الفهرس 
IntroductionOnly 14 pages are availabe for public view
 |  | from | 115 |  |  |
| | | from | 115 | | |
Abstract
Anal fissure is one of the most common causes of severe anal pain. It commonly affects young and middle-aged adults. Anal fissures occur with equal frequency in both sexes. It is a linear ulcer, which occurs just distal to dentate line and is characterized by severe pain during and after defecation and passage of bright red blood. Most of the anal fissures are short-lived and heal spontaneously. If the fissure fails to heal within six weeks then it requires definitive treatment as it is associated with hypertonia of internal anal sphincter (Utzig MJ et al., 2003). The pathogenesis of chronic anal fissure remains incompletely understood but most are associated with a high resting anal pressure and reduced perfusion of blood at the fissure site due to persistent hypertonia and spasm of internal anal sphincter [Utzig MJ et al., (2003) and Jenkins JT et al., (2008)]. The relief of internal anal sphincter spasm is the key for providing fissure healing, that is why all the methods of treatment of chronic anal fissure are directed at reducing the spasm of the internal anal sphincter [Collins EE et al ., (2007) and Suknai S et al ., (2008)]. Medical treatment of the anal fissure relies on application of local anesthetics and stool softeners and the addition of high fiber diet, nitroglycerine paste and botulinum toxin. Many fissures heal in this way, especially the acute anal fissure. When a fissure becomes chronic, surgery is recommended. As 1-manual dilatation of the anus (Lord’s dilatation), 2- Fissurectomy (not a routine operation now a days) and 3-Internal sphincterotomy, which may be done by open or closed method, Among many treatment modalities for chronic anal fissure lateral internal sphincterotomy remains the first line of treatment [Mazier WP et al., (1995) and Nahas SC et al., (1997)]. In various studies the lateral internal sphincterotomy was found to be safe and simple operation if done by skilled proctologic surgeons (Simkovic D et al., 2000). Aim of theWork: This study was designed to compare the postoperative complications and the results of closed and open technique of lateral internal sphincterotomy. Place and duration of the study: Surgical department, Menoufiya University Hospital. from June 2011to May 2012. Patients and Methods: Thirty patients with chronic anal fissure were included in the study after taking informed consent. Fifteen patients were randomized into each group (A & B). Group ‘A’ patients were treated by open (A 1cm curvilinear or transverse incision is made overlying the intersphincteric groove. The intersphincteric plane is opened by scissor or forceps.The sphincter is then identified and elevated. The lower 1.5 cm of the internal anal sphincter was divided. Homeostasis was made and the wound was left open for drainage, and anal sponge was inserted for 6 hours), while those in Group ‘B’ were treated by the closed technique under general anesthesia (GA) or caudal anesthesia (A 1cm curvilinear incision is made overlying the intersphincteric groove ,the knife is positioned in a similar position as with open sphincterotomy, but the difference is that the knife is inserted in the intersphincteric groove, rotated 90°, and advanced toward the anal mucosa. Haemostasis is achieved by direct pressure, and this puncture wound is not closed). Patients were discharged and called/ contacted for follow up after six weeks and six months. Results: Thirty patients (12 males and 18 females), aged 20 to 48 years with chronic anal fissure had lateral internal sphincterotomy. Satisfactory pain relief (more than 50% reduction) was equivalent, 14 (93.33%) in Group A compared to 13 (86.66%) in Group B. Immediate/ early complications were equivocal as only one patient with open technique developed post-operative hemorrhage and one with closed sphincterotomy had hematoma formation. There were no cases of infection/ abscess formation. Among late complications, recurrence was slightly more common in closed sphincterotomy (2/15 compared to 1/15), while there was a slightly higher incidence (2/15 compared to 1/15) of incontinence in open technique. None developed postoperative fistulae. CONCLUSION: There is no significant difference between open and closed lateral internal sphincterotomy in terms of symptomatic relief and postoperative complications in patients of chronic anal fissure.