Stage III anal fissures are one of the common causes of anal pain, and their incidence is very high, with surgical treatment being the mainstay. There are many surgical methods for treating stage III anal fissures, but all of them have recurrence and are unsatisfactory. Our department uses sentinel hemorrhoid trimming with inverted V flap transfer suture to treat stage III anal fissure with satisfactory results. This method has the advantages of low tension after flap transfer suture, short course, high cure rate, few complications and low recurrence rate. Based on clinical observation, we believe that the inverted V flap transfer suture is the best procedure for the treatment of stage III anal fissure. It is reported as follows.
1. Data and methods
1.1 General data 230 cases were randomly divided into two groups according to the order of consultation. 100 cases were in the treatment group, 40 males and 60 females, aged 25-68 years old, with an average of 37.5 years old. The duration of the disease was 2 to 10 years. In the control group, there were 130 cases, 57 males and 83 females, aged 18-73 years old, all 35 years old. The duration of the disease was 2-15 years. There was no statistically significant difference between the two groups in terms of age, gender, disease duration and condition (P>0.05), which was comparable.
1.2 Diagnostic criteria: Referring to the diagnostic criteria for anal fissures in the Diagnostic Criteria for Hemorrhoids, Anal Fistulae, Anal Fissures and Rectal Prolapse[1] adopted by the Chinese Society of Traditional Chinese Medicine, Xiamen, China in November 2002: Stage I anal fissures: superficial longitudinal fissures in the skin of the anal canal with neat margins, fresh base, red color, obvious tenderness and elasticity of the wound surface. The wound edges are irregular, thickened, poorly elastic, and the base of the ulcer is purplish red or with purulent discharge. Stage III fissure: hardened ulcer margins, purplish-red base, purulent discharge, hypertrophy of anal papillae in the upper part adjacent to the anal sinus, sentinel hemorrhoids in the lower part of the trabecular margin, or formation of subcutaneous fistula.
1, 3 Preoperative preparation: routine administration of gentamicin and metronidazole 3 d before surgery, intestinal disinfection, skin preparation in the operative area, semi-liquid diet from the night before surgery, clean enema with warm saline 500 rnl, and abstinence from diet in the morning of surgery.
1.4 Surgical method: The operation was performed in the right lateral position, with a routine disinfection of the towel, and under rigid lumbar anesthesia, the perianal skin and the lower rectal segment of the anal canal were disinfected with iodophor, and the anus was dilated to accommodate 3. 4 fingers. Fully expose the anal fissure site. Treatment group: sharply excise the ulcerated surface of the anal fissure from the tooth line along the edge of the ulcerated surface to the inner edge of the sentinel hemorrhoid. A portion of the internal sphincter is severed below the incision. The proximal surface of the sentinel hemorrhoid is excised and the distal flap of the sentinel hemorrhoid is cut in the shape of an inverted V with the tip upwards, the size of the flap depending on the size of the fissure ulcer. The inverted V-shaped flap was appropriately freed to reduce the tension of the flap, and the blood supply between the flap and the basal tissue was preserved. shape. If the flap was under high tension after suturing, an arc-shaped decompression incision was made at the outer edge of the flap, reaching deep into the dermis, with a length equivalent to the two legs of the “^” flap. Control group: lateral internal sphincter picking out and cutting: a radial incision of 0.5-1.0 cm in length was made on the right side of the anal canal at 1.5 cm from the external anal margin, reaching deep into the subcutaneous layer. The lower part of the internal sphincter is picked out and cut from the incision under the guidance of the index finger, and the incision is sutured. At the same time, the hypertrophic anal papilla, pectineal band, and sentinel hemorrhoid were removed, and the inner opening was silk-ligated. The external orifice was trimmed with a shuttle. After surgery, all hemorrhoid nin pessary 1, taining pessary 1 nasal; Vaseline oil gauze filled with drainage, tower gauze and wide adhesive tape pressure fixation. Postoperatively, a liquid diet was given for 3 d, bowel movements were controlled for 48 h. After the bowel movement, the dressing was washed and changed, and hand paper was avoided. Appropriate antibiotics were given to prevent infection, and the wound sutures were removed 5-7 d after surgery.
1.5 Criteria for judging the efficacy: the efficacy criteria for anal fissure were formulated according to the “Diagnostic and efficacy criteria of the Chinese medicine industry standard of the People’s Republic of China” approved by the State Administration of Traditional Chinese Medicine r[2] and combined with clinical efficacy assessment criteria: healed: 100% wound healing rate, complete epithelialization of the wound surface, solid scar; effective: 75%≤ <100% wound healing rate, fresh granulation tissue on the wound surface, bright red color; effective: 75%≤ <100% wound healing rate, fresh granulation tissue on the wound surface, bright red color. Effective: 25% ≤ trauma healing rate <75%, trauma granulation tissue is fresh and red; Ineffective: trauma healing rate <25%, trauma granulation tissue is dark, little growth, no obvious reduction trend. Cured + effective = total effective.
1.6 Statistical treatment The rank sum test was used to compare the efficacy of the two groups, and the difference was statistically significant with P<0< span="">.05.
2, Results
The efficacy of the two groups was evaluated after comparison, and the results showed that the efficacy of the treatment group was better than that of the control group, and the difference was statistically significant. See Table 1.
l Comparison of the results and efficacy between the two groups
Number of cases Cured Effective Ineffective Total effective rate Wound healing time
1, Group / case / case / case / case (%) (±s,d)
Treatment 100 90 9 1 99 8,5 ± 1,3
Control 130 97 20 13 90 15, 5 ± 5, 4
P<< span=""> 0,05 compared with the control group
One case in the treatment group had a wound dehiscence and long-term non-healing, followed by colonoscopy to confirm the diagnosis of Crohn’s disease. It improved after oral administration of mesalazine.
3. Discussion
3.1 Anal fissure is an ischemic ulcer caused by a severe deficiency of blood supply to the anal canal induced by spasm of the internal sphincter [3]. Clinical experiments have confirmed that high sphincter tone can induce ischemia of the anal canal skin and lead to the formation of anal fissure due to ischemia; if the sphincter tone is reduced and the blood supply to the anal canal skin is restored, the fissure will heal. Therefore, releasing the spasm of the sphincter has become the main principle in the treatment of anal fissure in recent times. Usually, internal sphincterotomy or anal dilation is used. Is internal sphincter spasm a cause or a consequence of anal fissure? Almost all chronic anal fissures are associated with internal sphincter hypertonia and high anal pressure, and Schouten (1996) [4] recently determined the mean maximum anal canal resting pressure (MARP), which was significantly higher in patients with anal fissures than in normal controls (121.07 ± 16.97; 68.78 S 24.48 mmHg). north-maun et al. 1974 found that in patients with anal fissures, instead of relaxation, the internal sphincter was excessively contracted during rectal distention. This abnormal activity of the internal sphincter has been tested to prove that internal sphincter spasm is not secondary to pain [5] and is usually considered to be the result of chronic inflammatory stimulation of anal fissure and spasm of the internal sphincter. All reasonable and effective therapies should try to release the vicious cycle of ischemia-spasm-more ischemia.
3,2 There are many treatment methods for Ⅲ degree anal fissure, especially combined with sentinel hemorrhoids and anal papillary hypertrophy, mainly surgical treatment. Such as: botulinum toxin injection, “pectus excision”, longitudinal cut and suture, internal sphincter picking and cutting, etc. However, sometimes the release of the internal sphincter is not complete, and some patients need a second operation; simple longitudinal transverse suturing often leads to wound dehiscence due to the large displacement of the middle part of the transverse suture incision, and the incision has to withstand fecal extrusion, resulting in surgical failure; simple excision of the ulcerated surface of anal fissure (“pectineal band”), resulting in new trauma. However, in most patients with anal fissures, especially those with stage III fissures, simple excision of the fissure ulcer surface can lead to postoperative recurrence due to scar contracture and anal stenosis. Weng Tianran et al [6] pointed out that almost all anal fissures have varying degrees of anal narrowing. Therefore, resolving anal stenosis and improving the blood supply to the anal canal skin is the key to treating stage III anal fissures. The flap selected in the inverted V advancement flap transfer suture has a rich blood supply, and after it is sutured to the fresh wound where the ulcerated surface of the fissure has been removed, the subcutaneous blood supply outside the ship’s edge in the flap fully improves the blood supply to the original ischemic area of the anal canal, thus creating a strong condition for the stage I healing of the fissure defect. At the same time, it avoids the stimulation of the internal sphincter by wound inflammation and cuts off the vicious circle of anal fissure formation; furthermore, the two edges of the c-cut sentinel hemorrhoid distal surface with inverted V-shaped flap are sutured with the two traumatic edges of the anal fissure with little tension and easy survival, and the postoperative scar is small and the patient has no foreign body feeling after surgery.
3,3 The latest version of the American Society of Colorectal Surgeons (ASCRS) clinical guidelines for anal fissures (2004) states that nudge flapplasty is an alternative treatment to lateral internal sphincterotomy (LIS), which is worth promoting in combination with the authors’ clinical observations.