Fissurectomy Versus Lateral Internal Sphincterotomy in the Treatment of Chronic Anal Fissure: A Randomized Control Trial.

Abstract

IntroductionAn anal fissure is defined as a longitudinal split in the distal anoderm which extends from the anal verge to the dentate line. Fissures can be of primary or secondary type. The posterior midline is the most common location for primary fissures, while, anterior primary fissures, though rare, are more common in females. The cause of primary fissure is idiopathic. But secondary fissures are associated with other systemic diseases and can occur at an abnormal position anywhere in the anoderm. A high percentage of acute fissures heal spontaneously within three weeks with conservative medical management comprising of a high fiber diet, warm sitz bath, and topical analgesic with steroids. Secondary anal fissures will not heal in any form of treatment until the primary cause is addressed. These fissures often need surgical treatment. The lateral internal sphincterotomy (LIS) is one of the most practiced treatments for chronic anal fissure. Nonetheless, anal incontinence is one of the worrisome complications of LIS. Fissurectomy is one of the options among those techniques which address the issues with LIS. Some studies showed that patients with chronic fissures who are refractory to medical treatment responded well to fissurectomy. Hence, this study was conducted to compare the outcomes of fissurectomy and lateral internal sphincterotomy in the treatment of chronic anal fissure and compare recurrence and postoperative complications among both the procedures.MethodsAll consecutive patients attending the department of surgery with chronic fissure and age above 18 years were included in the study. All the included patients were randomized into two groups (fissurectomy and LIS) using the serially numbered opaque-sealed envelope (SNOSE) technique. The patients were discharged on the third day. The first visit was scheduled after two weeks and subsequent visits on the first and second months. Then the patients were followed up by telephonic conversation for the next six months. At the end of the follow-up, post-surgical complications were enquired, recorded, and interpreted.ResultsIn the present study, out of a total of 87 patients, 80 patients were included in the study. Among all the patients, 16 patients (20%) developed retention of urine. Four patients in the LIS group showed retention of urine whereas in the fissurectomy group it was twelve. The difference was not statistically significant (p-value: 0.025). A total of 10 patients required catheterization postoperatively. More patients in the fissurectomy group developed incontinence to flatus (p-value: 0.02). Incontinence to liquid and solid was significantly higher in the fissurectomy group (p-value: 0.03 and 0.002, respectively).ConclusionIn the present study, it was found that LIS was a better treatment option for chronic anal fissure than Fissurectomy. The postoperative complications were less in LIS than in fissurectomy. But the recurrence was higher in the LIS group while there was no recurrence in the fissurectomy group.