Anal fissure is defined as a linear ulcer or tear in the anoderm, most commonly occurring distal to the dentate line. It typically presents in the posterior midline of the anal canal due to anatomical and vascular predisposition. An anal fissure lasting less than six weeks is classified as acute, while persistence beyond six weeks indicates chronicity. Chronic anal fissures often present with characteristic features such as sentinel pile, hypertrophied anal papilla, and exposure of internal sphincter fibers at the base of the ulcer. The most common etiological factors include chronic constipation, passage of hard stools, and prolonged straining during defecation. These repeated mechanical traumas not only contribute to fissure formation but also trigger a vicious cycle involving increased internal sphincter tone, leading to severe pain during defecation. This pain causes voluntary sphincter spasm, resulting in further ischemia and impaired healing, perpetuating the cycle of chronic fissure. Clinically, patients typically present with sharp, agonizing pain during and after defecation, often accompanied by bleeding per rectum, seen as blood streaks on the stool or staining of toilet tissue. Chronic anal fissure is frequently encountered in surgical outpatient departments and remains a common cause of morbidity. Manometric studies have consistently demonstrated that patients with chronic anal fissures exhibit increased resting pressure of the internal anal sphincter and reduced anodermal blood flow at the base of the fissure. This local ischemia further impairs healing and contributes to the chronic nature and recurrence of the ulcer. Based on this pathophysiological understanding, modern treatment approaches aim to reduce sphincter tone and restore perfusion, thereby facilitating healing. Management of chronic anal fissure can be broadly categorized into conservative (non-surgical) and surgical options. Initially, all patients are offered conservative therapy, which includes warm sitz baths , stool softeners , laxatives , topical agents such as 2% diltiazem , 0.2% glyceryl trinitrate (GTN) , local anesthetics like lignocaine, oral analgesics, and dietary modification (high-fiber intake and avoidance of junk food). However, in cases where conservative management fails to provide symptomatic relief, surgical intervention becomes necessary. Surgical options include Botox injection, Lord’s anal dilatation, and lateral internal sphincterotomy (LIS). While each modality has demonstrated efficacy, LIS is generally considered superior by many surgeons due to its lower recurrence rates and predictable outcomes. In contrast, Lord’s dilatation has faced criticism due to higher recurrence rates (ranging from 2% to 80%) and incontinence rates reported up to 51% in uncontrolled procedures. Nonetheless, when performed carefully in a controlled and standardized manner, Lord’s procedure can yield excellent outcomes with minimal complications. The most commonly reported postoperative complications in both techniques include bleeding, pain, persistent constipation, incontinence, and ulcer recurrence. In our institutional setting, both LIS and Lord’s dilatation are practiced routinely. However, there exists a lack of robust comparative data evaluating their outcomes based on objective scoring systems. Hence, this study aims to compare the efficacy and safety of LIS and Lord’s anal dilatation in terms of pain relief, ulcer healing, constipation improvement, incontinence, and recurrence rates. Outcome measures include the Wong-Baker Facial Pain Rating Scale for pain assessment, the Modified Longo Score for constipation evaluation, and Wexner’s Score for fecal incontinence. By employing these validated scoring systems, this study intends to provide a quantitative comparison of the postoperative outcomes associated with the two procedures in the treatment of chronic anal fissure.

AIM

Study to compare postoperative outcomes of lord’s anal dilatation and lateral anal sphincterotomy in chronic anal fissure.

This prospective observational study was conducted in the Department of General Surgery, Government R.D.B.P. Jaipuria Hospital, affiliated with RUHS-CMS, Jaipur. It included patients undergoing lateral internal sphincterotomy or Lord’s anal dilatation between August 2023 and March 2024. On average, 1 to 3 out of every 100 OPD patients presented with chronic anal fissure. Patients aged 18 to 60 years of both sexes who consented were included. Exclusion criteria were age <18 or >60 years, known cases of gastrointestinal tuberculosis, Crohn’s disease, ulcerative colitis, HIV, hemorrhoids, or refusal for surgery. Only patients fit and willing for surgical intervention were selected. The study aimed to compare surgical outcomes. Validated scoring systems were used postoperatively.

Table 1: Distribution of patients according to their Age Group

The mean age of the patients included in our study population was 32.12(7.73). The majority of patients belong to the age group 26-35 years which is 44% followed by 28% of the age group 36-45 years and 24% in ≤ 25 years age group. The minimum number of patients belonged to the age group above 45 which is 4%.

Table 2: Distribution of patients according to their Bleeding per Rectum in LAD & LIS

Table 3 represents the distribution of bleeding per rectum in LAD and LIS. We found that it continuously decreased after operation in preoperative 46% & 48% in LAD and LIS. During hospital stay it decreased 12% & 16% in LAD and LIS. After 1 week it became 4% & 6% then after 15 days and 1 month there were no patients bleeding in LIS & LAD 0%.

Table 3: Distribution of patients according to their Recurrence in LAD & LIS

LAD and LIS after 15 days LAD operative recurrence is 4% and in LIS are 0%. In after 1 month it's 10% in LAD and 0% in LIS.

Table 4: Association between Type of surgery and Incontinence

The above table shows association between type of surgery and incontinence in which in LIS there are zero cases present in LIS and in LAD there are 3 cases of Incontinence present. 

Anal fissure, a common anorectal disorder first described by Recamier in 1829, is a linear, oval or elliptical tear of the anoderm distal to the dentate line. It typically begins at the anal verge and extends proximally for a variable length. Affecting individuals of all ages, it is a distressing condition often managed initially with lifestyle modifications, dietary changes, and medications.

There were a total of 50 patients in this study. In 26-patients lateral anal sphincterotomy had been done and 24 patients had lord’s anal dilatation done .Out of 50 patients 29 patients were females and 21 patients were males. distribution of patients according to their gender in which majority of patients are female which is 58% of the study rest 42% are male. The mean age of the patients included in our study population was 32.12 with standard deviation of (7.73). The majority of patients belong to the age group 26-35 years which is 44% followed by 28% of the age group 36-45 years and 24% in ≤ 25 years age group. The minimum number of patients belonged to the age group above 45 which is 4%. Mean age and incidence of chronic anal fissure among male and females was compared to following studies. Arunkumar Uttam et al study showed the majority of populations consisted of females with male to female ratio 1:1.8. mean age of study population is 34.13 years with standard deviation 12.32.

Patient admitted in hospital for the complaints of bleeding per rectum, constipation, pain during defecation.in our study 47 out of 50 (94%) patient give complaints of bleeding per rectum .in 23 patients with this complain lord’s anal dilatation had done and in 24 patients lateral anal sphincterotomy done. During the hospital stay 6 patients had bleeding per rectum post lord’s anal dilatation which is 12% of the study population. and 8 patients had bleeding per rectum post lateral anal sphincterotomy which 16 % is of the total study population. Bleeding is not clinically bothersome. No intervention required for bleeding per rectum. After 1 week of first visit in opd 2 patients post lord’s anal dilatation complains bleeding per rectum which is 4% of total study population and 3 patients post lateral anal sphincterotomy complains of bleeding per rectum which is 6% of study population. After two weeks of surgery 1 patient post lord's dilatation gives complaints of bleeding per rectum occasionally which is 2% of total population and no incidence of bleeding per rectum post lateral anal sphincterotomy after two weeks of surgery. After 1 month 1 patient post lord’s anal dilatation has bleeding per rectum which is 2% of the study population and no incidence of bleeding per rectum post lateral sphincterotomy after 1 month of the surgery. There is reduction in bleeding per rectum postsurgical intervention from 46 % to 2% in lord’s anal dilatation and from 48% to 0% after later anal sphincterotomy. Arunkumar Uttam et al study showed in 84 % patients bleeding per rectum was presenting complaint, bleeding per rectum postoperatively observed in 75% patients post lord’s anal dilatation and 85% in post lateral anal sphincterotomy. Bleeding is not clinically bothersome and subsided in subsequent days.

 For the assessment of constipation modified Longo score is used. 100% of patients in our study had complained of constipation. The mean of the modified Longo score is assessed during hospital stay. After one week, after two weeks and after one month of surgical intervention. After the surgical interventions oral stool softeners given to the patients for 1 month. After the procedure patients get relieved from constipation significantly in both the groups. During hospital stay mean score are in LAD group are 0.88 and in LIS group its 1.38 and it reduce further after 1 week the mean score are 0.25 in LAD and 0.08 in LIS after 15 days it become 0.08 for both in LAD and LIS but after 1 month the score in LAD are 0.13 and LIS are 0.00 and its shows a statistically significant difference between them after 1 month (p=0.034). Tayfun yucel et al study showed 21 patients out of 40 patients had complained of constipation among which 10 patients underwent for LAD and 11 patients underwent for LIS. Post procedure 2 patients in the LAD group and 3 patients in LIS group had constipation.

For the assessment of pain in anal region Wong baker pain score is used. Score is assessed during hospital stay. After one week, after two week and after one month of surgical interventions’ iv analgesic medications given to patients. post-surgical interventions during hospital stay. During hospital stay mean scores in LAD are 1 and in LIS its 1.19. Patient discharge on oral analgesic medication for 1 week. it reduces further after 1 week the mean score are 0.46 in LAD and 0.54 in LIS after 15 days it become 0.13 in LAD and 0.08 in LIS but after 1 month the score in LAD are 0.17 and LIS are 0.00 and its shows a statistically significant difference between them after 1 month (p=0.034).in both the procedures pain reduces significantly. Arunkumar Uttam et al study showed, there was no significant difference in the pain score between the two groups when evaluated subsequently i.e. before discharge, 1 month, 3 month and 6 months (p value- 0.1390, 0.6186, 0.4665) respectively.

For the assessment of incontinence Wexner incontinence score is used to assess during hospital stay, after one week, after two weeks and after one month of surgical interventions. No case of faecal and flatus incontinence was there after LIS During hospital stay and after 1 month.3 out of 24 patients have incontinence post LAD. 2 patients have flatus incontinence and 1 patient had faecal incontinence which is minor and not bothersome.no intervention required for this complaint in any group. Our study shows LIS had Better outcomes for incontinence as zero patient post LIS had incontinence. Muhammad aquil Razzaq et al study 2 out of 50 patients in which LAD had faecal incontinence and 9 out 50 patients of LAD group had flatus incontinence. In 50 patients of LIS group 6 patients had flatus incontinence and 1 patient had faecal incontinence.

Recurrence incidence post LIS in our study is 0.all the ulcer healed after 1 month of the surgery.in LAD group 2 patients develop complaints of recurrence after 15 days and 5 patients develop recurrence after 1 month of surgery. Tayfun et al study showed 3 patients in LIS group (total patients 20) had recurrence of fissure and 2 patients in LAD group (total patients 20) had recurrence. This study has different outcomes in terms of recurrence as compared to our study.

We conducted a prospective observational study comparing lateral anal sphincterotomy (LIS) and Lord’s anal dilatation (LAD) in chronic anal fissure. A total of 50 patients were enrolled and randomly assigned to either LIS or LAD. Both procedures showed satisfactory pain relief; however, LIS had better long-term pain outcomes. Bleeding per rectum resolved in both groups by one month postoperatively. Constipation significantly reduced in both groups, with no cases after one month in LIS group. Incontinence was more frequent in the LAD group compared to LIS.Recurrence was noted in 5 patients in the LAD group, while none occurred in the LIS group. LIS demonstrated superior outcomes in terms of pain relief, absence of incontinence, and lower recurrence rates. Both procedures were safe, but LIS provided more consistent long-term benefits.

Hence, lateral anal sphincterotomy is concluded to be the better surgical modality for chronic anal fissure.

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