A fissure is labeled as chronic or complicated if it fulfils the following criteria [₄].

1. Not responding to conservative treatment.

2. Association with a fibrous anal polyp at the level of dentate line.

3. Presence of an external skin tag.

4. Presence of hemorrhoids.

5. Induration at the edges of fissure.

6. Exposure of the fibers of the internal sphincter at the floor of the fissure.

7. Infection at the base of fissure.

8. A bridged fissure with underlying fistula [a post fissure fistula].

9. A post fissure granuloma.

10. A post fissure antibioma.

Various studies and references show that a case of fissure complicated by any of these factors would not heal spontaneously and the response to conservative therapy would be short termed and non satisfactory.

For these chronic fissures, various treatment options that had been advocated range from non-operative procedures like injection of botulin toxin [₅], nitroglycerine ointment [₆], endoscopic dilatation [₇], direct current probing [₈], cryotherapy [₉], anal stretching etc., or surgical procedures like fissurectomy, fissurotomy and sphincterotomy.

Many of the above methods are good enough to give relief to the symptoms of fissure in ano. Nevertheless, for the associated pathologies mentioned above, these procedures do not provide a satisfactory answer.

In the present study, we have introduced a combined approach of relieving the anal spasm by anal stretching followed by radio surgical procedure to eliminate the above-mentioned associated pathologies.

In our study, we have taken the help of radio frequency device to tackle these concomitant findings. By combining anal dilatation with radio frequency procedure, the associated lesions are either destroyed or removed.

This is one of the most favorite methods of treating the anal fissures [₁₀]. The great attraction of the procedure is due to its extreme simplicity and need of almost no instrument. The procedure could be performed even at an ill-equipped hospital situated at a remote place. Lateral subcutaneous internal sphincterotomy under general anaesthesia is a good operation for anal fissure but then a simple sphincter stretch is not inferior to it as a means of cure of fissure [₁₁]. The mechanism by which anal dilatation heals anal fissure is by reducing the anal canal pressure. Normally, a four-finger dilatation is considered adequate. A gradual anal stretching up to four (2+2) fingers with gentle circular maneuvering of the inserted fingers was used to achieve the desired effect. Few surgeons advocated upto a six or even eight-finger dilatation, but this has not proved to be of any added advantage. On the contrary, it could interfere with the sphincter function to a greater degree. We found support to our findings from the experiences of Weaver et al [₁₂] who established that manual dilatation of anus had no significant differences in outcomes than the internal sphincterotomy [₁₃]. Crapp and Alexander Williams had described anal dilatation as the procedure of choice for anal fissures [₁₄]. There are several studies which establish that when compared, the dilatation and the sphincterotomy showed no significant difference between the two approaches nor there was any clear advantage of one technique over the other [₁₅,₁₆]. Isbister [₁₇] in his study has recommended a gentle anal dilatation as first method of choice in anal fissures.

This additional procedure is performed in situations where the fissure is associated with pathologies like sentinel tags, hypertrophied anal papillae, fibrous polyps, post fissure fistula, internal hemorrhoids and the other situations mentioned above.

Radio surgery is the method of cutting and /or coagulation of tissues, using a high frequency alternate current. It is a method of simultaneous cutting and coagulating of the tissues. The effect of cutting, known as high frequency section, is executed without pressuring or crushing the tissue cells. This is achieved through the heat produced by tissue resistance to the passage of high frequency wave emanating from the RF unit [₁₈]. The heat makes the intracellular water boil, resulting in to an increase in the cell inner pressure to the point of breaking it from inside to outside [explosion]. This phenomenon is called as cellular Volatilization [₁₉].

We are using the modern radio surgical equipment Ellman Dual Frequency 4MHz by Ellman International, Hewlett, N.Y. This instrument produces an electromagnetic wave of a very high frequency that reaches 4 megahertz. The amount of energy to be delivered can be pre-set. It is graduated from o to 100. The unit is supplied with a handle to which different inter changeable electrodes can be attached as per the requirement [₂₀]. In our study, we have used the ball electrode for coagulation and a round loop electrode for shaving off the desired tissue [₂₁].

The distribution of pathologies found associated with patients of chronic fissure in ano in our study is given in Table No. 1[Fig.1].

Figure 1

Table 1: Pathologies found associated with chronic fissure in ano [Total No of patients under study- 283.].

Figure 2

Figure 1: Distribution Of Pathologies Found Associated With Chronic Fissure In Ano. [Total No. Of Cases Under Study: 283]

After the traditional four finger anal stretch, the aforementioned associated ailments were either shaved off or coagulated depending upon the situation.

It is a common finding in most of the cases [₂₂] of chronic fissure in ano and is responsible for minor associated complaints like discharge, a foreign body sensation, and occasionally being trapped in the tight sphincter. In our study, 136 patients were found having these papillae. These papillae were coagulated with the Ball Electrode using the COAG mode with energy ranging between 40 and 50 of unit. They immediately disappeared.

Sentinel pile or tags are a common accompaniment of all the chronic fissures. Surgeons often do not pay attention to them [₂₃] and leave them untouched while relieving the spasm of the internal sphincter. Nevertheless, from the personal experience, we are of the opinion that these are to be removed for two reasons. First, they may interfere with the healing of the fissure, and second, they may be a cause of concern for the patient who would continue to experience ‘something' still left behind [9]. Studies [₂₄] has shown that presence of sentinel tag adversely affects healing of fissure in ano. Its removal also facilitates in keeping a good anal hygiene [2]. According to us, if the tag is small, it could be directly coagulated with a Ball Electrode.

When it is sufficiently large, it is excised with the Round Loop attachment after holding it in a haemostat flush position to the skin [₂₅]. Thereafter, the base is coagulated with the Ball electrode. Out of the 283 patients examined, 146 patients were found having these sentinel tags. The tags numbered ranged between one and three. In 89 cases, the tags were acutely inflamed and were painful to touch. Rests were in shrunken position and were non-tender.

These are exaggerated anal papillae, which with time attains excessive fibrous thickening, and acquire a rounded expanded tip, which can even be felt on digital examination [1].

We found as many as 17 patients having these polyps during our study. These were subjected to coagulation using the ball electrode. In case of voluminous masses, these were shaved off with a Loop Electrode after coagulation of the base, which was held in the haemostat.

These usually develop when the fissure is suppurated. The base of the fissure is indurated. It becomes the constant and nagging source of a foreign body sensation accompanied by intermittent pus discharge. It can be felt during a digital anal examination in the form of a tender nodule usually at 6 or 12 o'clock position. Seven of the patients under our study did have this pathology. The chances of recurrence of ano rectal symptoms are high if this pathology is not treated [₂₆].

This granuloma is curetted by frequent sweeps of a Loop Electrode in COAG mode kept at 60. After removing the mass, which looks yellow in color, the base starts oozing. Such bleeders could be secured by using a Ball Electrode and the resulting cavity is lightly packed for next 24 hours. Complete healing period required is about six weeks. The new tissue formation is healthy and strong enough to lead to a complete resolution.

The associated [₂₇] early degree of non-prolapsing hemorrhoids can be quickly dealt with radio frequency coagulation. The piles are directly coagulated in situ with the ball electrode having a long length[--]. This makes the procedure very simple, easy, without a need to excise or remove the pile mass. The bleeding is negligible. 48 patients having concomitant hemorrhoids were treated by this maneuver.

The history was typical. An infected or suppurated fissure was treated with antibiotics and anti-inflammatory drugs without draining the pus. The abscess cavity became ‘sterilized', and persisted as a lump that intermittently turned painful and edematous. There was sterile pus inside, but it seldom burst open. We came across nine such patients during our study.

The aim of treatment was to curette the complete cavity. It could be achieved by incising the center of the cavity using a Fine Wire Electrode in CUT/COAG mode. Then all the granulation tissues, which felt hard and have a little bleeding were scrapped out with a Round Loop Electrode until a soft red base was reached. The bleeding points were secured and the wound was left without attempting any primary closure allowing it to be healed in natural way.

All the patients under study, as aforesaid, were discharged within 24 hrs. A regular diet was started right from the first day. No special dressing was recommended except a twice-daily Sitz bath and application of xylocain and antiseptic ointment over the wound. The patients were able to resume normal duties in next few days.

Post defecation pain, minor bleeding, oozing from the wounds, and pruritus were but a few common postoperative complaints. Most of them got resolved within two weeks of the procedure.

The patients were followed up after 4 weeks. No patient complained of incontinence to faeces, while 12% of them had incontinence to flatus for first few days in the immediate postoperative period. The wounds of radio surgery were present, but there was no pain. No patient had any postoperative wound infection. Less than half of them did have complaints like wetness, itching, and irritation. This was predominantly a post defecation problem.

A further follow up after 8 weeks of the procedure showed complete healing of the wounds. No patient had any pain or discharge. However, there were several complaints of pruritus. Appropriate medication helped them get rid of it. The average wound healing time taken was about 6 weeks.

Thirty-nine patients [13.7%] failed to report for a follow up. From the remaining two hundred and forty four patients, in 93% cases, there was no recurrence of fissure or associated pathologies. 3% had developed hemorrhoids and had a complaint of intermittent bleeding episodes. 4% patients were found to have fissure but they were superficial and were causing pain and discomfort in defecation. They were prescribed medication and were relieved of the complaint.

A questionnaire was prepared before subjecting the patients to the procedure and they were noted in each case under the following headings.

1. Itching

2. Feeling of uneasiness in the anal region

3. Crawling sensation in the anus.

4. Discharge.

5. Sense of incomplete evacuation of bowel.

6. Discomfort while sitting.

7. Prolapse at the anus.

The above symptoms were entered according to the patient's complaints. Same questions were asked again when they came for follow up after 8 weeks and re entered in the questionnaire.

The comparative data is given in Fig. 2.

Figure 3

Figure 2: Comparative data of complaints before and after the RF procedure.

To demonstrate that removal of sentinel piles by RF is superior to the conventional surgical procedure, we carried out the following study.

Forty patients having a single, inflamed sentinel pile, associated with fissure in ano were selected at random. After the procedure of anal dilatation, a traditional approach of cutting and ligation of the sentinel pile base was performed while in the remaining twenty patients; the sentinel pile was removed by RF method described above. The following observations were noted. [Table No. 2] [Fig. No. 3]

Figure 4

Table 2: Comparative findings after RF and conventional surgical removal of sentinel piles.

Figure 5

Figure 3: Comparison and conventional and RF excision of sentinel pile.

Removing a lesion on someone who is on aspirin or anticoagulant therapy may be accompanied by increased bleeding. This aspect is required to be taken care of.

The unit should not be used in presence of flammable or explosive liquids or gases. The surgeon is also expected to remember to deactivate the hand piece whenever the electrodes are needed to be changed to avoid injury to his self or the patient [₃₃].

As with all radio frequency surgery machines, a smoke is produced on its application. This problem needs to be attended carefully to avoid the unpleasant smell of burning. The burning odour could be arrested with a vacuum extractor, with the aid of an assistant [₃₄].

Conclusion- Associated pathologies like hypertrophied anal papillae, fibrous polyps, sentinel tags; granuloma, post fissure fistula, and internal hemorrhoids may become a cause of concern to the treating physician while dealing with a patient of chronic fissure in ano. Studies show that a combination of anal stretching and radio frequency surgery is very effective, is an easy, and hassle free way of treating the disease.

Except the radio frequency unit, the procedure needs no specialized instruments and the procedure can be performed in any routine surgical set up. Reduced hospital stay, early return to work, and minimum chances of recurrence of the problem are the noteworthy achievements of the radio frequency surgery technique.