مقايسه دو روش اسفنكتروتومي باز و بسته در درمان فيشر مزمن آنال

Comparison of Open and Closed Sphincterotomy in the Treatment of Chronic anal Fissure

ﺯﻣﻴﻨﻪ ﻭ ﻫﺪﻑ: ﻓﻴﺸﺮ ﻣﺰﻣﻦ ﺁﻧﺎﻝ ﺑﻴﻤﺎﺭﻱ ﺷﺎﻳﻌﻲ ﻣﻲ ﺑﺎﺷﺪ ﮐﻪ ﺑﺎ ﺩﺭﺩ ﻭ ﺧﻮﻧﺮﻳﺰﻱ ﻫﻨﮕﺎﻡ ﺩﻓﻊ ﻣﺪﻓﻮﻉ ﺑﺮﻭﺯ ﻣﻲ ﮐﻨﺪ. ﺩﺭ ﻣﻮﺍﺭﺩﻱ ﮐﻪ ﺩﺭﻣﺎﻥ ﻫﺎﻱ ﻧﮕﻬﺪﺍﺭﻧﺪﻩ ﭘﺎﺳﺦ ﻧﺪﻫﻨﺪ ﺟﺮﺍﺣﻲ ﺍﺳﻔﻨﮑﺘﺮﻭﺗﻮﻣﻲ ﺑﻪ ﺩﻭ ﺭﻭﺵ ﺑﺎﺯ ﻭ ﺑﺴﺘﻪ ﻗﺎﺑﻞ ﺍﻧﺠﺎﻡ ﺍﺳﺖ. ﺩﺭ ﺍﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻧﺘﺎﻳﺞ ﻭ ﻋﻮﺍﺭﺽ ﺍﺳﻔﻨﮑﺘﺮﻭﺗﻮﻣﻲ ﺑﺎﺯ ﻭ ﺑﺴﺘﻪ ﻣﻘﺎﻳﺴﻪ ﺷﺪﻩ ﺍﺳﺖ. ﻣﻮﺍﺩ ﻭ ﺭﻭﺵ ﻫﺎ: ﺩﺭ ﺍﻳﻦ ﻣﻄﺎﻟﻌﻪ ﮐﺎﺭﺁﺯﻣﺎﻳﻲ ﺑﺎﻟﻴﻨﻲ، 31 ﺑﻴﻤﺎﺭ ﻣﺒﺘﻼ ﺑﻪ ﻓﻴﺸﺮ ﺁﻧﺎﻝ ﻣﺰﻣﻦ ﺑﻪ ﺭﻭﺵ ﺑﺎﺯ ﻭ 29 ﺑﻴﻤﺎﺭ ﺑﻪ ﺭﻭﺵ ﺑﺴﺘﻪ ﺗﺤﺖ ﺍﺳﻔﻨﮑﺘﺮﻭﺗﻮﻣﻲ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻨﺪ. ﻃﻮﻝ ﻣﺪﺕ ﺟﺮﺍﺣﻲ، ﻣﺪﺕ ﺑﺴﺘﺮﻱ، ﺷﺪﺕ ﺩﺭﺩ ﺑﻌﺪ ﺍﺯ ﻋﻤﻞ ﻭ ﻋﻮﺍﺭﺽ ﺟﺮﺍﺣﻲ ﺩﻭ ﮔﺮﻭﻩ ﻣﻘﺎﻳﺴﻪ ﺷﺪ. ﺑﻴﻤﺎﺭﺍﻥ 6 ﻣﺎﻩ ﭘﺲ ﺍﺯ ﺟﺮﺍﺣﻲ ﺍﺯ ﻧﻈﺮ ﻋﻮﺩ ﺗﺤﺖ ﺑﺮﺭﺳﻲ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻨﺪ. ﻳﺎﻓﺘﻪ ﻫﺎ: ﻣﺪﺕ ﺟﺮﺍﺣﻲ ﺍﺳﻔﻨﮑﺘﺮﻭﺗﻮﻣﻲ ﺑﺴﺘﻪ 19/5±5/5 ﺩﻗﻴﻘﻪ ﻭ ﺍﺳﻔﻨﮑﺘﺮﻭﺗﻮﻣﻲ ﺑﺎﺯ 45/5 ±4/8ﺩﻗﻴﻘﻪ ﺑﻮﺩﻩ ﺍﺳﺖ ﮐﻪ ﺗﻔﺎﻭﺕ ﺑﻴﻦ ﺩﻭ ﮔﺮﻭﻩ ﺍﺯ ﻧﻈﺮ ﺁﻣﺎﺭﻱ ﻗﺎﺑﻞ ﺗﻮﺟﻪ ﺑﻮﺩ )P <0.001(. ﻣﺪﺕ ﺑﺴﺘﺮﻱ ﺑﻪ ﺩﻧﺒﺎﻝ ﺍﺳﻔﻨﮑﺘﺮﻭﺗﻮﻣﻲ ﺑﺴﺘﻪ 2/8±0/5 ﺭﻭﺯ ﻭ ﺑﻪ ﺩﻧﺒﺎﻝ ﺍﺳﻔﻨﮑﺘﺮﻭﺗﻮﻣﻲ ﺑﺎﺯ 3/2±0/4 ﺭﻭﺯ ﺑﻮﺩ ﮐﻪ ﺍﺧﺘﻼﻑ ﺍﺯ ﻧﻈﺮ ﺁﻣﺎﺭ ﻣﻌﻨﻲ ﺩﺍﺭ ﻣﻲ ﺑﺎﺷﺪ P= 0.003(. 46/9 ﺑﻴﻤﺎﺭﺍﻥ ﺩﺭ ﮔﺮﻭﻩ ﺍﺳﻔﻨﮑﺘﺮﻭﺗﻮﻣﻲ ﺑﺎﺯ ﻭ 20/7 ﺑﻴﻤﺎﺭﺍﻥ ﺩﺭ ﮔﺮﻭﻩ ﺍﺳﻔﻨﮑﺘﺮﻭﺗﻮﻣﻲ ﺑﺴﺘﻪ ﻧﻴﺎﺯ ﺑﻪ ﻣﺨﺪﺭ ﺟﻬﺖ ﺗﺴﮑﻴﻦ ﺩﺭﺩ ﺩﺍﺷﺘﻨﺪ ﮐﻪ ﺍﻳﻦ ﺍﺧﺘﻼﻑ ﺍﺯ ﻧﻈﺮ ﺁﻣﺎﺭﻱ ﻣﻌﻨﻲ ﺩﺍﺭ ﺑﻮﺩ )032.P = 0(. ﺍﺯ ﻧﻈﺮ ﺑﺮﻭﺯ ﺧﻮﻧﺮﻳﺰﻱ ﺑﻌﺪ ﻋﻤﻞ ﺍﺧﺘﻼﻓﻲ ﺑﻴﻦ ﺩﻭ ﮔﺮﻭﻩ ﻣﺸﺎﻫﺪﻩ ﻧﺸﺪP=0.285 (. ﺍﺯ ﻟﺤﺎﻅ ﻫﻤﺎﺗﻮﻡ ﺑﻪ ﺩﻧﺒﺎﻝ ﺟﺮﺍﺣﻲ ﺗﻔﺎﻭﺗﻲ ﺑﻴﻦ ﺩﻭ ﺭﻭﺵ ﺍﺳﻔﻨﮑﺘﺮﻭﺗﻮﻣﻲ ﺑﺎﺯ )6/3 ﻭ ﺍﺳﻔﻨﮑﺘﺮﻭﺗﻮﻣﻲ ﺑﺴﺘﻪ )10/3 ﻭﺟﻮﺩ ﻧﺪﺍﺷﺖ. ﺁﺑﺴﻪ ﺗﻨﻬﺎ ﺩﺭ ﻳﮏ ﻣﻮﺭﺩ ﺑﻪ ﺩﻧﺒﺎﻝ ﺍﺳﻔﻨﮑﺘﺮﻭﺗﻮﻣﻲ ﺑﺴﺘﻪ ﻣﺸﺎﻫﺪﻩ ﺷﺪ. ﺑﻲ ﺍﺧﺘﻴﺎﺭﻱ ﻣﺪﻓﻮﻉ ﺩﺭ ﻫﻴﭻ ﮐﺪﺍﻡ ﺍﺯ ﺑﻴﻤﺎﺭﺍﻥ ﺩﻭ ﮔﺮﻭﻩ ﺭﺥ ﻧﺪﺍﺩ. ﻋﻮﺩ ﺩﺭ ﻫﻴﭻ ﺑﻴﻤﺎﺭﻱ ﺍﺯ ﺩﻭ ﮔﺮﻭﻩ ﺑﻌﺪ ﺍﺯ 6 ﻣﺎﻩ ﻣﺸﺎﻫﺪﻩ ﻧﺸﺪ. ﻧﺘﻴﺠﻪ ﮔﻴـﺮﻱ: ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﻧﺘﺎﻳﺞ ﻣﺸﺎﺑﻪ ﺑﻴﻦ ﺩﻭ ﺭﻭﺵ ﻭ ﻣﺪﺕ ﺟﺮﺍﺣﻲ ﮐﻮﺗﺎﻩ ﺗﺮ ﻭ ﺩﺭﺩ ﮐﻤﺘﺮ ﺑﻌﺪ ﺍﺯ ﺍﺳﻔﻨﮑﺘﺮﻭﺗﻮﻣﻲ ﺑﺴﺘﻪ ﺑﻪ ﻧﻈﺮ ﻣﻲ ﺭﺳﺪ ﺍﺳﻔﻨﮑﺘﺮﻭﺗﻮﻣﻲ ﺑﺴﺘﻪ ﺑﺘﻮﺍﻧﺪ ﺟﺎﻳﮕﺰﻳﻦ ﻣﻨﺎﺳﺒﻲ ﺑﺮﺍﻱ ﺍﺳﻔﻨﮑﺘﺮﻭﺗﻮﻣﻲ ﺑﺎﺯ ﺑﺎﺷﺪ.

Introduction & Objective: Chronic anal fissure is a common anorectal disease which present itself with pain and hemorrhage during defecation. If conservative treatments with high fibers regiments and sitz bath don’t cure the chronic anal fissure, sphincterotomy can be done by open or closed technique. In this study we compare the outcomes and complications of open and close sphincterotomy. Materials & Methods: In this clinical trial study, 32 patients underwent open sphincterotomy and 29 patients underwent close sphincterotomy. The duration of surgery and hospital admission, post-operative pain and hemorrhage, late complications and recurrence were compared between the closed and open sphincterotomy. Results: The average surgery time of closed and open sphincterotomy were 19.5 ± 5.5 and 45.5±4.84 minutes respectively. The difference was statistically significant (P <0.001). The duration of hospital admission was 2.8 ± 0.5 and 3.2 ± 0.4 days after closed and open sphincterotomy respectively. This difference was statistically significant (P= 0.003). 46.9% of patients after open sphincterotomy and 20.7% of patients after close sphincterotomy needed opium to control post-operative pain which was significantly different between the two groups, (P = 0.032). There was no significant difference in post - operative hemorrhage or incontinency between the two groups. There was no recurrence after 6 months of follow up. Conclusions: The long term and short term outcomes are similar after open and closed sphincterotomy, but operation and admission times and post-operative pain was significantly less in closed sphincterotomy. So closed sphincterotomy seems a suitable alternative for open sphincterotomy.