Objectives: To compare surgical and functional outcome of segmental lateral internal sphincterotomy (SLIS) versus conventional lateral internal sphincterotomy (CLIS) for treatment of chronic anal fissure (CAF).Patients & Methods: The study included 120 patients with CAF divided randomly into two equal groups: Group C included patients assigned for CLIS and group S included patients assigned for SLIS. All patients underwent clinicalexamination and evaluation of pain severity during defecation and rest using 10-points pain visual analogue scale (VAS). Operative technique for SLIS included LIS for about 50% of internal sphincter midway between 4 and 5 O'clock and another incision for about 50% of internal sphincter at 3 O'clock; both incisions are about 1cm apart. For group C, LIS was done from anoderme up to dentate line or fissure apex. Wounds were left open to heal with secondary intention and sentinel pile was removed. Operative data included operative time, intraoperative bleeding or complications, surgical wound pain, time till oral intake and hospital discharge. Impact of LIS on continence was evaluated using the modified Wexner score at postoperative (PO) 1-week, 1-month and 3-months. Results: All patients passed uneventful intraoperative course with non-significant difference between both groups concerning operative and immediate PO data. Pain VAS scores determined at 1-m and 3-m PO were significantly lower in both groups at both rest and defecation compared to preoperative pain scores with significantly lower scores at 3-m compared to at 1-m PO in both groups. Pain scores at 1-m and 3-m PO were significantly lower in SLIS compared to CLIS. No patient had solid stool incontinence, 13 had liquid and 26 had flatus incontinence with significantly higher frequency of incontinent patients in group C compared to group S. For each of questionnaire items, incontinent CLIS patients were more frequent among usually and sometimes strata, while SLIS patients were more frequent among rarely and sometimes strata. Patients of both groups showed time-steep improvement of their continence with the difference in favor of SLIS. The impact of inconntinence on patients' quality of life showed progressive improvement with time and was in favor of SLIS.
Conclusion: Open segmental LIS for 100% (50% + 50%) of internal sphincter at two levels about 1 cm apart is appropriate therapeutic modality for CAF with acceptable surgical outcome and improved functional outcome manifested as perfect continence, regular pain-free bowel habit and improved quality of life. |
