An anal fissure is a common and distressing anorectal condition characterized by a longitudinal tear in the anoderm, typically extending distal to the dentate line.1 It presents most frequently with intense pain during defecation and is often accompanied by bright red rectal bleeding.2 The severity of the pain, often described as a sharp, burning sensation, significantly impairs the quality of life and can lead to emotional stress, anxiety, and even defecatory avoidance.3,4 The condition can be either acute or chronic, depending on its duration and response to conservative therapy. Approximately 90% of anal fissures are located in the posterior midline, while anterior fissures, though less common (around 10%), are more frequently observed in women5. Acute fissures are generally self-limiting and may heal within two weeks with conservative management6. In contrast, chronic fissures persist beyond 6–8 weeks and often become fibrotic with the development of a sentinel pile, hypertrophied anal papilla, and visible exposure of internal sphincter fibers. Chronic fissures are less responsive to medical treatment and thus may require more definitive surgical intervention7.The primary aim in managing anal fissure is to reduce the resting pressure of the internal anal sphincter, which is often elevated due to spasm, contributing to ischemia and delayed healing8. Initial management includes conservative measures such as increased dietary fiber, stool softeners, warm sitz baths, and topical anesthetics9. The American Society of Colon and Rectal Surgeons (ASCRS) recommends these modalities as the first-line treatment for acute fissures. Pharmacological therapies, often termed “chemical sphincterotomy,” include the topical application of glyceryl trinitrate, calcium channel blockers (e.g., diltiazem), and botulinum toxin injections. These aim to relax the internal anal sphincter temporarily, promoting healing of the fissure10.Despite the effectiveness of these nonsurgical approaches, recurrence and incomplete healing are common, especially in chronic fissures. Success rates of chemical sphincterotomy range from 65% to 75%, and relapse is not uncommon. Hence, when conservative and pharmacologic therapies fail, surgical intervention becomes necessary. Lateral internal sphincterotomy (LIS) has emerged as the gold standard surgical technique for chronic anal fissures over the past few decades. The procedure involves partial division of the internal sphincter to relieve spasm, thereby promoting healing. 11Numerous studies report a success rate ranging from 96% to 100%, with rapid symptomatic relief and low recurrence. However, LIS is not without potential complications. Although most patients recover uneventfully, complications such as wound infection, fistula formation, and minor bleeding may occur in a small percentage of cases. The most concerning long-term complication is fecal incontinence, which can range from transient flatus incontinence to, in rare cases, persistent fecal leakage. Reported incontinence rates vary widely, from less than 5% to as high as 30% in some series, often depending on patient selection, surgical technique, and postoperative care.

This study was designed to evaluate the safety, efficacy, and complication profile of LIS in patients with chronic anal fissures.12 We analyzed preoperative complaints, postoperative pain relief, recurrence rates, and incidence of incontinence to determine the overall success and patient satisfaction following LIS.

AIM

A Clinical Study to Evaluate the Outcome of lateral internal sphincterotomy in the Treatment of Chronic Anal Fissure.

This prospective observational study was conducted over six months, from August 2023 to March 2024, in the Department of General Surgery at Government R.D.B.P. Jaipuria Hospital, Jaipur, affiliated with RUHS-CMS. The study aimed to evaluate the outcomes and safety profile of lateral internal sphinctertomy in patients with chronic anal fissure. A total of 50 patients aged between 20 and 55 years, clinically diagnosed with chronic anal fissure lasting more than six weeks, were included. Detailed clinical history, symptom severity, and fissure characteristics were recorded. Patients with Crohn’s disease, ulcerative colitis, HIV, haemorrhoids, fistula, malignancy, or those managed conservatively were excluded. LIS was performed under spinal or local anesthesia by making a small incision at the intersphincteric groove and dividing the lower one-third of the internal anal sphincter under direct vision to relieve sphincter spasm. Postoperative follow-up was done to assess pain relief, wound healing, complications like incontinence, and recurrence. Data was analyzed to determine safety and effectiveness.

Table 1: Gender Distribution

In the present study, 60% of the patients were male (n=36) and 40% were female (n=24). Thus, a male predominance was observed among the study participants.

Table 2:Age-wise Distribution

In this study, the majority of patients (30%) belonged to the 31–40 years age group, followed by 23.3% in the 41–50 years group and 20% in the 20–30 years group. The 51–60 years age group comprised 16.7% of the participants, while only 10% were aged above 60 years. This indicates that most cases occurred in individuals between 31 and 50 years of age.

Table 3: Complaints:

All patients (100%) in the study presented with pain during defecation, making it the most common symptom. Bleeding per rectum was observed in 86.7% of cases, followed by constipation in 63.3%, and sentinel pile or tag in 56.7%. Pruritus ani was the least common symptom, seen in 33.3% of the patients.

Table 4: Operative Details

All patients (100%) underwent Lateral Internal Sphincterotomy (LIS), with 75% undergoing Closed LIS (CLIS) and 25% undergoing Open LIS (OLIS). Local anesthesia was the most commonly used, administered in 58.3% of patients, followed by spinal anesthesia in 25%. General anesthesia was used in 16.7% of cases.

Table 5: Healing Rate

At 2 weeks, 20% of patients had complete healing, which increased significantly to 63.3% by 4 weeks. By 6 weeks, a total of 13.3% more patients had healed. Only 3.3% experienced delayed healing beyond 6 weeks.

Table 6: Post -op Complications

Minor complications were observed in a few patients following LIS. Incontinence to flatus was the most common (8.3%), followed by minor bleeding in 6.7% and wound infection in 3.3%. Incontinence to liquid stool and abscess/fistula were seen in only 1.7% of patients each.

In the present study of 60 patients with chronic anal fissure, the majority were females (60%) and the most commonly affected age group was 21–30 years (48.3%). This aligns closely with the findings of Mapel et al. (2014),13 who reported a female predominance (58%) among 1,243 patients. Age-specific trends in the Mapel study showed the highest incidence in the 25–34-year age group (0.18%), which is comparable to the 21–30-year peak in the current study. Pediatric cases were infrequent in both datasets—only 3.3% of patients were under 10 years in the present study, while 12% of cases in Mapel et al. occurred in the 6–17-year age group. Overall, both studies indicate that anal fissures are more common in young adults and slightly more prevalent in females.

In my study, patients with chronic anal fissure predominantly presented with pain during defecation, which was the most distressing symptom reported. This was often accompanied by bleeding per rectum, typically seen as streaks of blood on the stool or toilet paper. Constipation was another frequent complaint, likely contributing to the persistence and worsening of the fissure due to repeated trauma to the anal mucosa. A smaller subset of patients also experienced pruritus ani and occasional perianal discharge, reflecting ongoing inflammation and irritation. These symptoms align closely with the classical presentation of chronic anal fissure observed in clinical practice.In comparison, the retrospective cohort study conducted by Al-Thoubaity et al. (2020) 14involving 691 female patients reported a similar symptom profile. The major presenting complaints in their cohort included pain, bleeding, constipation, pruritus, and perianal discharge. This close similarity in symptomatology between the two studies underscores the consistent nature of the clinical presentation of chronic anal fissure across different populations and study settings. It also highlights the significance of addressing these symptoms effectively for patient relief and treatment success.

In our study involving 60 patients with chronic anal fissure, all underwent Lateral Internal Sphincterotomy (LIS), with the closed technique being performed in 75% of cases and the open technique in 25%. This preference toward the closed approach aligns with the evidence from a pooled analysis of 16 clinical trials involving 1,711 patients with idiopathic chronic anal fissure. The meta-analysis by Tanveer 15demonstrated that the closed LIS (CLIS) technique significantly reduces the risk of delayed fissure healing (OR: 0.28, 95% CI: 0.10–0.77, P = 0.01), shortens hospital stay (MD: –0.82 days, 95% CI: –1.07 to –0.57, P < 0.00001), and lowers postoperative pain at 24 hours (MD: –0.30, 95% CI: –0.39 to –0.21, P < 0.00001). Furthermore, CLIS was associated with fewer overall complications (OR: 0.33), reduced risk of incontinence (OR: 0.28), and lower postoperative pain (OR: 0.56). These findings strongly support the use of CLIS and are consistent with our study’s outcomes, reaffirming its clinical advantage in terms of safety, reduced morbidity, and better postoperative recovery.

In our study of 60 patients undergoing Closed Lateral Internal Sphincterotomy (CLIS) for chronic anal fissure, local anesthesia was used in 58.3% of cases, spinal anesthesia in 25%, and general anesthesia in 16.7%, with local anesthesia being preferred due to its simplicity, safety, and faster recovery. A comparative study by Manoharan, Ravikumar16 involving 79 patients, with 42 receiving local anesthesia and 39 spinal anesthesia, found no statistically significant difference in healing rate, pain, infection, or incontinence between the two groups. However, the local anesthesia group had lower costs, shorter hospital stays, and fewer anesthesia-related risks. This comparison supports our findings and highlights that local anesthesia is not only clinically effective but also offers practical advantages, making it a favorable choice for LIS procedures.

In our study of 60 patients undergoing Closed Lateral Internal Sphincterotomy (CLIS), the healing rate was assessed at regular intervals. At 2 weeks, 12 patients (20%) had complete healing, which increased significantly by the 4th week, where 38 patients (63.3%) showed complete healing. By the 6th week, 8 additional patients (13.3%) had healed. Only 2 patients (3.3%) experienced delayed healing beyond 6 weeks. The majority of patients, therefore, achieved complete healing within the first month after surgery. These findings indicate a favorable early recovery profile following CLIS. The healing pattern observed in our study is consistent with standard postoperative expectations for LIS.

In our study of 60 patients undergoing Closed Lateral Internal Sphincterotomy (CLIS), postoperative complications were minimal and manageable. Minor bleeding was observed in 4 patients (6.7%), while 5 patients (8.3%) experienced transient incontinence to flatus. Incontinence to liquid stool occurred in only 1 patient (1.7%), and it resolved without long-term issues. Wound infection was reported in 2 cases (3.3%) and was successfully treated with antibiotics. Additionally, 1 patient (1.7%) developed a postoperative abscess or fistula. Overall, the complication rate was low and within acceptable limits. These outcomes affirm the safety and effectiveness of the CLIS procedure.

In conclusion, the present study reinforces the efficacy and safety of Closed Lateral Internal Sphincterotomy (CLIS) as a primary treatment for chronic anal fissure. The majority of patients experienced rapid symptom relief and significant healing within 4 weeks. Complications were minimal and self-limiting, with low rates of incontinence and infection. The preference for local anesthesia proved to be both clinically effective and economically advantageous. The results are consistent with existing literature, supporting CLIS as a reliable, minimally invasive option. Overall, CLIS offers a favorable recovery profile and improves quality of life in affected patients.

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