Successful Sentinel Pile Excision for Chronic Anal Fissure with Bleeding

Chief Complaints

A 50-year-old female patient with a body mass index (BMI) of 19 presented to the Surgical Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with a history of painful defecation, bleeding per rectum, and intermittent constipation for the past two years. The pain was sharp in nature and occurred during defecation. The bleeding was noted as streaks smearing the stool. She had been on medical treatment for these symptoms, with only partial relief.

The patient had no known comorbidities such as diabetes mellitus, hypertension, or other chronic systemic illnesses. She had no history of prior perianal surgeries or similar anorectal conditions. She was not on any long-term medications and had no significant past medical history contributing to her present condition.

On examination, the patient was conscious, coherent, and oriented, and was hemodynamically stable. General physical examination revealed no significant abnormalities, and there was no pallor, icterus, cyanosis, clubbing, or pedal edema. Abdominal examination showed a soft, non-tender abdomen with no palpable masses or organomegaly, and bowel sounds were normal. Perianal examination (under anesthesia findings) revealed a chronic anal fissure in the posterior midline at the 6 o’clock position with an associated sentinel skin tag, along with increased anal sphincter tone prior to dilatation. No other anorectal abnormalities were noted.

Upon admission to PACE Hospitals, the patient was thoroughly evaluated by the Surgical Gastroenterology team. She presented with a history of painful defecation, bleeding per rectum, and intermittent constipation for the past two years, with pain being sharp in nature and occurring during defecation. The bleeding was described as streaking the stool and was associated with significant discomfort. The patient had been on conservative medical management earlier, with only partial symptomatic relief.

The clinical presentation was suggestive of a chronic anal fissure in ano, likely associated with persistent internal sphincter spasm and formation of a sentinel skin tag due to long-standing disease. Further evaluation and perianal examination confirmed the presence of a chronic fissure in the posterior midline (6 o’clock position) with an associated sentinel pile.

Based on the clinical findings and confirmed diagnosis, the patient was advised to undergo Chronic Anal Fissure Treatment in Hyderabad, India, under the expert care of the Surgical Gastroenterology Department, aimed at relieving sphincter spasm, reducing pain during defecation, promoting healing of the fissure, and preventing recurrence.

After a detailed consultation with Dr. CH Madhusudan, Senior Consultant Surgical Gastroenterologist and Liver Transplant Surgeon, along with the team, including Dr. Suresh Kumar S, Consultant Surgical Gastroenterologist, a comprehensive evaluation was carried out considering the patient’s clinical symptoms of long-standing painful defecation, bleeding per rectum, and intermittent constipation, along with all relevant laboratory investigations. The findings were consistent with a diagnosis of chronic anal fissure in ano with associated sentinel pile formation, confirmed on perianal examination.

Based on the clinical presentation and examination findings, it was determined that Manual Anal Dilatation with Sentinel Pile Excision as the most appropriate therapeutic intervention. This decision was made with the intent to relieve internal anal sphincter spasm, reduce pain during defecation, improve local blood flow to facilitate fissure healing, excise the associated sentinel pile, and prevent recurrence of symptoms.

The patient and her family members were counselled regarding the diagnosis, the planned procedure, potential risks and benefits, postoperative care including dietary modifications and sitz bath, expected recovery course, and the importance of follow-up for optimal outcomes.

Following the decision, the patient was scheduled to undergo Manual Anal Dilatation with Sentinel Pile Excision Surgery in Hyderabad at PACE Hospitals, under the expert care of the Surgical Gastroenterology Department.

The procedure involved the following steps: 

• Patient Preparation and Positioning: The patient was taken to the operating room after obtaining informed consent and completing pre-anesthetic evaluation. Under appropriate anesthesia, the patient was positioned in the lithotomy position, ensuring proper exposure of the perianal region. Standard aseptic and antiseptic precautions were followed, and the surgical field was draped.

• Examination Under Anesthesia (EUA): A careful perianal examination under anesthesia was performed. A chronic anal fissure was identified in the posterior midline at the 6 o’clock position, along with an associated sentinel skin tag (sentinel pile). No additional anorectal pathology was noted.

• Sentinel Pile Excision: The sentinel pile/skin tag associated with the chronic fissure was carefully grasped and excised using appropriate surgical instruments. Hemostasis was achieved to prevent bleeding, and the excised tissue was managed as per standard protocol.

• Manual Anal Dilatation: Gradual manual anal dilatation was performed in a controlled manner to reduce internal anal sphincter spasm. The anal canal was gently stretched until two fingers could be easily admitted, ensuring adequate relaxation of the sphincter without causing trauma.

• Hemostasis, Final Check, and Completion: The surgical site was thoroughly inspected to ensure no active bleeding or complications. Hemostasis was confirmed, and the area was cleaned and dressed. The procedure was completed successfully and was uneventful, after which the patient was shifted to the recovery room for observation.
  

The procedure was uneventful. Postoperatively, the patient developed headache and vomiting, which were managed conservatively. A neurology opinion was obtained in view of the associated tingling sensation and persistent headache, and appropriate evaluation and recommendations were followed. The patient improved with conservative management and was discharged in a hemodynamically stable condition with the advised postoperative care and follow-up instructions.

The patient was discharged with medications prescribed for postoperative care, including agents to prevent infection, reduce pain and inflammation, provide gastric protection, and ensure bowel softening to avoid straining during defecation. Additional supportive medications were advised on an as-needed basis for management of breakthrough pain and associated symptoms.

The patient was advised to follow a high-fiber diet to maintain soft stools and prevent constipation. She was also instructed to take sitz baths three times daily to promote local hygiene, reduce discomfort, and aid in postoperative healing.

The patient was informed to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as Fever, pain, bleeding at the site, vomiting, or chest pain.

The patient was advised to return for a follow-up visit with the Surgical Gastroenterologist in Hyderabad at PACE Hospitals, after 3 days, to review her condition.

This case highlights a chronic fissure in ano managed successfully with manual anal dilatation and sentinel pile excision. The procedure was uneventful, and the postoperative course remained stable with conservative management of transient symptoms. The patient showed good clinical recovery and was discharged in a hemodynamically stable condition. She was advised of dietary modifications, a sitz bath, and regular follow-up for further evaluation.