Internal Sphincterotomy Group Research Articles

Fissurectomy versus lateral internal sphincterotomy in the treatment of chronic anal fissures: no advantages in terms of post-operative incontinence

PurposeThe standard treatment for chronic anal fissures that have failed non-operative management is lateral internal sphincterotomy. Surgery can cause de novo incontinence. Fissurectomy has been proposed as a sphincter/saving procedure, especially in the presence of a deep posterior pouch with or without a crypt infection. This study investigated whether fissurectomy offers a benefit in terms of de novo post-operative incontinence.MethodsPatients surgically managed with fissurectomy or lateral internal sphincterotomy for chronic anal fissures from 2013 to 2019 have been included. Healing rate, changes in continence and patient satisfaction were investigated at long-term follow-up.ResultsOne hundred twenty patients (55 females, 65 males) were analysed: 29 patients underwent fissurectomy and 91 lateral internal sphincterotomy. Mean follow-up was 55 months [confidence interval (CI) 5–116 months]. Both techniques showed some rate of de novo post-operative incontinence (> +3 Vaizey score points): 8.9% lateral internal sphincterotomy, 17.8% fissurectomy (p = 0.338). The mean Vaizey score in these patients was 10.37 [standard deviation (sd) 6.3] after lateral internal sphincterotomy (LIS) and 5.4 (sd 2.3) after fissurectomy Healing rate was 97.8% in the lateral internal sphincterotomy group and 75.8% in the fissurectomy group (p = 0.001). In the lateral internal sphincterotomy group, patients with de novo post-op incontinence showed a statistically significant lower satisfaction rate (9.2 ± 1.57 versus 6.13 ± 3; p = 0.023) while no differences were present in the fissurectomy group (8.87 ± 1.69 versus 7.4 ± 1.14; p = 0.077).ConclusionsLateral internal sphincterotomy is confirmed as the preferred technique in term of healing rate. Fissurectomy did not offer a lower rate of de novo post-operative incontinence, but resulted in lower Vaizey scores in patients in whom this occurred. Satisfaction was lower in patients suffering a de novo post-operative incontinence after lateral internal sphincterotomy.

A COMPARATIVE STUDY OF LATERAL SPHINCTEROTOMY AND 2% DILTIAZEM GEL LOCAL APPLICATION IN THE TREATMENT OF FISSURE IN ANO

troduction: Anal ssure is a non-healing linear tear in the distal anal mucosa below the dentate line and is a painful entity.Fissure in ano is a common proctologic disease affecting both men and womenparticularly young.They require surgery like manual anal dilation or lateral internal sphincterotomy which heal the ssure in more than 90% cases but with a signicant risk of impaired anal continence. Newer non surgical therapies such as topical 2% diltiazem gel, have shown good efcacy without impairing anal continence. The aim of the study is to compare the AIMefcacy of outcome of Lateral Sphincterotomy Versus 2% Diltiazem gel in the treatment of chronic ssure in ano. 70 Material and Methods: patients diagnosed with ssure in ano were randomly divided into 2 %Diltiazem and lateral sphincterotomy groups. Patient were followed up at regular interval for symptomatic relief and healing of ssure. Less 89.4% patients Result: in diltiazem group and 100% of patients in lateral internal sphicterotomy group ssure healed completely between 4-8 weeks. In the diltiazem group pain relief was fairly good. 42 patients (89.4%) had pain relief at the end of 14 weeks. But the pain relief in lateral internal sphincterotomy group was excellent with 100% patients having complete pain relief by 8 weeks. Mild headache was experienced with diltiazem patients.1 patient complained of atus incontinence with lateral internal sphincterotomy. We conclude that lateral sphincterotomy is the gold standard t Conclusion: reatment for the ssure in ano but chemical sphincterotomy using 2% topical diltiazem gel can be considered a good second line treatment option in those unt for surgery or for those not willing for surgery

Comparison of Glyceryl Trinitrate Ointment versus Internal Lateral Sphincterotomy for Anal Fissure Pain Relief

Background: Anal fissure is a linear painful mucosal tearing in the distal part of anal canal. It extends from dentate to anal edge. Aim: To compare the glyceryltrinitrate ointment and internal lateral sphincterotomy for anal fissure pain relief in acute/chronic pts. Study Design: Prospective study Place and duration of study: Department of Surgery Unit-II, Fatima Memorial Hospital, Shadman Lahore from 1st October 2018 to 31stDecember 2020. Methodology: 40 pts with acute and chronic anal fissure were enrolled. Half of the patients undergo internal lateral sphincterotomy while other opted 0.2% use of glyceryl trinitrate ointment. Each patient was followed for pain, recovery, complications and recurrence until 12 months for internal lateral sphincterotomy and 18 months in glyceryl trinitrate ointment. Results: There were 24 males and 16 females with a mean age of patients as 30±3.2 years. Initial follow-up of patients showed 100% pain and fissure improvement in internal lateral sphincterotomy group as compared to 60% in glyceryl trinitrate ointment group respectively. Conclusion: Internal lateral sphincterotomy is most efficient and reliable procedure in relieving anal fissure pains. Keywords: Anal fissure, Internal lateral sphincterotomy, Glyceryl trinitrate

A comparative study between lateral internal anal sphincterotomy and botulinum toxin injection in the treatment of chronic anal fissure

Background and objective: The gold standard for the treatment of chronic anal fissure is lateral internal sphincterotomy. Botulinum toxin injection provides temporary alleviation of sphincter spasm and allows the fissure to heal. This study aimed to compare the outcomes of lateral internal sphincterotomy and botulinum toxin injection treatments in patients with uncomplicated chronic anal fissure. Methods: A prospective comparative study was carried out at the surgical unit of Erbil teaching hospital, Erbil, Kurdistan Region of Iraq, from January 2017 to February 2018. Fifty-five patients were enrolled in this study. Five patients were excluded, and the remaining 50 patients were equally divided into two groups. Group A was managed with lateral internal sphincterotomy and group B with botulinum toxin. Postoperative pain relief, bleeding, fissure healing, incontinence, and relapse after six weeks and three months of follow-up were compared. Results: One month after treatment, 12% of the lateral internal sphincterotomy group had bleeding, while none of the botulinum toxin group (P = 0.234). Two patients (8%) of the lateral internal sphincterotomy group had pain while one (4%) of the botulinum toxin group (P >0.999).Three months after treatment, 4% of the lateral internal sphincterotomy group had bleeding, while none of the botulinum toxin group (P >0.999). None of the lateral internal sphincterotomy group had pain while one (4%) of the botulinum toxin group (P >0.999). Regarding healing, 96% of the lateral internal sphincterotomy group healed, while 92% in the botulinum toxin group (P >0.999). Conclusion: The outcome of lateral internal sphincterotomy and botulinum toxin were nearly the same, but lateral internal sphincterotomy required hospitalization, period off work, and risk of anesthesia. These risks were absent in botulinum toxin injection. Keywords: Chronic anal fissure; Lateral internal sphincterotomy; Botulinum toxin; Complications.

Anal Advancement Flap versus Lateral Internal Sphenecterotomy for Treatment of Chronic Anal Fissure with High-pressure Anal Canal.

Background: Anal fissure, is an ulcer-like, longitudinal tear in the anal canal squamous epithelium . Nowadays the standard treatment for anal fissure is Lateral internal sphincterotomy (LIS). Anal advancement flap (AAF) procedure is accomplished by transfer of healthy well-vascularized tissue onto the base of the fissure combined with fissurectomy, this improves wound healing and decrease anal stenosis risk.Methods: Forty patients with chronic anal fissure and hypertonic anal sphincter detected by anal Manometry. Allocated randomly into two groups .Lateral internal sphincterotomy group (A) and anal advancement flap group (B) . Objectives : the aim of this study is to compare the outcome of lateral internal sphincterotomy and anal advancement flap in management of chronic anal fissure.Results: A total number of 40 cases (20 cases in each groups). Manometry results showed no significant difference in the preoperative mean resting anal pressure was observed among the two groups. The Mean ± SD for group A was 104.3900 ± 12.93917 and for group B was 107.3900 ± 12.30241 as shown in. the operative time in Group A ranged from 8- 12 minutes with a mean operative time 10.0 ± 1.3 minutes. In Group B, the operative time ranged from 25-41 minutes with a mean operative time 32.0 ± 6.01752 minutes. As regard hospital stay in this study, no difference was found between both groups.Conclusions: In conclusion, anal advancement flap is a comparable procedure for LIS for treatment of chronic anal fissure in hypertonic anal canal.

A comparative study of chemical sphincterotomy (using 2% diltiazem) and lateral internal sphincterotomy for chronic anal fissure

Background: Anal fissure is the most common painful condition of anal region characterised by vertical ulcers affecting distal end of anal canal. The main aim of this study is comparing 2 % diltiazem and lateral internal sphincterotomy in the treatment of chronic anal fissure.Materials and Methods: The Study was conducted as a clinical trial in Sree Mookambika institute of medical sciences, Kulasekharam from May 2020 to November 2020.100 patients diagnosed with chronic fissure in ano on the basis of history of painful defecation with or without per rectal bleeding for more than 6 weeks and per rectal examination were enrolled in the study after obtaining an informed written consent from them. Results has been detailed in both descripted and statistical point of view and simplified in understandable format.Results: In 89.36% of patients in diltiazem group and 100% of patients in lateral internal sphincterotomy group fissure healed completely between 4-8 weeks. In the diltiazem group pain relief was good. 42 patients (89.4%) had pain relief at the end of 14 weeks. 5 patients (10.6%) had no pain relief. But pain relief in lateral internal sphincterotomy group was excellent with 100% patients having complete pain relief by 8 weeks’ time. Mild headache was experienced with diltiazem by 3(6.4%) patients.1 patient (2.1%) complained of flatus incontinence with lateral internal sphincterotomy.Conclusion: We conclude that lateral internal sphincterotomy is the gold standard treatment of chronic fissure in ano but chemical sphincterotomy using 2% diltiazem gel can be considered as a good second line treatment option in those unfit for surgery or for those not willing for surgery.

Comparative study between surgical lateral internal sphincterotomy and botulinum toxin injection in the treatment of chronic anal fissure

Introduction Anal fissure is a longitudinal ulcer from below the dentate line to above the anocutaneous line. In 90% of cases, it is posterior. The second location is anterior commissure. In women, ∼80% are posteriorly, whereas 20% occur anteriorly. Botulinum toxin (BTX) action is mediated by its action on the autonomic nervous system. The treatment goal for BTX is the interruption of the internal sphincter spasm. Indeed, sphincter manometry after BTX injection has demonstrated a lowering of resting internal pressure. The aim is to compare effectiveness of surgical lateral internal sphincterotomy (LIS) versus BTX injection. Patients and methods A total of 60 patients were randomly allocated into two equal groups of 30 patients each: group I (lateral internal sphincterotomy group) and group II (BTX injection group). Results Chronic anal fissure can be successfully treated with surgical LIS with a 90% healing rate after 2 months, with no recurrence rate recorded, in comparison with a 70% healing rate in BTX injection, with a 20% incidence of recurrence. Conclusion LIS is a satisfactory treatment for chronic anal fissure, being quick and easy to be performed with minimal complications. Recurrence is uncommon. BTX is safe and easy, with rapid relief of pain, with no risk of anesthetic or operative complications. It is relatively less invasive than surgical, with negligible complications, but it has a higher recurrence rate. The risk of anal incontinence is higher in the surgical group especially in elderly patients than BTX injection; therefore, BTX injection is preferred in middle aged and elderly patients, risk factor for anal incontinence, or those of recent complaint of anal fissure.

Role of Internal Sphincterotomy as an Adjunct to Open Haemorrhoidectomy for Management of Third- and Fourth Degree Haemorrhoids

<p><strong>Background and Objective</strong>: Post-operative pain and complications are common after open haemorrhoidectomy. Addition of internal sphincterotomy has shown to improve the post-operative outcomes. This study is conducted to compare the outcomes of open haemorrhoidectomy with and without internal sphincterotomy.<br /><strong>Methods:</strong> A prospective randomized controlled trial was conducted in the Department of Surgery at Sargodha Medical College/District Headquarter Hospital, Sargodha from February 2016 to December 2017. One hundred and twenty-two patients presenting with third and fourth degree haemorrhoids were divided in two equal groups. In group “A”, haemorrhoidectomy with internal sphincterotomy and in group “B”, haemorrhoidectomy alone was performed. Outcome variables such as pain scores based on Verbal Rating Scales (VRS), hospital stay, complications and wound healing were compared in both groups.<br /><strong>Results:</strong> The mean pain scores were less in the internal sphincterotomy group A i.e., 3.3 ± 0.3 while it was 3.6 ± 0.4 in group B at 1st post-op day. The mean duration of hospital stay was less in group A (2.3 ± 0.7 days) and it was 3.4 ± 0.9 days in group B. On the 7th post-operative day, 13 (21.3%) patients in group A and 4 (6.6%) patients in group B had flatus incontinence. Urinary retention was present in 4 (6.6%) cases in group A and 13 (21.3%) in group B. Post-operative bleeding was present in 44 (72.1%) cases of group A and 41 (67.2%) of group B. Constipation was higher in the group B (44.3% vs. 37.7%). Wound healing was better in group A (63.3%). Anal stenosis occurred in 3 (4.9%) patients who were treated with <br />haemorrhoidectomy alone.<br /><strong>Conclusion:</strong> Addition of internal sphincterotomy improves the outcome of open haemorrhoidectomy in patients of third- and fourth-degree haemorrhoids. It is therefore recommended to carryout internal sphincterotomy when operating on such patients</p>

A Combined Topical Treatment versus Surgical Treatment in Chronic Anal Fissure

In the treatment of chronic anal fissure, both surgical and topical treatment methods are used. The purpose of this study was to research a combined topical treatment that we prepared and to compare the effectiveness of lateral internal sphincterotomy in chronic anal fissure with this topical treatment. A total of 183 patients with chronic anal fissure were divided into two groups. One hundred and four patients had topical medical treatment (group 1) and seventy-nine patients underwent lateral internal sphincterotomy (group 2). In the first group, a topical combination of ointments consisting of bacitracin-neomycin sulfate, dexpanthenol, and diltiazem was applied to the anal area. Four weeks after treatment, pain and bleeding during defecation, gas/fecal incontinence, treatment-related adverse events and recovery rates were evaluated in both groups. Also, patients were examined for recurrence between the 8th and 10th weeks. There was no significant difference in recovery rates between the groups. In group 1, recovery rate was 82.7%, while in Group 2 it was 92.4% (p = 0.054). In both groups, gas/fecal incontinence ratio was significantly different, supporting the medical treatment (p = 0.02). The severity of pain and bleeding during defecation were compared between the groups. Only the severe pain was significantly higher in the medical treatment group (p = 0.018). The recurrence rate was 5.8% in the medical treatment group, but no recurrence was detected in the surgical group. Due to possible complications of surgical treatment and similar recovery rates, medical treatment of patients with chronic anal fissure can be tried before surgical treatment.

Early Outcome of Open versus Closed Lateral Internal Anal Sphincterotomy in the Treatment of Chronic Anal Fissure

Background: Chronic anal fissure is a benign disorder that is associated with considerable discomfort. Surgical treatment in the form of lateral internal sphincterotomy has long been regarded as the gold standard of treatment. Two methods of sphincterotomy are currently practiced: open or closed technique.
 Objective: The objective of this study was to compare the early outcome of closed versus open lateral internal anal sphincterotomy for the treatment of chronic anal fissure, based on the assessment of post-operative pain and complications.
 Methods: A comparative study was conducted at the department of surgery in Dhaka Medical College & Hospital, over a period of 6 months from April 2015 to September 2015. A total of 80 patients were purposefully included in this study and were equally divided into two groups; Group A included 40 patients undergone closed lateral internal anal sphincterotomy and Group B included 40 patients undergone open lateral internal anal sphincterotomy. Patients were followed up postoperatively for 6 weeks to assess any complications. The outcomes were compared between the groups using the Chi-square (x2) test and Student's "t" test.
 Results: Delayed postoperative healing was found in 7.5% patients of the open lateral internal anal sphincterotomy group. The mean pain score and duration of hospital stay were lower in closed lateral internal anal sphincterotomy group.
 Conclusion: Closed lateral internal sphincterotomy is preferred to open technique in the treatment of chronic anal fissure, as it is effective, safe, less expensive, and is associated with low complication rate.
 Journal of Surgical Sciences (2018) Vol. 22 (1): 52-57

Comparative efficacy of medical treatment versus surgical sphincterotomy in the treatment of chronic anal fissure.

Anal fissure which is defined as a longitudinal tear in anoderm below the dentate line is one of the most common benign diseases of anorectal area. Severe pain during the defecation and emotional stress that it causes may reduce people's quality of life. In this randomized clinical trial, we aimed to compare the efficiency of the topical ointment with medical treatment and surgical lateral internal sphincterotomy. This is a randomized clinical trial of 550 patients who were treated for chronic anal fissure. Patients were randomly divided into 4 groups according to the treatment type they received. In a vast majority of the patients, the primary complaint was pain (92.3%) and bleeding during defecation (62%). Both pain relief and healing of the fissure, which are the components of response to treatment, had not been observed in 56 (37.3%) patients of topical nitroglycerin ointment group until the second month. Among the recalcitrant patients in both topical nitroglycerin (56) and topical diltiazem ointment (47) groups, 27 (48.2%), and 36 (76.5%) patients underwent surgery, respectively. The best response to treatment was also obtained in lateral internal sphincterotomy group. LIS is still the gold standard for the treatment of chronic anal fissure when the physicians would like to avoid recurrence and obtain the best pain relief.

Comparative Study of Chemical Sphincterotomy and Lateral Internal Sphincterotomy for Chronic Anal Fissure

Introduction Fissure-in-ano is a very common problem which causes considerable morbidity and affects the patient's quality of life to a great extent. This warrants prompt treatment of the condition with appropriate methods. In this study, we assess and compare the efficacy and adverse effects of topical application of 2% Diltiazem gel with that of Lateral internal sphincterotomy. Method 100 patients with chronic fissure in ano were divided into Diltiazem gel and Lateral internal sphincterotomy groups and followed up at regular intervals for symptomatic relief and healing. Results Fissure was completely healed in 42 (89.36%) out of 47 patients by 8 weeks in the Diltiazem group, 3 patients experienced mild headache, 2 local irritation, 13 patients were pain-free at the end of 4 weeks, 26 patients were 8 weeks and 3 patients by 14 weeks. 5 patients were not relieved of pain at the end of 14 weeks. Completely healed in 48 (100%) out of 48 patients by 4 weeks in the Lateral Internal Sphincterotomy group.21 patients experienced post-operative pain and incontinence for flatus in 1 patient. 32 patients were pain-free by 4 weeks and all the patients were free of pain by 8 weeks. Conclusion The current study shows results in favour of lateral internal sphincterotomy with a healing rate of 100% with a faster pain-relief and minimal complications if performed by the experienced surgeon. However topical 2% diltiazem gel is an effective agent can be safely prescribed for patients having contraindications for surgery. With a healing rate close to 90%, topical 2% Diltiazem therapy can be advised as the first line of treatment for the treatment of chronic anal fissure.

Comparative evaluation of fissurectomy versus lateral internal sphincterotomy in the treatment of chronic anal fissure

Background: Anal fissure is a common anorectal condition that affecting all age groups, but it is seen in young and healthy adults with equal incidence across both the sexes. The objective of this study was to evaluate and prospectively compare fissurectomy versus lateral internal sphincterotomy in the treatment of chronic anal fissure in terms of symptomatic relief, healing, recurrence and incontinence, if any.Methods: 50 patients with chronic anal fissure were alternately divided in two groups. In one group fissurectomy was done and in another group, patients underwent lateral internal sphincterotomy and comparative evaluation was done.Results: Complete healing was observed in 92% patients in fissurectomy group and 96% patients in lateral internal sphincterotomy group at the end of 6 weeks. Fissurectomy group patients reported early cut through of sutures and infection whereas in lateral internal sphincterotomy group two patients developed perianal hematoma at 3 months of follow up.Conclusions: While considering surgical management for treating chronic anal fissure, fissurectomy is comparable to lateral internal sphincterotomy in terms of symptomatic pain relief, healing rates with minimal side effects and low recurrence.

A comparison of segmental internal sphincterotomy versus lateral internal sphincterotomy in management of chronic fissure in ano

Background: Fissure in ano is one of the commonest benign and painful proctologic condition encountered in surgical practice treated by conservative line of management. Lateral sphincterotomy is the ideal treatment option for chronic refractory fissure in ano. A newer modality segmental internal sphincterotomy shows good promise in terms of early resolution of symptoms, fissure healing and prevention of anal incontinence involving division of the internal sphincter at two different levels.Methods: In comparative nonrandomized trial patients with chronic fissure in ano satisfying the inclusion and exclusion criteria were allocated to lateral sphincterotomy and segmental internal sphincterotomy groups. The outcome factors were perianal sepsis, pain relief using VAS as assessed on passing the first motion, duration of healing of fissure, assessment of incontinence using Wexner’s continence score on 30th post-operative day.Results: A total of 54 cases were enrolled, of them 31 patients underwent lateral internal sphincterotomy and 23 underwent segmental internal sphincterotomy with the mean age of patient was 34.76 years and a male to female ratio of 1.07:1. The pain score (VAS) on passing stool for the first time postoperatively was 4.5 with lateral sphincterotomy and 3.91 with segmental internal sphincterotomy which was statistically significant (P value < 0.010). The duration of postoperative healing was observed to be 27.94 days and 28.09 days in lateral sphincterotomy and segmental internal sphincterotomy group respectively. The post-operative anal incontinence was evaluated by using Wexner’s continence grading after one month which was not statistically significant between two groups.Conclusions: Segmental internal sphincterotomy could be a good surgical modality with its healing effect on fissure in ano and post-operative complications which are similar to standard lateral internal sphincterotomy.

Randomized clinical trial of transcutaneous electrical posterior tibial nerve stimulation versus lateral internal sphincterotomy for treatment of chronic anal fissure

ObjectivesThe objective of this study was to evaluate the efficacy of transcutaneous electrical posterior tibial nerve stimulation in treatment of patients with chronic anal fissure and to compare it with the conventional lateral internal sphincterotomy. Patients and methodsConsecutive patients with chronic anal fissure were randomly allocated into two treatment groups: transcutaneous electrical posterior tibial nerve stimulation group and lateral internal sphincterotomy group. The primary outcome measures were number of patients with clinical improvement and healed fissure. Secondary outcome measures were complications, VAS pain scores, Wexner's constipation and Peascatori anal incontinence scores, anorectal manometry, and quality of life index. ResultsSeventy-three patients were randomized into two groups of 36 patients who were subjected to transcutaneous electrical nerve stimulation and 37 patients who underwent lateral internal sphincterotomy. All (100%) patients in lateral internal sphincterotomy group had clinical improvement at one month following the procedure in contrast to 27 (75%) patients in transcutaneous electrical nerve stimulation group. Recurrence of anal fissure after one year was reported in one (2.7%) and 11 (40.7%) patients in lateral internal sphincterotomy and transcutaneous electrical nerve stimulation groups respectively. Resting anal pressure and functional anal canal length were significantly reduced after lateral internal sphincterotomy. ConclusionTranscutaneous electrical posterior tibial nerve stimulation for treatment of chronic anal fissure is a novel, non-invasive procedure and has no complications. However, given the higher rate of clinical improvement and fissure healing and the lower rate of fissure recurrence, lateral internal sphincterotomy remains the gold standard for treating chronic anal fissure.

The Efficacy and Morbidity of Different Surgical Treatment Techniques for Chronic Anal Fissure: An Academic Colorectal Experience

Up to 40 per cent of chronic fissures will fail to heal with medical treatment alone. Open (OLIS) and closed (CLIS) lateral internal sphincterotomies are considered by many to be the treatment of choice for chronic anal fissures (CAF). The aim of this study was to compare the efficacy and clinical outcomes of different surgical techniques for treatment of CAF. We performed a retrospective chart review of 387 patients with CAF who underwent surgical intervention performed by colorectal surgeons between 2006 and 2012 at Greenville Hospital System. Of 387 patients, 199 underwent OLIS, 124 CLIS, and 64 patients underwent fissurectomy alone (FE). We investigated the effect of the surgical technique on time of healing, rate of flatus incontinence, wound infection, recurrence, and the need for additional intervention. There was no statistically significant difference among patients undergoing OLIS, CLIS, and FE in demographic characteristic, time of healing, rate of wound infections, and fecal continence, or recurrence rate. Comparison of a combined lateral internal sphincterotomy (LIS) group with FE showed that there is similar time of healing (P = 0.58), no statistical difference in flatus incontinence rate (P = 0.61), urinary retention (P = 1.0), fissure recurrence (P = 0.11), and prolonged healing (P = 0.2). Patients in FE group more likely required additional treatment to complete wound healing (P = 0.02). LIS is a safe and effective technique for treatment of CAF. Although there was no difference in complications rate and healing time, patients in the FE group required additional surgical or medical treatment more frequently to achieve complete healing.

Comparative study of local calcium channel blocker application and lateral internal sphincterotomy in the treatment of chronic anal fissure: study of 50 cases.

Background: The treatment of chronic anal fissure has changed greatly during the past two decades with ongoing research directed at lowering the internal anal sphincter tone and avoiding the risk of fecal continence disturbance. Glycerin trinitrate, topical calcium channel blockers and anal dilators and botulinum toxin injection alone are all known to be able to lower the internal anal sphincter tone but results have been disappointing in curing chronic anal fissure, often marginally better than to placebo. The surgical treatment in the form of lateral internal sphincterotomy is the gold standard for chronic anal fissure. Aims & Objective: The aim of this prospective study was to assess the efficacy of medical treatment in form of topical calcium channel blocker and surgery in the management of chronic anal fissure. The objective is to compare the efficacy with regard to complete healing, recurrence, incontinence and other complications after treatment with topical calcium channel blocker and lateral anal sphincterotomy. Material and Methods: From October 2010 to October 2012, 50 patients with typical chronic anal fissure completed the study. 25 patients were initially treated with topical calcium channel blocker for 8 weeks and rests 25 were treated with lateral anal sphincterotomy. During the follow-up healing rates, symptoms, incontinence scores, and therapy adverse effects were recorded. Results: Overall healing rates were 60% after 8 weeks therapy with topical calcium channel blocker. Whereas overall healing after lateral internal sphincterotomy group was 88% with no recurrence. Conclusion: Lateral internal sphincterotomy is far more effective than medical treatment, with significantly increased healing rates while avoiding risk of incontinence.

Botulinum toxin injection versus lateral internal sphincterotomy for the treatment of chronic anal fissure: randomized prospective controlled trial

Lateral internal sphincterotomy has been the gold standard treatment for chronic anal fissure, but it still carries the risk of permanent damage of the anal sphincter, which has led to the implementation of alternative treatment like botulinum toxin injection. The aim of this randomized prospective controlled trial was to compare the efficacy and morbidity of botulinum toxin injection and lateral internal sphincterotomy in the treatment of chronic anal fissure. Fifty consecutive adults with chronic anal fissure were randomly treated with either lateral internal sphincterotomy or botulinum toxin (BT) injection with 50 U BT into the internal sphincter. The complications, healing and recurrence rate, and incontinence score were assessed 2, 3, 6, 12 months after the procedure. Inspection at the 2-month visit revealed complete healing of the fissure in 11 (44 %) of the patients in the BT group and 22 (88 %) of the patients in the lateral internal sphincterotomy (LIS) group (p = 0.001). At the 3-month visit, there was no significant difference between the two groups in healing. The overall recurrence rate after 6 months in the BT group was higher than in the LIS group (p < 0.05). In the 3-month follow-up, the LIS group had a higher rate of anal incontinence compared to the BT group (p < 0.05). The final percentage of incontinence was 4 % in the LIS group (p > 0.05). The treatment of chronic anal fissure must be individualized depending on the different clinical profiles of patients. Botulinum toxin injection has a higher recurrence rate than LIS, and LIS provides rapid and permanent recovery. However, LIS carries a higher risk of anal incontinence in patients.

A Comparison Between the Results of Fissurectomy and Lateral Internal Sphincterotomy in the Surgical Management of Chronic Anal Fissure

BackgroundWe compare lateral internal sphincterotomy as an effective treatment of chronic fissure in ano to fissurectomy, which is as an alternative surgical treatment. MethodsSixty two consecutive patients were divided into two groups through sequential sampling. Thirty patients underwent fissurectomy and 32 underwent lateral internal sphincterotomy. After a median follow-up of 22 months, we compared the results of the two procedures. In addition to frequent visits on a predetermined basis, a telephone inquiry into fissure recurrence and continence status was made. ResultsAll patients in both groups were pain-free and without bleeding within 1 week. In both groups, urinary retention was noted in one patient. Incontinence to flatus was noted in the fissurectomy (F) group in two (6.2%) patients, but no incontinence was noted in the lateral internal sphincterotomy (LIS) group. There was one patient (3.1%) with fissure recurrence in the F group but none in the LIS group. No patient in either group was afflicted with anal stenosis or perianal infections. All wounds healed within 8 weeks. Twenty nine patients (96.6%) in the LIS group and 28 (87.5%) in the F group reported satisfactory results with their procedure. ConclusionIn the surgical treatment of chronic anal fissure not responding to conservative management, LIS may be the better treatment and, perhaps, the preferable surgical technique with fewer total complications (P < 0.005).

Comparison of internal sphincterotomy with topical diltiazem for post-hemorrhoidectomy pain relief

To assess the efficacy of internal sphincterotomy compared with application of topical 2% Diltiazem ointment after hemorrhoidectomy for pain relief. Prospective randomized study. In an 18-month period, 108 subjects with uncomplicated Grade 3/ 4 hemorrhoids were enrolled in the study and were randomized into two equal groups: Subjects in Group A underwent internal sphincterotomy at time of primary surgery while those in Group B received 1 g of 2% Diltiazem ointment locally, thrice daily for seven days. Postoperative pain perception was measured using visual analog score (VAS) and on the basis of number of analgesic tablets (Tab tramadol 50 mg) required in each group. Time to discharge, time to return to work and incidence of complications measured and compared. Statistical techniques applied were Student T test, Chi-square and Fisher's Exact Test. There were 102 analyzable subjects (Group A: 50 and Group B: 52). The mean VAS score was significantly less in the internal sphincterotomy group from the fourth postoperative day onwards compared to topical Diltiazem (2.23 vs. 3.72; P =0.031). Similarly, the mean requirement of analgesic tablets [10.54 vs. 15.40; P =0.01] was much lower in Group A. There was no significant difference in terms of time to discharge and time to return to work between the two groups. The incidence of complications was more with the internal sphincterotomy group (11.5% vs. 3 %; P =0.488). In patients undergoing hemorrhoidectomy, addition of surgical internal sphincterotomy results in lesser pain in the postoperative period as compared to those receiving topical application of Diltiazem.