|Year : 2014 | Volume
| Issue : 2 | Page : 419-422
A comparative study between internal sphincterotomy and sentinel pile flap in treatment of chronic anal fissure
O El-Sebai1, AA El-Sisy1, MS Amar1, Mohamed Hamdy El-Shafey2
1 Department of General Surgery, Faculty of Medicine, Menoufiya University, Menoufiya, Egypt
2 Department of General Surgery, Shebin El-Koum Teaching Hospital, Shebin El-Koum, Egypt
|Date of Submission||19-Mar-2013|
|Date of Acceptance||11-Jun-2013|
|Date of Web Publication||26-Sep-2014|
Mohamed Hamdy El-Shafey
MBBCh, Department of General Surgery, Shebin El-Koum Teaching Hospital, Shebin El-Koum
Source of Support: None, Conflict of Interest: None
The aim of the study was to compare the results of internal sphincterotomy and sentinel pile flap (SPF) in the treatment of chronic anal fissure.
Patients and methods
This prospective study on consecutive 40 patients was conducted from July 2010 to February 2013. Patients were divided into two groups; 20 patients underwent lateral internal sphincterotomy (LS) and 20 patients underwent SPF. All patients were evaluated with respect to operative time and postoperative complications. Results were documented and statistically analyzed.
The mean time of LS operation was 5.9 ± 0.97 min and that of SPF was 9.2 ± 0.89 min. Flatus incontinence was reported in 8/20 (40%) patients of the LS group and 2/20 (10%) patients of the SPF group; wounds healed within 2 weeks in 12/20 (60%) patients of the LS group and 18/20 (90%) patients of the SPF group; and recurrence occurred in 2/20 (10%) patients of the LS group and did not occur in the SPF group.
On the basis of this study, we conclude that SPF operation has several advantages over LS in treatment of chronic anal fissure.
Keywords: Chronic anal fissure, internal sphincterotomy, sentinel pile flap
|How to cite this article:|
El-Sebai O, El-Sisy A A, Amar M S, El-Shafey MH. A comparative study between internal sphincterotomy and sentinel pile flap in treatment of chronic anal fissure. Menoufia Med J 2014;27:419-22
|How to cite this URL:|
El-Sebai O, El-Sisy A A, Amar M S, El-Shafey MH. A comparative study between internal sphincterotomy and sentinel pile flap in treatment of chronic anal fissure. Menoufia Med J [serial online] 2014 [cited 2020 Apr 6];27:419-22. Available from: http://www.mmj.eg.net/text.asp?2014/27/2/419/141718
| Introduction|| |
Anal fissure is a cut or a crack in the anal canal or anal verge that may extend from the mucocutaneous junction to the dentate line. It may occur at any age. It can be acute or chronic. It is the most common cause of rectal bleeding in infants .
The cause of anal fissure has been long debated. Trauma to the anal canal secondary to the passage of a hard stool is believed to be a common initiating factor. A history of constipation is not universally obtained; however, some patients reported an episode of diarrhea before the onset of symptoms. Physiologic studies using ambulatory manometry have confirmed the presence of sustained resting hypertonia in fissure patients. Some of the anterior fissures occurring in women result from childbirth. The majority of fissures occur in the posterior midline of the anal canal; multiple or lateral fissures may have other causes, such as Crohn's disease, ulcerative colitis, tuberculosis, and infection with HIV or syphilis .
The cardinal symptom of anal fissure is pain in the anus during and after defecation. The pain is very agonizing to the patient; it is described as a sharp, cutting, or tearing sensation during and after passage of stool. Subsequently, the pain may be less severe and may be described as a burning discomfort that may persist from a few minutes to several hours. Bleeding is very common with fissure but is not invariably present. The blood is bright red and usually scant in amount. In addition, pruritus ani may accompany up to 50% of cases .
Once an anal fissure develops, there is usually excessive activity of the internal anal sphincter with high resting anal pressure, which perpetuates this condition .
The aim of surgery is to reduce resting anal canal tone due to the internal anal sphincter, thereby increasing blood supply to the anoderm to improve healing. Surgical options include lateral sphincterotomy (LS), fissurectomy, and advancement in flap procedures. In the past, anal dilatation and posterior sphincterotomy have been used, but there is little evidence to support their continued use. In patients with a low resting pressure, an anal advancement flap is a logical option. Surgery is referred for medical treatment failures or to meet immediate patient wishes .
The disadvantages of internal sphincterotomy include disturbance of continence, bleeding, fistula, abscess, persistent wound pain, and long time of recovery .
| Patients and methods|| |
Forty patients with chronic anal fissure were admitted to Menoufiya University and Shebin El-Kom Teaching Hospitals from July 2010 to February 2013. Patients who were diagnosed with chronic anal fissure based on medical history and physical examination and who were treated for minimum of 6 weeks with conservative treatment (high residue diet, analgesics, and warm baths) were included. Chronic anal fissure is defined as the presence of a fibrous induration or exposed internal anal sphincter. Sentinel tag must be neither fibrosed nor infected. Patients were randomly divided into two groups: the LS group included 20 patients who underwent internal LS and the sentinel pile flap (SPF) group included 20 patients who underwent SPF operation. All patients in both groups were kept on liquid diet, and enema was performed 24 h before operation.
Lateral sphincterotomy group
LS was performed through 0.5-1 cm incision at 3 o' clock position in the intersphincteric plane. The internal sphincter is then looped on an artery forceps and brought up into the incision [Figure 1]. The internal sphincter is then cut under direct visualization. A gap can then be palpated in the internal sphincter through the anal mucosa. Skin wound was left open and covered with antiseptic dressing without packing.
Sentinel pile flap group
Sphincterotomy was initially described at the base of the fissure, in which the internal anal sphincter is divided in the posterior midline from level of the dentate line distally; this was usually completed through the fissure itself, refreshment of edges of sentinel pile, eversion of sentinel pile to close raw area and suturing of the flab by vicryl 2-0, then covering of wound with antiseptic dressing without packing.
| Results|| |
A total of 20 patients underwent LS, four male patients (20%) and 16 female patients (80%); they were between 18 and 40 years, with mean age of 27.1 ± 5.3 years. In all, 20 patients underwent SPF, three male patients (15%) and 17 female patients (85%); they were between 17 and 38 years, with mean age of 24.2 ± 4.05 years. The mean time of operation was shorter in the LS group (5.9 min ± 0.97) than that in the SPF group (9.2 min ± 0.89) [Table 1].
In this study, regarding operative bleeding, in the LS group 16/20 patients (80%) soaked less than three pads and 4/20 patients (20%) soaked three pads or more, whereas in the SPF group 17/20 patients (85%) soaked less than three pads and three patients (15%) soaked three pads or more. Regarding postoperative pain, there was a significant difference between the two groups of patients; the use of nonsteroidal anti-inflammatory drugs for relief of postoperative pain was higher in the SPF group (80%) than in the LS group (40%), whereas the use of opioids was higher in the LS group (60%) than in the SPF group (20%). In this study, 4/20 patients (20%) in the LS group complained of pruritus ani postoperatively, whereas in the SPF group 5/20 patients (25%) complained of pruritus ani postoperatively. In the present study, there was no patient who had postoperative bleeding in the LS group, whereas in the SPF group 2/20 patients had postoperative bleeding [Table 2].
|Table 2: Distribution of the studied groups with respect to operation results|
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On comparing the healing between the two groups, at the end of the second week of treatment, 12/20 patients (60%) in the LS group showed healing of fissures as compared with 18/20 patients (90%) in the SPF group; this shows that healing was earlier in the SPF group than in the LS group. In this study, flatus incontinence was reported in 8/20 patients (40%) of the LS group, whereas in the SPF group only 2/20 patients (10%) complained of flatus incontinence. Regarding recurrence, it was recorded in 2/20 patients (10%) of the LS group, whereas there was no recurrent cases in the SPF group [Table 2].
| Discussion|| |
The mean value of operation time was significantly higher in SPF; this is explained by the time taken for flap preparation and suturing to the anal mucosa in SPF operation, but the time of SPF operation is still short and operation does not consume much time.
In this study, regarding operative bleeding, the amount of operative bleeding was trivial in both groups; it was relatively higher in the SPF group due to the flap preparation and suturing to the anal mucosa. There was no significant difference between the LS group and the SPF group regarding operative bleeding [Figure 2].
In the present study, regarding postoperative pain, the pain was severe in the LS group. There was a significant difference between the two groups of patients; this is explained by closure of the raw area in the SPF group and less fibrous tissue reaction and formation, which decrease the postoperative pain.
In this study, there was no significant difference between the two groups of patients with respect to pruritus ani postoperatively; 4/20 patients (20%) in the LS group complained of pruritus ani postoperatively. This is not in agreement with the study by Laghari  in which 1/50 patients complained of pruritus ani; this is explained by bad hygiene and lack of patient compliance, as pruritus ani can be caused by the irritation due to continuous moisture in the anus caused by frequent liquid stools or escape of small amounts of stool (incontinence), and moisture increases the possibility of infections of the anus, especially yeast.
However, in the SPF group 5/20 patients (25%) complained of pruritus ani postoperatively.
In the present study, there was no significant difference between the two groups regarding postoperative bleeding. No patient had postoperative bleeding in the LS group, which agrees with previous study by Laghari , 0/50 patients, whereas in the SPF group 2/20 patients had postoperative bleeding; the bleeding was mild (only soaking of the dressing) and lasted for 1 day only.
On comparing the healing between the two groups, within 2 weeks of treatment 12/20 patients (60%) in the LS group showed healing of fissures, which agrees with previous study by Mishra , 11/20 patients (55%), as compared with 18/20 patients (90%) in the SPF group; this shows that healing was earlier in the SPF group than in the LS group. This is explained by closure of the raw area in the SPF group and healing by primary intention, which minimize the time needed for healing.
In this study, there was significant difference between the two groups regarding flatus incontinence; it was reported in 8/20 patients (40%) of the LS group. Some other series reported that after sphincterotomy incontinence rate varied between 0 and 35% .
It was found that the high number of incontinence noted in some of the studies was as a result of short period of follow-up because of which the observers were unable to differentiate transient incontinence from permanent incontinence. That is why the technical review said that the complications after LS reflect the care and nature of follow-up more than the differences in surgical skills.
In the SPF group, only 2/20 patients (10%) complained of flatus incontinence; this is explained by that, in SPF operation, posterior sphincterotomy was performed under vision of internal anal sphincter at the base of the fissure and in the fibrosed part of internal anal sphincter, whereas in LS the cut of sphincter occurs in the fleshy part, and hence it gapes away and in turn may cause flatus incontinence.
Regarding recurrence, there was no significant difference between the two groups of patients; it was recorded in 2/20 patients in the LS group (10%), which agrees with the previous study by Laghari , 3/50 patients, whereas there was no recurrent cases in the SPF group.
The advantages of the SPF operation over LS are as follows: healing occurs by primary intention rather than secondary intention, which occurs in LS, less fibrous tissue reaction and formation, minimal postoperative pain due to closure of the raw area and less fibrosis, better sensation during defecation and sampling, less incidence of flatus incontinence as sphincterotomy is performed in the SPF technique in the fibrosed part of internal anal sphincter so that it does not gape, addition of a new tissue for the anal canal to avoid stenosis, and healing is much more rapid than LS.
| Conclusion|| |
The SPF is a simple and easy operation and used in selected patients with sentinel tag neither fibrosed, nor infected. It has a short healing time, minimal postoperative pain, and low incidence of flatus incontinence.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]