionable keyhole deformities, three of whom probably had classic defects. There were six females and one male. Only two of the deformities were associated with surgery for ulcer-in-ano. One of these was easily repaired and the other patient had a full rectal prolapse. In addition, of 186 patients undergoing fistula surgery, 77 who had posterior midline transsphincteric fistulas were studied and ten of these patients went on to complete recovery without any permanent problems resulting from severance of the sphincter. It can generally be concluded that, although there is such a defect as the keyhole deformity, it occurs only rarely, especially after surgery for ulcer-in-ano, and that many times it is not associated with anal incontinence.

Fissurectomy with superficial midline sphincterotomy. A viable alternative for the surgical correction of chronic fissure/ulcer-in-ano

A series of 121 patients with chronic fissure-in-ano who underwent fissurectomy with superficial midline sphincterotomy was studied. The mean follow-up was 8.1 years. Minor problems with anal competence occurred after the operation in 30 patients (25 per cent). Within two months, this problem had resolved in all patients. One patient (0.8 per cent) had a true recurrence. Five patients (4.1 per cent) had recurrent acute anal abrasions as the result of passage of a hard stool. These healed spontaneously. Twelve patients (9.9 per cent) had fragile scars, but this was a significant problem in only five (4.1 per cent). No patient had significant stricture formation, keyhole deformities, or major persistent problems with anal competence. The patients graded their operations with regard to satisfaction: 118 (97.5 per cent) reported satisfactory results and three (2.5 per cent) reported unsatisfactory results. This study shows that fissurectomy with superficial midline sphincterotomy is a viable approach to the surgical management of chronic fissure-in-ano.

Subcutaneous lateral internal sphincterotomy for chronic fissure-in-ano

The results of subcutaneous lateral internal sphincterotomy for chronic fissure-in-ano were analyzed in a series of 60 patients operated upon over a period of two years. Immediate relief from pain with painless first bowel movement was accomplished in 97 per cent of the patients with very low morbidity rates. All patients were treated on an outpatient basis and had a minimum follow-up of two years without any recurrences. The incidence of sphincter dysfunction is very low and is usually only temporary.

Anal sphincteric pressure in fissure-in-ano before and after lateral internal sphincterotomy

Resting anal canal pressure was measured in 15 patients with anal fissure before and after lateral internal sphincterotomy. This pressure was found to be significantly higher in these subjects (mean 95 +/- 23.08 mm HG) than in the control group (mean 66.10 +/- 14.28 mm Hg) before surgery (P less than 0.005). After surgery, a normal anal canal pressure was produced. The authors maintain that anal canal spasm is responsible for chronicity of anal fissures.

Surgical correction of chronic anal fissure: results of lateral internal sphincterotomy vs. fissurectomy--midline sphincterotomy

A restrospective study of 300 patients with chronic anal fissue is presented. Lateral internal sphincterotomy offers shorter hospital stay, rapid wound healing, low recurrence rate, and no permanent defect in continence, and is, therefore, the procedure of choice in uncomplicated anal fissures. Fissurectomy-midline sphincterotomy should be reserved for patients in whom local fistulization has complicated anal fissure.

Lateral internal sphincterotomy

Lateral internal sphincterotomy proved to be effective in 99 per cent of the 418 procedures in which it was performed. The complication rate of 5 per cent was an improvement over most of the rates reported in the medical literature and over our previous experience with posterior sphincterotomy and anoplasty. Anal wounds and fissures healed faster than with previous procedures. It is encouraging that this simple and rapid procedure has such great efficacy with a minimum of complications.

[Treatment of primary chronic fissure-in-ano by anal dilatation versus sphincterotomy (author's transl)]

A double-blind, randomized, controlled trial in the treatment of primary chronic fissure-in-ano by digital stretching of the anal canal or by a modified lateral subcutaneous sphincterotomy is reported. Whereas there was no difference in the postoperative course of both groups, by checking 65 of 66 patients 6 months postoperatively, we found significantly more lacks of continence after stretching. There was no difference regarding recurrence rate. Pressure monitoring of the anal canal showed significantly higher values at rest in both groups before operation. No correlation between results of monitoring anal pressure and defects of anal continence has been seen. These results point out that in treatment of primary chronic fissure-in-ano the lateral subcutaneous sphincterotomy is superior to anal dilatation regarding postoperative defects of anal continence. The recurrence rate in the present study does not force to prefer one of these two methods. Manometric investigations show that the resting pressure in anal canal seems to be elevated in primary chronic fissure-in-ano.

Lateral subcutaneous internal sphincterotomy for chronic anal fissure, an outpatient procedure

We have adapted the lateral internal sphincterotomy technique for the repair of chronic anal fissure to a strictly office or outpatient procedure. The early cure rate in this review of our first 200 patients was very good - well in excess of 98 per cent. Complications were exceedingly minor, the considerable cost to the patient of hospitalization and time off from work has been saved, and patient acceptance has been excellent.