Outcome of Lateral Internal Sphincterotomy as Compared to Manual Anal Dilatation
Background Fissure in ano (anal fissure) is a common anorectal condition. Concern is drawn here because if acute, the degree of patient discomfort and disability far exceeds that which might be expected for any otherwise rather trivial lesion. Objectives The study evaluated the outcome of lateral internal sphincterotomy as compared to manual anal dilatation as a basis for future practice. Anal fissure can be classified into two: acute and chronic fissure. It can occur at any age: but is usually a condition of young adults. Sex distribution is males to females is I: I, however, women are much more likely to develop this condition than men. Fissures in ano can occur anteriorly at 12 o'clock or posterior at 6 O'clock. They are commonly found in the midline, this is because of the elliptical arrangement of the external sphincter, which is felt to provide less support to the anal canal in the antero-posterior axis thus rendering this location most susceptible to trauma. Blood supply, which is already tenuous, may be further compromised by compression and contusion as the branch of the inferior rectal artery passes through the internal anal sphincters. Clinical diagnosis of fissure in ano is made from history and physical examination. Setting A prospective study carried out at Kenyatta National Hospital wards 5A, 5B and 50. Methods and patients In the study period of nine months, from June 2004 to February 2005, both months inclusive, we sampled seventy-eight patients of whom forty underwent lateral internal sphincterotomy and thirty-eight underwent manual anal dilatation (Lords procedure). Procedures were carried out under spinal or general anaesthesia Early complications noted were such as bleeding and haematoma formation. These were noted immediately after surgery and up to 24 hrs post surgery. Late complications were noted from the third day, and these were such as incontinence of flatus, incontinence of stool, pruritus ani, and abscess formation. Result Fifty six percent of the patients who underwent manual anal dilatation developed stool incontinence while none developed this with lateral internal sphincterotomy. Eighty four point eight percent of those who underwent manual anal dilatation developed incontinence of flatus. While 15.2% of those who underwent lateral internal sphincterotomy developed incontinence of flatus. Eighty percent developed pruritus ani in manual anal dilatation while 20% developed this in lateral internal sphincterotomy. Abscess formation was seen in 92(10 of those who underwent manual anal dilatation while 8% of this was seen in lateral internal sphincterotomy. On discharge the patients were reviewed and the early complications resolved. Late complications were seen up to four weeks post surgery these resolved with time and conservative management. This tells us that complications were temporary. Those who underwent lateral internal sphincterotomy had a short duration of stay in hospital while those who underwent manual anal dilatation had a longer duration of stay for the complications to be treated. Recurrence was found to be more in manual anal dilatation than lateral internal internal sphincterotomy whereby of those who underwent MAD, 14 (36.8%) had recurrence whereas in LIS 8 (20%) had recurrence. The study showed that more men suffered than women to the ratio of 1.66: I. More complications were seen with manual anal dilatation than lateral internal sphincterotomy therefore patients were forced to stay longer in hospital for the complications to be treated. Since our patients came to us after two months (chronic fissures) conservative management had no role. Therefore, lateral internal sphincterotomy remains the attractive option for many patients suffering from this painful condition.