A Prospective Study To Evaluate Medical Management Vs Surgical Intervention In Pain Relief And Healing Of Anal Fissure

Introduction: Anal fissure is a commonly encountered problem for surgeons. It is a longitudinal tear in distal anal canal with or without an ulcer. It causes significant changes in quality of life. This study was done to compare the efficacy of medical management and surgical intervention in cases of anal fissures.
Methods: 50 patients were divided into two groups of 25 each. Group A patients were treated with topical application of 2% diltiazem gel and Group B patients were treated with Lateral sphincterotomy. Both groups were examined weekly for 4 weeks for pain using VAS score and at 12 weeks for healing.
Results: 21(84%) patients were pain free after 4 weeks under Group A, 24 (96%) patients were pain free after 4 weeks under Group B. 22(88%) patients were completely healed at 12 weeks under Group A, 25(100%) patients were completely healed at 12 weeks under Group B.
Conclusion: Lateral sphincterotomy can be advocated as treatment of choice for anal fissures. It has better pain relief and healing rates compared to topical application of 2% diltiazem gel. Medical Management can be used in patients refusing surgery or unfit for surgery


Introduction
Amongst the various causes of pain in the anorectal region, routine clinical practice. 1,2 on quality of life because of the pain associated with it on defecation. 3 A longitudinal tear in the distal anal canal 1,2 on the duration of onset of symptoms. An acute anal weeks either spontaneously or by medical management. A onset of symptoms and is usually associated with a sentinel pile distally. 1,2 based on etiology. The exact etiology of primary anal with local trauma to the distal anal canal due to hard stools, prolonged diarrhoea, vaginal delivery, repetitive injury or penetration. 4 This is followed by a triad of pain on defecation, internal anal sphincter spasm and ischaemia. 1,5 pathology like Tuberculosis, AIDS etc. Thus chronic hypertonicity may generally be the underlying cause and patient generally presents with pain on defecation and blood in stools. 1,2 and is thus a common problem for a surgeon. 6 There are various treatment options, both medical and reducing the spasm of anal sphincter and facilitating blood supply and tissue healing. 1,2 The mainstay of treatment includes correction of constipation by conservative methods vegetables and wholegrain. 4 Along with dietary changes, sitz bath which involves warm bathing of the perineum. 7,8 Medical management includes muscle relaxants, calcium channel blockers (diltiazem, nifedepine), nitrates (isosorbide dinitrate, glyceryl trinitrate) which help in reducing sphincter tonicity in resting state and improve healing. 9 Diltiazem and Glyceryl trinitrate have similar healing rates, but side those of glyceryl trinitrate. The incidence of headaches and perianal itching are low with use of diltiazem compared to that of glyceryl trinitrate. 10 In a study on 39 patients with diltiazem topically had similar healing rates to that of 0.2% It was also concluded in the same study that topical 2% to treatment with 0.2% glyceryl trinitrate. 11 Surgical management includes the most commonly performed lateral sphincterotomy and less commonly performed manual anal dilatation both of which are incontinence as a complication. 1 50 patients were divided into two groups of 25 each. Convenience sampling was used and each successive patient was enrolled alternatively in group 1 and group 2 in a non-randomized manner. Group 1 consisted of patients treated with 2% diltiazem application and Group 2 consisted of patients treated with lateral sphincterotomy. Informed consent from each patient was taken. Each patient was examined weekly for 4 weeks for sphincter tone, bleeding Group 1 patients were advised to apply 1.5-2 cm length of 2% diltiazem gel upto 1.5cm within the anus twice a day for four consecutive weeks. Patients were instructed to wash hands before and after application of gel.
13 with higher concentrations of diltiazem. 17 Group 2 patients underwent lateral sphincterotomy under spinal anaesthesia after proper anaesthetic clearance. Patient was kept nil by mouth preoperatively and upto the evening on the day of operation.
All 50 patients were advised to take mild laxative like ml, per 15 ml of emulsion) three teaspoons at bedtime from the night of application of gel and surgery. Sitz bath was advised from the 2nd post-operative day. Group 2 patients were discharged on the 3rd post-operative day and examined on the 7th post-operative day for any bleeding or hematoma.
Patients of both Groups were examined 1st, 2nd, 3rd and was analysed. Patients were assessed for pain using visual analogue scale (VAS) 12 which is a scale ranging from 0-10 determining minimal and maximal pain as described by the patient. VAS 0 was considered as patient being pain-free. Patients were examined at 12th week for analysing the

Results
In this study, there was a higher male predominance (Figure 1) and most cases belonged to Age group 25-30 years (Figure 2) followed by age group 30-35 years. Out of (6'o clock) in location while only 4 patients had anterior Figure 3) Out of 25 patients taken for the study 21(84%) patients were pain free while 4(16%) patients were not completely pain free after 4th week of treatment as shown by Table  1. After 12 weeks, 22 out of 25 patients (88%) showed complete healing.

Group 2: Lateral Sphincterotomy Group
Out of 25 patient taken for the study, 24(96%) patients were pain free while 1(4%) patient was not completely pain free after 4th week of treatment. All 25 patients (100%) showed complete healing after 12th week as shown in Table 2.

Discussion
One of the most common problems faced by patients all to quality of life and is discomforting to the patient. There is a slight male predominance and it is most commonly found in young adult, this has also been observed in our present study. 13,14 management or surgical intervention which helps in reducing pain and anal spasm which is responsible for the use of warm bathing of perineum (warm sitz baths) has been hypothesized to provide relaxation to internal anal 15 channel blockers like Diltiazem and Nifedipine have been used which help in lowering the resting anal pressure 16 , with minor complications like headache 7 and perianal constipation.
The surgical interventions include procedures like anal dilatation and lateral internal sphincterotomy. Lateral sphincterotomy is the surgical procedure of choice to be internal sphincterotomy reduces the anal pressure and 1 In this, healing is faster than patients treated by medical management 17 and postoperative management is simple but there is a risk of developing complications like permanent anal incontinence.
Patients who received treatment with 2% Diltiazem Gel were reviewed on 1st, 2nd, 3rd, 4th and 12th week on an outpatient basis. In our study, 88% of patients had rates in several studies varied from 47-80%. 9,16,18,19 After 4 weeks, 84% patients were relieved of pain while 16% were not pain free. In a study done by Carmine Antropoli, M.D. et. Al, 65% of the patients were pain free and 35% of patients still had pain after 3 weeks. 20 Under Spinal anaesthesia, patients underwent lateral internal sphincterotomy. In our study, 96% of patients who underwent surgery did not complain of pain while 4% still had complains after 4 weeks. In a study conducted by Motie et al, 98% of cases who underwent surgical intervention were relieved of pain. 21 In a study conducted by Sileri et al, the healing rates were found to by 94% among the patients who underwent lateral internal sphincterotomy. 22 In contrast to this our study showed 100% healing rates after surgical intervention.
In our study anal incontinence was not encountered in any of our patients while in a research conducted by Melange of 27% while there was a 2% incidence for passive soiling after surgery. 23

Limitations of the study:
• Small sample size whose results cannot be generalized • • Non-randomized sampling method has potential to introduce selection bias • We do not know the proportion of acute and chronic with the two treatment strategies. • Other variables like safety, cost, patient acceptance have not been studied in our study.

Conclusion
It is evident from the study that Lateral Sphincterotomy has better healing rates compared to therapy with local application of 2% Diltiazem gel. Lateral sphincterotomy has an advantage over 2% Diltiazem that it has a better pain relief and faster healing rates.