Utilization of a Combined Procedure for Hemorrhoids and Chronic Anal Fissure Is Safe and Feasible

Abstract

Background: Hemorrhoids and anal fissure are among the most common benign anorectal conditions. The incidence of synchronous symptomatic hemorrhoids and chronic anal fissure is unknown. In this study we evaluated the outcomes of our experience with concomitant surgical treatment for both these conditions. Methods: In this retrospective study we included consecutive patients who underwent surgical treatment for symptomatic hemorrhoids combined with lateral internal sphincterotomy for chronic anal fissure, during a time period of over 5 years. Eligible patients were contacted by phone and were asked to answer a questionnaire to evaluate recurrent symptoms, fecal incontinence, satisfaction, and improvement in quality-of-life. Results: A total of 56 patients were included, and 29 (51.8%) were female; the mean age was 46.9 ± 13.7 years, and the median follow-up time was 45.4 months. The median self-assessed improvement in quality-of-life on a scale of 0–10 was 10 [IQR 8, 10]. No significant differences were observed in satisfaction or self-assessed improvement in quality-of-life between genders or across different surgical procedures for hemorrhoids. Conclusions: Patients who underwent concomitant surgical treatment for hemorrhoids and chronic anal fissure were satisfied. This study supports our approach for synchronous treatment for different anorectal pathologies given the right patient selection, being safe and feasible.

1. Introduction

Symptomatic hemorrhoids and anal fissure are the two most common reasons for proctologist consultations [1]. The symptoms of these pathologies are sometimes overlapping. The true incidence of benign anorectal disease is unknown due to inaccurate diagnosis and underreporting [1,2,3].

Surgical treatment should be considered in patients with chronic anal fissure after a course of 6–8 weeks of conservative treatment consisting of topical treatment or botulinum toxin injection [1,4]. About 10–20% of patients with symptomatic hemorrhoids will eventually undergo a surgical procedure. The incidence of synchronous chronic anal fissure and symptomatic hemorrhoids is unknown [5].

Although the conservative treatment for both pathologies is based on ensuring bulky, soft, and regular bowel movement, the surgical treatment options are different. There are many types of interventional procedures for treating symptomatic hemorrhoids. Excisional hemorrhoidectomy and stapled hemorrhoidopexy are two of the procedures which are recommended for high-grade hemorrhoids [6]. Lateral internal sphincterotomy (LIS) is considered the gold standard surgery for patients with chronic anal fissure [1,7]. The aim of LIS is reduction in sphincter tone and hence improvement in blood supply to the anal mucosa which enhances wound healing [3]. One of the most troublesome complications after LIS is anal incontinence, although its incidence following LIS is estimated to be as low as 3–6% [1,3,8,9]. Some old reports suggest that post LIS complications such as anal incontinence increase when the procedure is combined with other anorectal procedures [10].

In this study, we evaluated the outcomes of patients who underwent concomitant surgical intervention for hemorrhoids combined with LIS for chronic anal fissure.

2. Materials and Methods

2.1. Study Design and Patient Inclusion

The study was conducted under the supervision of the Hadassah Medical Center Institutional Review Board (approval number 0098-21-HMO). We conducted this study according to the principles of the Declaration of Helsinki. All included patients gave their informed consent to participate.

We evaluated for inclusion all consecutive patients aged ≥18 years who underwent surgical treatment for hemorrhoids concomitantly with LIS for chronic fissure at our institution between 1 January 2015 and 30 June 2020. The exclusion criteria included patients with impaired cognitive function or language difficulty, who could not complete the questionnaire, and patients who were unable or unwilling to participate. Informed consent was provided by all patients who agreed to participate in the study.

2.2. Peri-Operative Management and Surgical Technique

All patients had symptomatic hemorrhoids, and all had failed previous conservative or surgical treatment attempts. In addition, all the patients also had chronic anal fissure which failed conservative treatment. All surgeries were performed by or under the direct supervision of a fellowship-trained colon and rectal surgeon.

The surgical procedure for hemorrhoids was selected by the surgeon and patient according to the patient’s complaints and findings on the physical examination from the following options. We utilized the Ferguson technique for excisional hemorrhoidectomy (EH) or stapled hemorrhoidopexy (SH) using the Ethicon procedure for prolapse and hemorrhoids (PPH) circular stapler, or a combination of SH and simultaneous resection of residual hemorrhoidal tissue in patients with significant internal as well as external hemorrhoidal component (CH). For the anal fissure, all the patients underwent lateral internal sphincterotomy (LIS) via the open technique: incision at the intersphincteric groove, identification and separation of the internal sphincter from the submucosa and external sphincter, and division of the internal sphincter using Bovie cautery. The incision was then closed with Vicryl sutures.

2.3. Outcome Measures

All eligible patients were contacted over the phone by a member of the research team. Following informed consent, the patient was asked to answer a questionnaire regarding current symptoms (anal pain, tissue prolapse or swelling, bright red blood per rectum or perianal itching, fecal incontinence (Wexner fecal incontinence score [FIS])) and overall satisfaction from surgery (each patient was asked to state if they would repeat the surgery if needed and how would they evaluate their improvement in quality-of-life after surgery on a scale of 0–10) [Supplementary Materials].

Retrospective data collected from the patients’ medical records included demographics, comorbidities, surgical technique, type of anesthesia and simultaneous procedures, peri-operative complications, and post-operative follow-up.

2.4. Statistical Analysis

Statistical analysis was performed using EZR (version 1.55) and R software (version 4.1.2) [11]. Categorical data were expressed as numbers and percentages and were analyzed with Fisher’s exact or χ² test. Continuous variables were presented by median and interquartile range (IQR). Student’s t-test or the Mann–Whitney test was employed on continuous variables. A p-value ≤ 0.05 was considered significant for all comparisons.

3. Results

A total of 56 patients underwent combined surgical procedures for hemorrhoids and anal fissure during the study period. Twenty-nine (51.8%) were females, and the mean age was 46.9 ± 13.7 years. The median follow-up time was 45.4 months (ranged between 21.5 and 86.4 months). All the patients underwent LIS for the fissure. Thirty-six patients (64.3%) underwent EH, twelve patients (21.4%) underwent SH, and eight patients (14.3%) underwent CH. Forty of the procedures (71.4%) were performed under general anesthesia and the rest under spinal anesthesia, and for three patients it was a repeated intervention for their hemorrhoidal disease. Two patients (3.6%) experienced post-operative complications; one had urinary retention following PPH combined with LIS and one was readmitted to the hospital due to rectal bleeding which required blood transfusion after CH combined with LIS. At the end of the follow-up, both had no recurrent symptoms and were very satisfied with the surgery.

Table 1. Cohort characteristic.

Factors		n	%
Patients		56
Age (Mean ± SD)		46.9 ± 13.7
Sex	Female	29	51.8
	Male	27	48.2
Type of Procedure for Hemorrhoids	Excisional hemorrhoidectomy	36	64.3
	Stapled hemorrhoidopexy	12	21.4
	Combined hemorrhoidopexy with excision of residual hemorrhoids	8	14.3
Type of Anesthesia	General	40	71.4
	Spinal	16	28.6
Short Term Complications		2	3.6
Follow-up Time (Median, Range)		45.4 months (21.5–86.4)

demonstrates the cohort characteristic.

Twenty-six patients (46.4%) reported symptom that could be attributed to recurrent hemorrhoidal disease, of whom 14 (25%) required any treatment and only one required interventional treatment. Most of these patients did not seek medical evaluation, so it remains in doubt if they truly had a recurrence. Seven patients (12.5%) developed other anorectal pathologies after surgery, and two patients (3.6%) had recurrence of an anal fissure.

The median total FIS was 0 [IQR 0, 3] and the median score for gas incontinence was 0 [IQR 0, 2.5]. Thirty-six patients (64.3%) reported a FIS of 0, and only two patients (3.6%) had a FIS ≥ 10. Out of all the cohort, only one patient with a FIS score of 7 reported deterioration in his continence status following surgery.

The overall satisfaction of the combined LIS and hemorrhoid surgery was good; forty-six patients (82.1%) said they would undergo surgery again if needed; six patients (10.7%) said they would not repeat it and four patients (7.1%) replied “maybe”. The self-assessed improvement in quality-of-life was good with a median score of 10 [IQR 8.0, 10]. There were no differences in the rate of patient satisfaction and self-assessed improvement in quality-of-life score between the three different types of hemorrhoid surgeries (p = 0.52, p = 0.65, respectively). Similarly, there were no differences in the rate of patient satisfaction (p = 1.00) and self-assessed improvement in quality-of-life score (p = 0.63) between female and male patients.

4. Discussion

The incidence of synchronous chronic anal fissure and hemorrhoids is unknown and the literature discussing concomitant surgical intervention is scarce. In this study we performed a long-term follow-up interview with patients who underwent a combined surgical treatment for both chronic anal fissure and symptomatic hemorrhoids in a single procedure. Our findings indicate that concomitant surgery is safe and achieves high satisfaction rates.

Some surgeons advocate for a routine LIS at the time of excisional hemorrhoidectomy, due to the theory that it might help reduce spasm and hence reduce the pain following hemorrhoidectomy [5,12,13]. A review by Emile et al. showed that LIS is efficient in decreasing post-hemorrhoidectomy pain as well as other complications, mainly urinary retention, and anal stenosis, while increasing the rate of fecal incontinence (although it was non-significant, and usually low degree and temporary incontinence). They advocated adding sphincterotomy to chosen patients, with an attention to patients at risk of developing fecal incontinence [12].

The incidence of anal incontinence following LIS is estimated to be between 3 and 6% [1,3,8,9]. In this study we found that 3.6% of the patients had significant FIS, and only one patient (1.8%) experienced deterioration in his continence status following surgery.

Some data suggest concerns regarding LIS being performed in female patients due to shorter sphincter length and potential sphincter disfunction after childbirth, and suggest avoiding sphincterotomy in female patients [1,8]. However, other studies have shown no gender differences in anal incontinence following internal sphincterotomy [4,8]. Our findings further support that no gender-based differences should be expected in satisfaction rates following a combined procedure to treat symptomatic hemorrhoids and LIS.

The rate of other short-term complications following LIS such as bleeding and urinary retention is low—less than 5% of patients [1]. Post-hemorrhoidectomy complications include hemorrhage (1–2%), urinary retention (1–15%), and pain. In our series of combined surgeries, the overall rate of short-term complications was 3.6% consisting of one case of bleeding and one case of urinary retention.

Leong, in 1994, published a series of patients who underwent LIS combined with other anorectal procedures (mostly hemorrhoidectomy) [10]. He found no increase in post-operative complication rates after the combined surgery, including fecal incontinence. In his study, none of the patients had permanent incontinence (with a mean follow-up of 3.3–4.6 months). He found no higher recurrence rates of the fissure in the combined group compared to the LIS group. In our cohort, two patients (3.6%) experienced recurrence of the fissure with a median follow-up of 3.7 years, similar to previous reports of recurrence rates of 4.4% [9].

Kanellos, in 2005, reported a series of 26 patients who underwent stapled hemorrhoidopexy in combination with LIS for hemorrhoids and chronic anal fissure. He found it was safe and effective [14] but reported twelve patients with complications, four of whom had fecal incontinence which resolved completely at week 10, except for one patient with low-degree incontinence for flatus and a Wexner FIS of 2.

When comparing our current data presented in this study to our previously published data of patients who underwent surgical procedures for hemorrhoidal disease during the same time period [15], we found that adding internal sphincterotomy to any surgical procedure for hemorrhoids did not increase FIS. In our previously published series of a cohort of patients undergoing surgery for hemorrhoids, 76.5% of the patients reported perfect continence [FIS = 0] and only 6.1% of the patients had a FIS ≥ 10.

Our study has several limitations: First, its retrospective nature which might have created a selection bias. In addition, relying only on patients’ self-reported recurrent symptoms may have overestimated the true recurrence rate. Although not very different from previous studies focusing on this specific group of patients with concomitant symptomatic hemorrhoids and chronic anal fissure, the sample size in our study is relatively small. Lastly, the incontinence score was not recorded prior to the surgery which did not allow us to estimate the true influence of surgery on this outcome.

5. Conclusions

Patients undergoing concomitant surgical treatment for hemorrhoids and chronic anal fissure were satisfied with the combined approach, regardless of the type of surgical intervention for hemorrhoids. Concomitant treatment for different anorectal pathologies is safe and feasible. Further evaluation of the severity and duration of incontinence following LIS is warranted.