Combined Tailored Lateral Internal Sphincterotomy with V- Y Advancement Flap Versus Lateral Internal Sphincterotomy Alone in Treatment of Chronic Anal Fissure

Background: Anal fissure is one of the most common ano-rectal diseases and 10% of patients ultimately receive surgery. Lateral internal sphincterotomy is highly effective and is the surgical treatment of choice for curing chronic anal fissure with hypertonicity after failure of conservative measures. LIS has a high success rate, but can have complications as bleeding and incontinence. There can be delayed or non healing of the sphincterotomy surgical site, and persistence of symptoms or recurrence of fissure. The Aim of the Study: Was to evaluate the results of VY advancement flap combined with tailored open lateral internal sphincterotomy in comparison with open lateral internal sphincterotomy alone in treatment of chronic anal fissure. Patients and Methods: Between April 2011 and December 2012, twenty patients fulfilling the criteria of having chronic anal fissure with persistence of symptoms inspite of conservative treatment for a period of 4-6 weeks were randomly assigned into two treatment groups. Group A was assigned to do open lateral internal sphincterotomy (LIS) alone, while in Group B, Tailored lateral Internal sphincterotomy (TLTS) combined with V-Y advancement anal flap was done. Response to the treatment was assessed in terms of postoperative pain, time and rate of fissure healing and occurrence of complications. Follow-up of the patients was done every week for three months to detect short term postoperative outcomes and every 3 months for one year to detect recurrence. Results: In Group B, no severe pain was present and less time interval and doses for analgesia was observed. By the end of second week 90% in Group B showed complete healing and acceptance of V-Y-flap wheras only 20% showed complete healing in Group A. By the end of fourth week the rest of patients in Group A showed complete healing except one patient with failure of healing due to infection. Postoperative Bleeding, and infection was found in Group A and flap dehiscence was present in one patient in Group B. Soiling was noticed in all patients of Group A, during first and second Correspondence to: Dr. Tarek Hegazi, The Department of General Surgery, Faculty of Medicine, Cairo University week while in Group B, soiling was present in three patients only on the first day. No incontinence was observed in Group B and only one patient in Group A showed incontinence with no recurrence in both groups. Conclusion: Tailored lateral internal sphincterotomy with V-Y advancement flap appears to produce the greatest and rapid healing rate, with few complications and no incontinence and recurrence rate.