INTRODUCTION

Anal fissure is a common proctological problem, which presents with pain in the anal region during and after defecation. Anal fissure is a linear tear at the anal verge. It can be seen either in the anterior or the posterior midline just distal to the dentate line. 90% of all fissures occur posteriorly and only 10% of the fissures are seen in the anterior midline. Such fissures are more common in the women. Less than 1% of patients have a fissure in both the anterior and posterior positions.

 The pathogenesis of this condition is still not fully explained, but it appears to be related to the passage of hard stool or prolonged diarrhoea with stretching of the anal canal resulting in a split in the anoderm. The presenting symptoms of this condition include tearing pain on defecation, which may last for a variable period after defecation and anal bleeding, which appears as a bright streak on the side of stool. Pain and irritation results in spasm of the internal anal sphincter muscle which, then, fails to relax during defecation thus further aggravating the condition.

 History and clinical examination is always diagnostic. Digital palpation of the anus is usually not possible as it causes severe pain. If at all possible, it reveals not only the fissure but also the characteristic spasm of the internal anal sphincter muscle.

Medical treatment of the fissure relies on application of local anaesthetics and stool softeners and the addition of high fibre diet, nitroglycerine paste, botulinum toxin. Many fissures heal this way, especially the acute anal fissure. When a fissure become chronic, surgery is recommended. It consists of manual dilatation of the anus (Lord’s dilatation), internal sphincterotomy, which is done by both the open and closed method and fissurectomy (not a routine operation these days). Lateral internal sphincterectomy was described by Eisenhammer in 1951 and 1959. Among many treatment modalities for chronic anal fissure lateral internal sphincterotomy remains the first line of treatment.1,2 It is more popular in North America.1 It is performed by two techniques i.e. Closed method and Open method.

The closed (lateral internal subcutaneous) sphincterotomy is usually performed under general anesthesia, but it can be carried out under local anesthesia3 in the outpatient department. This operation remains the primary form of treatment for chronic anal fissure. The aim of lateral internal sphincterotomy is to divide the distal third to one half of the internal anal sphincter4 to decrease the resting anal pressure by decreasing the hypertonia of the internal sphincter. Closed lateral internal sphincterotomy is also an effective procedure in treating fissure in children.5

In open method, internal sphincterotomy can be performed under local or general anesthesia.6  The patient is positioned in the lithotomy, lateral (side) or jack-knife positions according to the surgeon’s preference. It can be performed in the office or in the hospital. It is more time consuming and usually requires suturing.

 This study was designed to compare the results of open and closed technique of lateral internal sphincterotomy and to find postoperative complications. 

MATERIALS AND METHODS

The study was done at Nishtar Hospital, Multan. The patients undergoing surgery were divided into two groups. Group-A included all patients undergoing surgery by closed method and group-B included all patients undergoing surgery with open method. One hundred patients i.e. 50 patients for open method and 50 patients for closed method were included. All patients having age 20–50 years of both sexes with uncomplicated anal fissure were included. Surgically unfit patients and age above 50 years or below 20 years with complicated fissure were not included in the study.

Closed method of Notaras was followed in this study which is minimally invasive method for division of the internal sphincter. After insertion of an anal retractor, the tight distal internal sphincter is palpable as a tight band within the canal. The intersphincteric groove, which marks the distal end of the internal sphincter, is easily palpable. A narrow blade scalpel (Beaver’s blade) is introduced through the perianal skin at the left lateral aspect of the canal sandwiched parallel between the anoderm and the internal sphincter. When the tip reaches the dentate line,7 the blade is turned outwards, and the internal sphincter muscle divided with the blade. The operator can easily be determined when the sphinterotomy is completed because of the “give” when these fibres have been divided. The blade is removed, and gentle pressure is applied to control bleeding. Patients were followed for 6 months following surgery to assess the complications i.e. pain, bleeding, infection, incontenence and recurrence.

In open method, a bivalve type of anal speculum and a long number 7 scalpel handle carrying a small number 10 blade are the instruments needed for this operation. Small gauze pladgets soaked in 1 in 1000 solution of adrenaline hydrochloride, are handy in controlling the hemorrhage and permitting a better view of the operation site. The anal speculum is inserted into the anus to place the internal sphincter on a slight stretch to assist in its identification. A radial incision is made laterally at the lower border of the internal sphincter into the intersphincter groove. The distal internal sphincter is grasped with Allis forceps and bluntly freed. The lower one third to one half is divided with scissors.8 The wound heal secondarily or closed with chromic catgut 4/0 suture.1,8,9 Follow up of the patients to find complications was done fortnightly.

RESULTS

One hundred patients with chronic anal fissure were chosen for the study from those who were presented from July 2002 to December 2002 in surgical OPD of Nishtar Hospital, Multan. Following were the results of study:  32 patients were between 20–30, 46 patients were between 31–40 and 22 patients were between 41–50 years of age. Average age was being 35 years (Table 1). There were 84 male patients and 16 female patients with ratio of 5.1:1 respectively (Table 2).

Table 1: Age distribution

Table2:  Sex distribution

In all 100 patients included in the study the position of anal fissure was noted. Most of the patients were having posterior midline fissure. 88 (88%) patients were having posterior midline fissure and 10 (10%) patients were having anterior fissure. On patient was having fissure on lateral walls of anal canal (Table 3).

Table 3: Site of fissure

The patients included in the study, presented in OPD of Nishtar Hospital, Multan, with history of pain especially during defecation, bleeding per rectum, pruritis ani and swelling at the level of anal verge. The chief complaint of most of patients was pain on defecation. Out of 100 patients, 88 patients complained of pain during and after defecation. The pain was also associated with bleeding per rectum especially in the form of streak over the stool (Table 4).

Table  4: Mode of presentation

66 patients had the chief complaint of bleeding per rectum. The bleeding was usually of small amount and occurred at the time of defecation. It was also seen as a streak over the stool matter. This number includes those patients also who complained of some degree of anal pain associated with bleeding. 10 patients also presented with perianal swelling. On examination this was sentinel pile. Only one patient presented with pruritis ani due to discharge.

 Only few patients showed complications. Six (8%) patients complaint of pain in group A while 2 patients in group B. Bleeding was in 2 patients. Infection was in 4 patients; 2 in each group. No major incontinence only minor incontinence in group A i.e. 6 patients while 2 patients in group B. Recurrence was in 6 patients in group A and 6 patients in group B (Table 5-6).

Table 5: Open lateral internal sphincterotomy

Table 6:  Closed lateral internal sphincterotomy

DISCUSSION

In present study, 50 patients were treated by open lateral internal sphincterotomy, and 50 patients were treated by closed lateral internal sphincterotomy. The main aim of the study was to use best technique for the treatment of chronic anal fissure.

Most of the fissures were found in middle age group. 46% of the patients were between 31-40 years and mean age in present study was 35 years. Mean age reported in different studies range from 30 – 45 years.2,10,11,12,13 

Eighty four percent of patients were male, and 16% of patients were females with a sex ratio of 5.1:1 respectively. In the study done by Nahas2, 70% of males and 30% females had chronic anal fissure with a ratio of 2.3:1. 55.2% males and 47.8% females with a ratio of 1.15:1 presented with chronic anal fissure in the study done by Melange.14 Oh C12 reported 50.3% males and 49.6% females had chronic anal fissure. The ratio of male to female for chronic anal fissure in the present study is close to the study conducted by Badar, Qamaruddin and Hafizullah in which 80.9% male and 19% female patients presented with chronic anal fissure with the ratio of 4.2:1 respectively.

The patients suffering from anal fissure complain of pain, bleeding, discharge and pruritis ani. 88% patients presented with pain during or after defecation and 66% patients presented with bleeding with or without pain which was very close to the 90.80% and 71.4% respectively reported by Hanel and Gorden.11

In the present study 88 patients (88%) presented with posterior midline fissures and 10 patients (10%) presented with anterior anal fissure and 2 patients (2%) with lateral fissure. Mazier and Levien1 described that anal fissures are more common posteriorly. Cushieri15 also described that most of the fissures are posteriorly midline. Nahas2 reported 86.1% posterior midline and 13.9% anterior fissure.

In patients, undergoing open lateral internal sphincterotomy, 46 out of 50(90%) were free of symptoms on the next postoperative pain and in patients ,undergoing closed lateral internal sphincterotomy, 44 out of 50(88%) were free of symptoms.

Matikainen17 has described the similar results in case closed lateral internal sphincterotomy. In this study, when the results of open and closed techniques were compared regarding pain (4 vs 8 per cent), bleeding (4 vs zero per cent), infection (4 vs 4 per cent), incontinence (32 vs 24 percent) and recurrence (12 vs 12 percent), it was noted that both methods are effective in the  treatment of chronic anal fissure. However, this study showed that closed lateral sphincterotomy is significantly better than open lateral internal sphincterotomy (P = 0.01).

Pernikoff, Salvati, Eisentat18 has also reported that complication rate is relatively higher in open lateral internal sphinctrotomy than closed lateral sphincterotomy.  Kortbeek, Langevin, Khoo19 had concluded in their study that closed lateral internal sphincterotomy for chronic anal fissure is effective and may result in significantly less postoperative discomfort, shorter postoperative length of stay and a comparable rate of complications compared with the open lateral internal sphincterotomy.

From above statistics and discussion, it is seen that both open and closed techniques are effective for treatment of chronic anal fissure.

CONCLUSION

Closed lateral internal sphincterotomy is treatment of choice for chronic anal fissure and can be done effectively and safely with acceptable rate of complications. Our recommendations are that closed technique should be adopted by experienced surgeons and persons, who are not so much experienced or trained, should adopt open technique for treatment of chronic anal fissure.  Trainee should be initially trained by open technique then be shifted to closed technique.

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