Internal Sphincterotomy Research Articles

Comparison of The Postoperative Outcomes of Surgical Lateral Internal Sphincterotomy and Botulinum Toxin Injection in Patients Presenting With Chronic Anal Fissure At CMH, Rawalpindi

Objective: To compare the postoperative outcomes in Lateral Internal Sphincterotomy Group and in Botulinum toxin injection Group in patients managed for chronic anal fissure. Study Design: Quasi-experimental study. Place and Duration of Study: Department of Surgery, Combined Military Hospital, Rawalpindi Pakistan, from Aug 2021 to Feb 2022. Methodology: All patients of either gender, aged 30 to 70 years, who had presented to CMH, were included in this study. Block randomization was done to allocate half of them to Lateral Internal Sphincterotomy and half to Botulinum toxin injection. Patients in both Groups were followed for four weeks to assess and compare various short and long term post-surgical outcomes. Results: There were 82 patients in total with 41 in each treatment arm. In the Lateral Internal Sphincterotomy Group, 35 85(37%) of the patients reported postoperative pain relief at 24 hours, 39(95.12%) patients healed, only 2(4.88%) patients had a recurrence. In the Botulinum toxin Group, 29(70.73%) reported postoperative pain relief at 24 hours, 35(85.37%) patients healed, whereas 6(4.63%) had a recurrence. There was no statistical difference in any parameter between either Group. Conclusion: Both methods did not show any statistically significant difference in post-operative outcomes thus other parameters like patient’s choice, cost and expertise may be considered in treatment of chronic anal fissure.

Is Dilip's Transmucosal Internal Sphincterotomy a Modification of Closed Lateral Internal Sphincterotomy?

Is Dilip's Transmucosal Internal Sphincterotomy a Modification of Closed Lateral Internal Sphincterotomy?

Tailored lateral internal sphincterotomy (T-LIS) for chronic anal fissure by LigaSure Small Jaws©: a comparison with other non-conservative treatments for anal fissures

An anal fissure is a small tear in the thin tissue (mucosa) that lines the anus. Anal fissures typically cause pain and bleeding with bowel movements. The cause is not fully understood, but low intake of dietary fiber may be a risk factor. Chronic anal fissure was defined as a split or ulceration in the posterior or anterior anoderm for at least 6 weeks: have distinct anatomic features such as muscle fibers visible in the wound. Anal fissures can be attributed to constipation or repeated straining: a hard fecal bolus cut the mucosa of anal canal that is relatively thigh at sphincter level management and optimal treatment of the disease is controversial. Many studies recommend conservative and medical treatment modalities as the initial treatment options since they are non-invasive and do not have risks such as anal sphincter injury. Lateral internal sphincterotomy (LIS) is considered the gold standard for treatment of chronic anal fissure. Nonetheless, anal incontinence is one of the worrisome complications of LIS. Fissurectomy is another option among those techniques which address the issues with LIS. LigaSure© (Valleylab) is a bipolar electrosurgical device designed to deliver high current and very low voltage to tissue. It monitors tissue impedance between the jaws of the instrument and continuously adjusts the delivery of energy. The use of LigaSure Small Jaw was never reported for anal fissures in literature. We have applied the use of this device to a group of patients complaining for chronic anal fissure in order to verify if there is any advantage to perform it compared to traditional technique (blade, scissors, electrocautery).

A comparative study of the outcome of unilateral versus bilateral internal anal sphincterotomy in treatment of chronic anal fissure

Background: Gold standard treatment for chronic anal fissure is lateral internal sphincterotomy. Bilateral internal sphincterotomy (BIS) as a treatment option for chronic anal fissure has not been evaluated. Aims and Objectives: The aims and objectives of the study are to compare the efficacy of unilateral versus bilateral internal anal sphincterotomy in treatment of chronic anal fissure. Materials and Methods: Study design: A prospective randomized comparative study. Study area: Patients coming to General Surgery outpatient department at College of Medicine and Sagore Dutta Hospital with chronic anal fissure. Study period: July 2022 to December 2023 (18 months). Sample Size: 100 patients. Study Group: Group A=Patients who had undergone unilateral internal sphincterotomy (UIS)=50 patients and Group B=Patients who had undergone BIS=50 patients. Results: 2 (4%) patients in Group A and 3 (6%) patients in Group B developed incontinence for flatus postoperatively. No patients in either group developed incontinence for stools. The Mean Fissure Healing Time (Mean±SD) (Weeks) post-sphincterotomy was 4.32±0.91339 in Group A and 2.66±0.65807 in Group B. There were 6 cases of recurrence in the unilateral sphincterotomy group. Second surgery was needed in 4 patients who underwent unilateral sphincterotomy. Conclusion: As compared to UIS, BIS results in a faster healing of chronic anal fissure, with no increase in incontinence, decreased pain score, and less recurrence rates.

Is Botox an Alternative to Surgery for Anal Fissure?

Objective To compare the results of the lateral internal sphincterotomy(LIS) technique and high dose botulinum toxin, which is one of the treatments applied when medical treatment is insufficient in anal fissure. Materials and methods The files and outpatient clinic notes of the patients who underwent lateral internal sphincterotomy and botulinum toxin injection due to lack of response to medical treatment due to anal fissure between May 2020 and May 2023 were examined retrospectively. Preoperative and postoperative visual analog scale (VAS) scores, five-point horizontal scale (FPHS) scores, hospitalization times, fissure locations, follow-up periods, anesthesia type, and postoperative complications of the patients were recorded. Results Total 30 LIS and 24 botulinum toxin-treated patients were included. Hospitalization time was shorter in botulinum toxin groups than in the LIS group (p<0.001). First-week VAS score was lower than botulinum toxin injection group (p<0.001). There was no significant difference between the groups in terms of FPHS scores, follow-up periods, and recurrence (p:0.15, p:0.07, p:0.14). Conclusion: While LIS is faster in the early period, botulinum toxin injection can be considered as an alternative to surgical treatment for long-term results.

Belgian consensus guideline on the management of anal fissures.

Acute and chronic anal fissures are common proctological problems that lead to relatively high morbidity and frequent contacts with health care professionals. Multiple treatment options, both topical and surgical, are available, therefore evidence-based guidance is preferred. A Delphi consensus process was used to review the literature and create relevant statements on the treatment of anal fissures. These statements were discussed and modulated until sufficient agreement was reached. These guidelines were based on the published literature up to January 2023. Anal fissures occur equally in both sexes, mostly between the second and fourth decades of life. Diagnosis can be made based on cardinal symptoms and clinical examination. In case of insufficient relief with conservative treatment options, pharmacological sphincter relaxation is preferred. After 6-8 weeks of topical treatment, surgical options can be explored. Both lateral internal sphincterotomy as well as fissurectomy are well-established surgical techniques, both with specific benefits and risks. The current guidelines for the management of anal fissures include recommendations for the clinical evaluation of anal fissures, and their conservative, topical and surgical management.

Comparing Outcomes of Lateral Internal Sphincterotomy and Laser sphincterolysis in the Management of Chronic Anal Fissure

Comparing Outcomes of Lateral Internal Sphincterotomy and Laser sphincterolysis in the Management of Chronic Anal Fissure

Dilip's Transmucosal Internal Sphincterotomy: A Simplified Approach to Lateral Internal Sphincterotomy for Fissure in Ano.

Fissure in ano is a prevalent and painful condition, typically treated by lateral internal sphincterotomy after conservative measures fail. Dilip's transmucosal internal sphincterotomy introduces a simplified approach that reduces the risk of damaging the external sphincter, making it particularly suitable for less experienced surgeons. This innovation offers a less invasive method with minimal risk of incontinence, providing a safer, more accessible option. Transmucosal internal sphincterotomy simplifies the internal sphincterotomy process, offering a tailored approach that eliminates the need for extensive dissection. This method allows surgeons complete control over the internal sphincter bundle, facilitating a precise, customizable cut without the risks associated with traditional internal sphincterotomy, especially in obese patients where the intersphincteric groove is not visible, leading to potentially harmful blind incisions. The procedure is performed under saddle block anesthesia with the patient in the lithotomy position. A distinctive approach involving the use of retractors and stay sutures allows the internal sphincter to be made prominent and secured without extensive dissection. The division of the internal sphincter is achieved through a minimal mucosal incision, requiring no closure and significantly reducing postoperative pain and complications. Between December 2020 and February 2022, 124 patients received transmucosal internal sphincterotomy, showing significant benefits with a median operative time of 7 minutes and low postoperative pain. With a 2.5% infection rate effectively managed and a 3% transient incontinence rate, the majority healed within 9 weeks. Recurrence was rare at 1.6%. Transmucosal internal sphincterotomy presents significant advantages over traditional internal sphincterotomy, including reduced pain, lower risk of complications, such as hematoma, abscess, or fistula formation, and the absence of painful postoperative nodules. The success of transmucosal internal sphincterotomy suggests that it should be incorporated into surgical education, offering a less daunting and more reproducible method for treating fissure in ano that is especially beneficial for junior surgeons and improving patient outcomes.

Management of Chronic Fissure in Ano: A Case Study on Conservative vs. Surgical Treatment Approaches

The conservative treatment arm includes dietary modifications, stool softeners, topical analgesics, and sitz baths. This approach focuses on symptom relief, promoting healing, and preventing recurrence. In contrast, the surgical intervention arm involves procedures like lateral internal sphincterotomy (LIS) or advancement flap repair. These techniques aim to address the underlying sphincter hypertonicity or poor blood supply to the fissure site. The case study will present two patient profiles: one managed conservatively and the other surgically. Parameters such as pain scores, healing rates, time to symptom resolution, and recurrence rates will be compared between the two groups. Additionally, quality of life metrics and patient satisfaction will be assessed. Insights from this case study can aid clinicians in selecting the most appropriate treatment modality for chronic anal fissures, considering factors such as severity, patient preference, and potential risks. Ultimately, the study seeks to contribute valuable evidence to the ongoing debate surrounding the optimal management strategy for this prevalent colorectal condition. Furthermore, the impact on the patient's quality of life and satisfaction with the chosen treatment approach is examined. Through a multidisciplinary approach involving gastroenterologists, colorectal surgeons, and the patient, this case study highlights the importance of individualized care and shared decision-making in managing chronic fissure in ano.

Comparative Analysis of Open and Closed Sphincterotomy for the Treatment of Chronic Anal Fissure: Safety and Efficacy Evaluation.

BACKGROUND Chronic anal fissure is a common condition that causes pain and discomfort and has a significant impact on quality of life. When conservative management fails, surgical sphincterotomy can be successful. This retrospective study from a single center in Turkey included 188 patients with chronic anal fissures and aimed to compare outcomes from open and closed sphincterotomy. MATERIAL AND METHODS This retrospective study included 188 patients treated with lateral internal sphincterotomy (LIS) for chronic anal fissure between January 2015 and December 2021 in our hospital. Open LIS procedure was performed in 91 patients and closed LIS was performed in 97 patients. Demographic characteristics, postoperative complications, and recurrence were compared for these 2 methods. RESULTS Of the 188 patients included in the study, 47.9% were women and 52.1% were men. The mean age was 42.9 (20-84) years. In the open LIS group, recurrence occurred in 2 patients (2.19%), and no incontinence was observed. In the closed LIS group, recurrence occurred in 3 patients (3%; P=0.703), and incontinence developed in 5 patients (5.15%; P=0.035). CONCLUSIONS Comparing the 2 methods used in chronic anal fissure surgery, and considering the recurrence and risk of incontinence, the most feared outcome by the patient and surgeon, open LIS stands out as a superior technique, especially in young male patients.

Enhanced Approach to Treating Chronic Anal Fissures: Fissurectomy with Vertical Non-full-thickness Midline Sphincterotomy and Mucosal Advancement Flap.

Lateral internal sphincterotomy is a conventional surgical intervention for chronic anal fissures, yet the potential for postoperative anal incontinence underscores the need for an alternative approach. This study aimed to evaluate the outcomes of patients with chronic fissures who underwent a combination of fissurectomy, vertical non-full thickness midline sphincterotomy (VNMS), and mucosal advancement flap (MAF), as a means of mitigating the risk of incontinence. This retrospective analysis included forty-six consecutive patients with chronic anal fissures, unresponsive to topical diltiazem, who underwent fissurectomy combined with VNMS and MAF between April 2018 and May 2023. Primary outcome measures encompassed fissure healing rates. Continence was assessed using the Fecal Incontinence Severity Index (FISI), and manometric assessments were conducted before the procedure and three months postoperatively. With a median follow-up of 27 months, there were no postoperative complications, and the overall fissure healing rate reached 96% (44/46). At three months post-procedure, FISI scores were reduced to 0, with no instances of fecal soiling. Anal resting pressure exhibited a significant reduction at 3 months [pre-op: 133 (95% CI, 128-150) vs. 3 mo: 109 (95% CI, 100-117) cmH2O; p = 0.01]. Similarly, maximum anal squeeze pressure showed a significant decrease three months post-surgery [pre-op: 317 cmH2O (95% CI, 294-380) vs. 3 mo: 291 cmH2O (95% CI, 276-359), p = 0.03]. The combination of fissurectomy, VNMS, and MAF proved to be an effective approach for chronic anal fissures, yielding favorable medium-term outcomes without postoperative anal incontinence.

Study of Open Hemorrhoidectomy Versus Open Hemorrhoidectomy Along with Internal Sphincterotomy in the Management of Post - Operative Pain

Study of Open Hemorrhoidectomy Versus Open Hemorrhoidectomy Along with Internal Sphincterotomy in the Management of Post - Operative Pain

Botulinum toxin injection for chronic anal fissure: a prospective controlled study with long follow-up.

Botulinum toxin is an effective therapeutic option for chronic anal fissure. However, there is no evidence about treatment standardization and long-term follow-up. We aimed to evaluate the short- and long-term efficacy and safety of botulinum toxin compared to close lateral internal sphincterotomy, with a 5-year follow-up. This was a prospective, controlled, single-center study conducted at University Hospital of Ferrara, Ferrara, Italy. The primary outcome was fissure healing at 1 month. Secondary outcomes were Quality-of-Life (QoL) at 1 month and after 5 years, and fissure recurrence at 6 months and 5 years. A total of 59 patients received botulinum toxin injection (Botox), and 32 underwent lateral internal sphincterotomy. At 1 month after treatments, postoperative pain decreased faster and significantly more in the Botox group (30 vs. 60 mm; P<0.001); fissure re-epithelization was observed in 59.4% of the surgical group compared to 25.4% of Botox (P=0.0001). Anal sphincter pressures decreased more in surgical group (P=0.044), although severe anal incontinence was present only in this subset (6.2%; P=0.041). Compared to surgery, patients who received Botox had higher satisfaction rates (P<0.001). Fissure recurrence at 6 months was more common in Botox than surgical group (16.9% vs. 3.2%, respectively; P=0.053). The overall healing rate improved in all patients and persisted at 12 months and 5 years in both groups with overall high patient satisfaction despite mild anal incontinence in 21.8% in the surgery group (P<0.05). Botox, rather than surgery, should be considered the first-line treatment for chronic anal fissure.

Outcomes Following Intrasphincteric Injection of Botulinum Toxin for Treatment of Anal Fissures.

Background Intrasphincteric injection of botulinum toxin is an alternative treatment for anal fissures, which may present less risk of fecal incontinence than more invasive procedures, such as lateral internal sphincterotomy. The aim is to compare cure and complication rates between these two treatments. Methods We conducted a retrospective audit of patients who underwent treatment of anal fissures with intrasphincteric botulinum toxin or lateral internal sphincterotomy from 2016 to 2020 at the Colorectal Surgery Unit of Monash Health, Melbourne, Australia, excluding those who had previously had either procedure. Results Fifty-one patients received intrasphincteric botulinum toxin, and 40 patients underwent lateral internal sphincterotomy. Most patients in the botulinum group had a total dose of either 80 (53%; n=27) or 100 units (37%; n=19) and had the dose administered bilaterally at the 3 o'clock and 9 o'clock positions (n=41; 80%).Thirty-one patients in the botulinum group (61%) had complete resolution of symptoms, with a mean time to cure of two months, compared to 36 patients (90%) in the sphincterotomy group with a mean time to cure of 1.5 months. In most cases, postoperative incontinence was transient, although one patient in the botulinum group had persistent incontinence of flatus, and two patients in the sphincterotomy group had persistent fecal incontinence. Conclusion Intrasphincteric botulinum injection is an effective, less-invasive alternative to sphincterotomy for the treatment of anal fissures, with incontinence usually temporary when it occurs. Further research is needed to optimize the dose and location of injection and guide future recommendations.

Close lateral internal sphincterotomy versus open lateral internal sphincterotomy for chronic anal fissure: a systematic review and meta-analysis

Background: Lateral internal sphincterotomy (LIS) has been the gold standard for treating chronic anal fissure (CAF) that persists despite other measures. The authors aim to evaluate the effects of the close method (CLIS) of performing LIS as compared to the open method (OLIS). Methods: Databases were searched for relevant studies and results were screened to identify eligible articles, and all concerned outcomes were pooled as odd ratio (OR) or mean difference (MD) with 95% CI in the meta-analysis models using RevMan 5.4. Results: Pooled data from 16 trials with 1,711 patients with idiopathic CAF showed that the CLIS has significant lower risk of delayed fissure healing [OR: 0.28, 95% CI (0.10, 0.77), P = 0.01], duration of hospital stay [MD: -0.82 with 95% CI (−1.07, −0.57), P &lt; 0.00001] and postoperative visual analogue pain score (VAPS) at 24 h [MD: −0.30 with 95% CI (−0.39, −0.21), P &lt; 0.00001]. Also, the risk of overall complications [OR: 0.33 with 95% CI (0.19, 0.55), P &lt; 0.0001], incontinence [OR: 0.28 with 95% CI (0.20, 0.38), P &lt; 0.00001], and postoperative pain [OR: 0.56 with 95% CI (0.35, 0.91), P = 0.02] was significantly lower with CLIS. Conclusion: CLIS is a safer option than OLIS for treating anal fissure. The risk of delayed fissure healing, incontinence, post-op pain and overall complication was significantly lower. However, the risk of surgical site infection, postoperative bleeding and recurrence did not differ. Future research with more prolonged follow-up is necessary to document recurrence reliably.

Initial Outcome of Lateral Internal Sphincterotomy with or without Fissurectomy in the Surgical Management of Chronic Anal Fissure

Chronic anal fissure is a common proctological condition characterized by severe pain and bleeding during defecation. Surgical intervention is often required for chronic cases unresponsive to conservative treatment. This study aims to compare the outcome of lateral internal sphincterotomy (LIS) with and without fissurectomy. In this single-centered study, 50 purposively selected patients with chronic anal fissures were divided into two groups: Group A underwent LIS with fissurectomy, while Group B underwent only LIS. The primary outcomes measured were postoperative anal pain relief and fissure healing rates, while secondary outcomes included hospital stay duration and the occurrence of complications such as anal discharge, pruritus, bleeding spot, urine &amp; stool incontinence. Group A showed a significant reduction in postoperative pain within 3 days (60% of patients) compared to Group B, which showed relief within 6-8 days (32% of patients). Fissure healing times were faster and hospital stay duration were shorter in Group A, with a mean duration of 5.12±1.616 days versus 8.32±3.18 days in Group B. The incidence of postoperative complications was lower in Group A, with anal discharge occurring in 16% of patients compared to 44% in Group B. These above differences were statistically significant. The study demonstrates that LIS with fissurectomy may offer better outcomes in the treatment of chronic anal fissures than LIS alone, including faster pain relief, improved healing rates and fewer postoperative complications. Given the limitations of a small sample size and single-center design, larger multi-center trials are recommended to confirm these findings and potentially adjust clinical practice guidelines.

Effectiveness and safety of botulinum toxin injection in the treatment of recurrent anal fissure following lateral internal sphincterotomy: cohort study.

Effectiveness and safety of botulinum toxin injection in the treatment of recurrent anal fissure following lateral internal sphincterotomy: cohort study.

Does routine partial lateral sphincterotomy with open hemorrhoidectomy improve postoperative pain?

Objective In this study we aimed to detect the difference regarding the postoperative pain and continence in patients with third and fourth degree hemorrhoidal disease who underwent either hemorrhoidectomy alone or combined hemorrhoidectomy with partial internal sphincterotomy for the treatment of hemorrhoidal disease. Patients and methods This prospective comparative randomized clinical trial was conducted at hospitals of Tanta University during the period from March 2021 to August 2022 on 100 patients with third or fourth degree hemorrhoids who were randomly assigned either to group A, patients who only underwent hemorrhoidal excision by the classical technique of Milligan–Morgan or group B, with added partial lateral sphincterotomy to the classic technique. All patients in both groups underwent anorectal manometry both preoperatively and postoperatively. Pain following surgery was analyzed by using visual analog scale system at 24 h, 48 h, and on 10th postoperative day, other complications including incontinence, infection, hematoma, bleeding, and anal stricture were evaluated at 24 h, 48 h, 10th postoperative day, 1 month, and after 3 months. Results Total 100 patients were divided among both groups. The mean age of the patients was 37.7±11.3 and 36.3±11.3 years in group A and group B, respectively. Thirty-two males and 18 females were in group A in comparison to 33 males and 17 females in group B. During follow-up periods, patients in group B had less postoperative pain than those in group A with statistically significant difference. None of the patients developed fecal incontinence for solid or liquid stools in both groups, except for nine patients developed only mild degree of incontinence for flatus in the first week that improved gradually till completely resolved before the end of the 3 months follow up. Conclusion The addition of partial internal sphincterotomy to the classical haemorrhoidectomy technique significantly improves postoperative pain without increasing overall related morbidity.

Comparative Study of Lateral Internal Sphincterotomy versus Local 0.4% Glyceryl Trinitrate Ointment for the Treatment of Chronic Anal Fissure

Objectives: To compare the outcomes of “Lateral Internal Sphincterotomy (LIS)” versus local “0.4% Glyceryl Trinitrate (GTN)” ointment for the treatment of chronic anal fissure. Study Design and Setting: Randomized controlled trial, Combined Military Hospital (CMH) / Pak Emirates Military Hospital (PEMH), Rawalpindi from October 2022 to March 2023. Methodology: A total of 100 patients [50 in GTN group and 50 in LIS group] who underwent treatment for chronic anal fissure were included in study. Patients in both groups were followed up at eight weeks after the surgery to assess for the outcomes including anal pain healing and recurrence of fissure. Data was analyzed by SPSS 22.00. Results: In our study, mean age was 30.48 ± 5.82 years. 61 (61.00%) were male while 39 (39.00%) were female. Mean duration of having anal fissure was 10.69 ± 2.59 weeks. Mean post-therapy pain VAS at week 8 follow up in “GTN” group was 0.64 ± 1.06 while in “LIS” group it was 0.16 ± 0.37, (p = 0.003). Complete healing of chronic anal fissure was achieved in 35 (70.00%) in “GTN” group while in “LIS” group healing was achieved in 42 (84.00%), (p = 0.096). Recurrence occurred in 2 (4.00%) of patients in “GTN” group and none in “LIS” group, (p = 0.153). Conclusion: “Lateral Internal Sphincterotomy (LIS)” is a better treatment option for management of chronic anal fissure.

Surgical management of post hemorrhoidectomy benign anal stenosis - an experience of eleven patients

Anal stenosis is a serious but fortunately rare complication of anorectal surgical procedures. It has been shown that approximately 90% of anal stenosis develops after hemorrhoidectomy, and 1.5-3.8% of all hemorrhoidectomies. The surgical methods such as stricture release, sphincterotomy and advancement flap are common techniques to repair anal stenosis. This is a retrospective observational study of 11 patients with benign anal stenosis managed surgically from January 2017 to April 2022. A total of 11 patients (nine males and two females), mean age 45.6 years (range- 33-90 years), underwent various surgical procedures like partial lateral internal sphincterotomy (PLIS) (n=04), V-Y flap anoplasty (n=03) and diamond flap anoplasty (n=04) with PLIS in both types of anoplasties as an associated procedure. After follow up period of two months to three years, all patients of PLIS had 100% healing rate, V-Y flap anoplasty had 66% healing rate with re-stenosis in one patient and diamond flap anoplasty had 100% healing rate with no restenosis. In moderate to severe anal stenosis and failed conservative management, various anoplasty techniques can be used with lateral sphincterotomy with good results, especially diamond flap anoplasty.