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Abstract

OUTCOME OF CLOSE LATERAL INTERNAL ANAL SPHINCTEROTOMY FOR CHRONIC ANAL FISSURE UNDER LOCAL ANESTHESIA

*Dr. Ejaz Ul Hassan, Dr. Shabbar Hussain Changazi, Dr. Ahmed Masood Qureshi, Dr. Anam Zahra, Usman Ismat Butt and Samiullah Bhatti

ABSTRACT

Introduction: Anal fissure is a linear tear in the lower anoderm that presents with moderate to severe pain during and after defecation along with streaks of fresh blood. The pathophysiology is thought to be related to trauma from either the passage of hard stool or prolonged diarrhea. A tear in the anoderm causes spasm of the internal anal sphincter, which results in pain, increased tearing, and decrease blood supply to the anoderm. This cycle of pain, spasm and ischemia contributes to development of a poorly healing wound that becomes a chronic fissure. The majority of fissures occur in the posterior midline. Ten to 15% occur in the anterior midline. Less than 1% of fissures occur off midline. Multiple fissures are associated with Crohn‘s disease, Ulcerative colitis and Tuberculosis. Therapy focuses on breaking the cycle of pain, spasm and ischemia. Conservative management includes laxatives, analgesics, local ointments i.e. lignocain or Glyceryl Trinitrate and injection of botulinum toxin(Botox®). Surgical therapy is recommended for chronic fissures that have failed medical therapy and patients with associated anorectal pathology needing surgical intervention. Surgical means to treat anal fissure includes manual anal dilatation, sphincterotomy, fissurectomy, and posterior anal flap. Sphincterotomy can either be done by open or closed technique addresses the problem in much controlled way. There are fewer chances of incontinence and bleeding, once the operator is well versed with the technique. This study was aimed to evaluate outcome of closed lateral internal sphincterotomy for chronic anal fissure under local anesthesia and low rate of complications. Objectives: The main objective of the study was to determine outcome of close lateral internal sphincterotomy for chronic anal fissure under local anesthesia. Main Outcome Measures: Outcome was measured in terms of symptomatic relief and complication rate occurring during first eight weeks including incontinence to flatus or stool, and hospital stay. Recurrence rate was measured at eight weeks. Study Design: Descriptive case series. Setting: The study was completed at Department of General Surgery Unit III, Services Hospital, Lahore. Duration of Study: Six months starting from April 19, 2013, to Octuber 18, 2013. Sample Size: 135 patients with chronic anal fissure fulfilling the inclusion criteria. Methods: 135 consecutive patients of chronic anal fissure fulfilling the inclusion criteria were included in this study. All patients were operated and closed lateral internal sphincterotomy was done under local anesthesia. Data was collected on specific proforma and was put to ―SPSS‖ version 16. In the demographic variables the age and sex presented as frequencies and rate, for age mean and standard deviation was given. Symptoms were described as frequency and proportion. Signs will be measured as present or absent and presented as types and proportions. T-test was applied for quantitative variables like age and Chi-squared test for qualitative variables like incontinence and sex. P value of 0.05 or less was taken as significant. Results: In this study 100 (70.0%) patients were male and 35 (30%) patients were female with age ranging from 20 to 75 years with mean age of 38.53. Duration of symptoms was more than 6 months. All these patients presented with pain and 55 (88.3%) presented along with constipation as well. In 53(88.3%) of patients fissure was located in anterior midline while 5(8.3%) had fissure in anterior midline and 2(3.2%) had fissure in anterior and posterior midline. Thirteen (21.7%) patients had sentinel tag as well. Adequate pain relief was observed in 68.3% with in 48 hours of surgery. Complete healing of fissure was observed in 96.7% of patients at 6 week. Wound infection was observed in one case. Flatus incontinence was observed in 3.3% of patients that improved up to 10th week. Only one patient presented with recurrence after about one year. Conclusion: On the basis of this study, it was conclude that closed lateral internal sphincterotomy is the treatment of choice for chronic anal fissure. It cure fissure in majority of patients with very low rate of complications and excellent rate of fissure healing.

Keywords: Anal fissure, lateral internal sphincterotomy, glyceryl trinitrate.


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