Research Article
Surgical Treatment of Anal Fissures: Population and Outcomes of an Ambulatory Surgical Center
Wilson Malta1*, Teresa Correia1, Eurico Castro Alves1,2 and Ana Povo1,3
1Department of Surgery, General Ambulatory Surgery Unit, Centro Integrado de Cirurgia de Ambulatório -Centro Hospitalar do Porto, Portugal
2Instituto de Ciências Biomédicas Abel Salazar-Universidade do Porto, Portugal
3Department of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal
*Corresponding author: Wilson Malta, Department of Surgery, General Ambulatory Surgery Unit, Centro Integrado de Cirurgia de Ambulatório -Centro Hospitalar do Porto, Nº 15, 3ºB, 4400-698 Vila Nova de Gaia, Portugal
Published: 02 Dec, 2016
Cite this article as: Malta W, Correia T, Alves EC, Povo A.
Surgical Treatment of Anal Fissures:
Population and Outcomes of an
Ambulatory Surgical Center. Clin Surg.
2016; 1: 1192.
Abstract
Purpose: To characterize the population of patients undergoing surgical treatment of anal fissures; to assess the outcomes and complications of the procedures in an ambulatory surgical center; and to
evaluate the satisfaction degree of the patients.
Methods: Demographic data, type of procedure and complications of patients who underwent
surgical treatment for anal fissuresin the Integrated Center for Ambulatory Surgery of Centro
Hospitalar do Porto - CICA-CHP) were reviewed. A questionnaire (created by the authors to
assessthe satisfaction, the quality of life and restrictions after the surgery and to identify the main
advantages for an outpatient care) and the Cleveland Clinic Incontinence Score and the Fecal
Incontinence Quality of Life Instrument (FIQLI) were applied.
Results: The study included 88 participants; the mean age was 47.2 years and 62.5% were female;
75% underwent lateral internal sphincterotomy (ELI) and 25% fissurectomy and V-Y. The global
satisfaction was 9.6/10, the absence of hospitalization was considered an advantage(4.5/5), the mean
period of inability for professional activitieswas 11.8 days; the pain was moderate (2.9/5) and the
pain control with oral analgesics wasclassified in 4.5/5. In the FIQLI no one had concern about
accidental bowel leakage nor felt sad in relation to its proctologic health. In the Cleveland Clinic
Incontinence Scoreno patients referred incontinence.
Conclusion: The treatment of anal fissure has been evolving and with this work we realize that anal
fissure surgery can be safely performed on an outpatient basis respecting the dignity and comfort
of the patient.
Keywords: Anal fissure; Proctologic surgery; Lateral internal sphincterotomy; Fissurectomy; V-Y anoplasty
Introduction
The anal fissure is one of the most common anorectal problems encountered in clinical practice. It represents an elongated ulcer of the anoderm that begins at or just below the dentate line and extends distally to the external anal margin [1,2]. Anal fissure can be medical management in the acute fissure or surgical management in chronics one’s [3]. The surgical procedures for the treatment of proctologic pathology have been developed in the last years, in order to minimize some complications such as postoperative pain and bleeding, increase the comfort of patients and enable a faster recovery [4]. Because of this, most of proctologic cases are now performing as day case surgery [1]. The aims of the study were characterize the population of patients undergoing surgical treatment of anal fissures and assess the outcomes and complications of the procedures in an ambulatory surgical center. Additionally, we intended to evaluate the satisfactiondegree of the patients.
Material and Methods
Medical records of patients who underwent surgical treatment for anal fissuresin the Integrated Center for Ambulatory Surgery of Centro Hospitalar do Porto - CICA-CHP), from March/2011 to July/2014, were reviewed; and demographic data, type of procedure and complications were collected. Then, a questionnaire was created by the authors (Annex 1) to assessthe satisfaction of the patients with the procedure, the institution and the health providers; to evaluate the quality of life after the surgery including the pain management, the restrictions to the daily life or professional activities andthe need to go to the urgency department for any complication; and finally to identify the main advantages for an outpatient care. Furthermore, the patients have to answer the Cleveland Clinic Incontinence Score and the Fecal Incontinence Quality of Life Instrument (FIQLI). Bothquestionnaires were anonymous and applied telephonically. The data was statistically analyzed through SPSS®.
Table 1
Table 1
Distribution of the surgical treatment of anal fissures in the ambulatory
surgical center by gender.
Table 2
Table 3
Table 3
Satisfaction degree with the absence of hospitalization for surgical treatment of anal fissures.
Table 4
Table 5
Results
During the study period, 91 patients underwent surgical treatment
of anal fissures; of these 88 answered the questionnaire and 3 never
replied the call.
The mean (±SD) age of the patients was 47.2 (±13.7) years, with
the mode being the 55 years; 62.5% were female. The most used
surgical technique was the lateral internal sphincterotomy (ELI) in
75% of patients; the remaining 25% cases underwent fissurectomy
and V-Y anoplasty (Table 1).
The mean period of inability for daily life or professional
activities was 11.8 days. Eight patients needed to be attended in
urgency department in the immediate postoperative period due to
bleeding (n=5), infection (n=2) and dehiscence of the wound (n=1);
however, there was no need of invasive measures, such as surgery, or
hospitalization. The mean pain intensity was 2.9/5; though, usingthe
oral analgesics that were prescribed the patients reported a great pain
relief, with a meanof 4.5/5 (mode 5) for the relief degree. Regarding
the FIQLI, 86.3% of patients considered their general health good or
very good; no one had concern about accidental bowel leakage nor
felt sad in relation to its proctologic health. In the Cleveland Clinic
Incontinence Scoreno patients referred incontinence (Table 4). The
recurrence rate of the fissure was 3.4% (n=3); of these 67% were
submitted to ELI while 33% to fissurectomy and V-Y anoplasty.
Discussion
The epidemiological data presented in our study are identical to
those described in the literature, specifically the predominance of the
female gender in anal fissures of 58% [5] are closely to our 62.5% of
cases. The age obtained a peak incidence at 47.2 years, slightly above
the average reported in the literature of 35 years [5].
To our knowledge there are no other studies evaluating the
satisfaction degree of patients submitted to surgical treatment of anal
fissures in an ambulatory center.
In our study, patients achieved an excellent pain control with the
oral analgesia prescribed, classified in 4.5/5; furthermore, the mean
pain level without medication was moderated (2.9/5).
Our evaluation demonstrated the satisfaction of the patients with
the ambulatory surgical center (9.6/10), considering the absence of
hospitalization an advantage (4.5/5) for this type of surgery.
One of the most feared complications for anorectal surgeons is
the anal incontinence, thus we decided evaluate it using the Cleveland
Clinic Incontinence Scoreand no patients reported incontinence
attesting very good results.Reviewing the literature the rate of
incontinence after ELI runs the 3-45% and after fissurectomy with or
without V-Y anoplasty the incontinence rate is about 33%, [8,9] quite
different from the results we have obtained.
The treatment of anal fissure has been evolving and with this
work we realize that anal fissure surgery can be safely performed on
an outpatient basis respecting the dignity and comfort of the patient.
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