Changing patterns of treatment for chronic anal fissure.

To assess changing patterns of treatment for chronic anal fissure, a retrospective analysis of treatment for chronic anal fissure within one hospital between January 1990 and December 1996 was undertaken. A total of 221 patients received treatment for a chronic anal fissure in this period, of whom 209 had a surgical procedure. Manual dilatation of the anus was performed in 21 patients (10%) and has not been performed since 1995. Lateral internal sphincterotomy was performed in 183 patients (88%) and continues to be the mainstay of treatment. Five female patients (2%) were identified as having a sphincter defect by anal manometry combined with endoanal ultrasound and were treated by an anal advancement flap. From 1996 onwards, 15 patients (7%) were treated by topical glyceryl trinitrate (GTN) paste as the first line of treatment. Of these patients, nine have experienced healing of their fissure, and three have had relief of pain without healing of the fissure. Three have gone on to have a lateral internal sphincterotomy. Lateral internal sphincterotomy remains the primary form of treatment for chronic anal fissure. GTN cream has increasingly been offered as preliminary treatment over the last 12 months. Perioperative use of endoanal ultrasound allowed identification of patients who may be at high risk of postoperative incontinence from a sphincterotomy. An anal advancement flap has been used as an alternative surgical approach for these patients.     

A Study of Fecal Incontinence in Patients with Chronic Anal Fissure: Prospective,Randomized, Controlled Trial of the Extent of Internal Anal Sphincter Division During Lateral Sphincterotomy

Background Troublesome fecal incontinence following a lateral internal sphincterotomy is often attributed to faulty surgical technique. However, it may be associated with coexisting occult sphincter defects. Whether continence is related to the extent of sphincterotomy remains debatable. The aim of the study is to identify fecal incontinence related to chronic anal fissure before and after lateral internal sphincterotomy and its relationship to the extent of internal anal sphincter division. Methods One hundred eight patients with chronic anal fissure were prospectively studied before and after lateral internal sphincterotomy. A questionnaire was completed for each patient before and after surgery with regard to any degree of fecal incontinence. Fecal incontinence severity index was assessed using the Cleveland Clinic Incontinence Score. The patients with preoperative perfect continence were randomized into two groups (46 patients in each group): Group 1 underwent traditional lateral internal sphincterotomy (up to the dentate line) and Group 2 were underwent a conservative internal anal sphincterotomy (up to the height of the fissure apex or just below it). Results Minor degrees of incontinence were present before surgery in 16 patients (14.8%). Results of the randomized trial revealed that temporary postoperative incontinence was newly developed in 6/92 of patients (6.52 %) who did not have it before surgery. Five of the six (10.86%) were in Group 1 one (2.17%) was in Group 2 (p = 0.039). Persistent incontinence occurred in two in Group 1 (4.35%). All of them were females. All have had a history of one or more vaginal deliveries. Conclusion A mild degree of fecal incontinence may be associated with chronic anal fissure at presentation rather than as a result of internal sphincterotomy. Troublesome fecal incontinence after lateral internal sphincterotomy is uncommon. Sphincterotomy up to the dentate line provided faster pain relief and faster anal fissure healing, but it was associated with a significant postoperative alteration in fecal incontinence than was sphincterotomy up to the fissure apex. Care should be exercised in female patients with a history of previous obstetric trauma, as internal anal sphincter division may further compromise sphincter function.     

Advancement flap in the management of chronic anal fissure: a prospective study

Lateral internal sphincterotomy is the surgical treatment of choice of chronic anal fissure after failure of conservative measures. Several randomized trials identified an overall risk of incontinence of 10 % mostly for flatus. Fissurectomy is the most commonly used procedure to preserve the integrity of the anal sphincters. However, a possible complication is keyhole defect that may lead to faecal soiling. In this study, chronic anal fissure (CAF) was treated by fissurectomy and anal advancement flap to preserve the anatomo-functional integrity of sphincters and to reduce healing time and the risk of anal stenosis. In patients with hypertonia, surgical treatment was combined with chemical sphincterotomy by injection of botulinum toxin to enhance tissue perfusion. Forty eight patients with CAF underwent fissurectomy and anal advancement flap. In 22 subjects with hypertonia of the internal anal sphincter, intrasphincter injection of 30 UI of botulinum toxin at the completion of the surgical operation was used. All patients were followed up to 24 months. Since the first defecation, the intensity and duration of pain were significantly reduced. Two patients had urinary retention, five had infections and three had partial breakdowns. No anal stenosis, keyhole deformity or necrosis flap was recorded. At the 24 months follow-up visit, anal incontinence was similar to those detected preoperatively. Only four recurrences were detected at 18 and 20 months. After medical treatment failure, fissurectomy with advancement flap is a valid sphincter-conserving procedure for treatment of anterior or posterior CAF, regardless of hypertonia of the internal anal sphincter.     

Conservative versus surgical treatment for chronic anal idiopathic fissure: a prospective randomized trial

Anal fissure is a tear in the lining of the anal canal distal to the dentate line, which most commonly occurs in the posterior midline. Anal fissure was defined chronic if the patient presented with history of anal pain during defecation for at least 2 months with the observation of sphincter fibers at the base of the lesion. One hundred and forty-two consecutive patients with a chronic anal fissure with hypertonicity of internal sphincter on proctological examination were selected for this study from October 2008 to October 2010. Patients enrolled for the study were randomized to two groups by using a computer-generated list. Patients who underwent lateral internal sphincterotomy (LIS) were operated as day surgery procedures under local or epidural anesthesia. Patients randomized to conservative treatment were prescribed to use warm anal dilator with a nifedipine ointment 5 min twice daily for 4 weeks. Patients were clinically examined after 2, 4 and 8 weeks of treatment to evaluate if there was complete healing of the fissure. All patients were required to record pain after the first defecation, on 3rd and 7th postoperative day on a self-administered VAS scale in cm (0–10). Sixty-eight patients were randomly assigned to LIS, 74 to the conservative approach. Fifty-one patients of topical nifedipine group (68.9 %) and 60 patients of LIS group (88.2 %) presented an anal fissure healed at 8 weeks with a p value of 0.0077. As regards post-operative pain, 43 patients of LIS group (63.2 %) and 25 patients of topical nifedipine group (33.7 %) referred first defecation as painless. In the topical nifedipine group 43 (58.1 %) after 3 days since treatment and 35 (47.3 %) after 7 days had pain. In the LIS group 22 (32.3 %) after 3 days and 9 (13.2 %) after 7 days referred pain. There was no statistical difference between LIS and topical nifedipine group concerning side effects. Lateral internal sphincterotomy is an effective, less painful, fast recovery treatment for chronic anal fissure. Incontinence rate is overestimated and often the fear of a continence disturbance, albeit with a low incidence following surgery, may obscure the need to relieve symptoms which may be so severe as to make the patient’s life intolerable.     

Anal Stretch Plus Fissurectomy for Chronic Anal Fissure

Introduction : Anal fissure is a common disease. Usually chronic anal fissures are managed medically. When conservative management fails, surgical treatment should be considered. Lateral internal sphincterotomy has been advocated as the first choice invasive treatment but it has a reported rate of major fecal incontinence of 5%. In order to reduce the onset of major fecal incontinence after anal fissure surgery, it has been proposed to use the anal stretching plus fissurectomy.

Methods : From 2008 to 2011, 457 patients have been operated for chronic anal fissure.

Results : Twenty-seven patients underwent lateral internal sphincterotomy, two patients underwent posterior sphincterotomy and 428 patients underwent anal stretch plus fissurectomy. Satisfactory results have been reported in 95% of the cases. Transient incontinence rates have been of 3% after anal stretch and of 14,8% after lateral internal sphincterotomy (p < 0,05). Major and persistent incontinence rates have been reported in a case after later internal sphincterotomy (3%) but never after anal stretching (p = 0,059). Recurrence occurred in 2% of the patients after anal stretch and in 3% of the cases after lateral internal sphincterotomy (p = ns).

Conclusion : Lateral internal sphincterotomy and anal stretch have nearly a reported 95% of good results but the first have 3–5% rates of major incontinence.     

Nonsurgical treatment of chronic anal fissure: nitroglycerin and dilatation versus nifedipine and botulinum toxin.

BACKGROUND: Surgical sphincterotomy for chronic anal fissure can cause fecal incontinence. This has led to the investigation of nonsurgical treatment options that avoid permanent damage to the internal anal sphincter. METHODS: We conducted a retrospective, ongoing chart review with telephone follow-up of 88 patients treated for chronic anal fissure between November 1996 and December 2002. During the first half of the study period, patients were treated with topical nitroglycerin and pneumatic dilatation. With the availability of new therapies in June 1999, subsequent patients received topical nifedipine and botulinum toxin injections (30-100 units). Lateral anal sphincterotomy was reserved for patients who failed medical treatment. RESULTS: In 98% of patients the fissure healed with conservative nonsurgical treatment. The combination of nifedipine and botulinum toxin was superior to nitroglycerin and pneumatic dilatation with respect to both healing (94% v. 71%, p < 0.05) and recurrence rate (2% v. 27%, p < 0.01). There was no statistical difference between the number of dilatations and botulinum toxin injections needed to achieve healing. Three patients who received botulinum toxin reported mild transient flatus incontinence. At an average telephone follow-up of 27 months, 92% of patients reported having no pain or only mild occasional pain with bowel movements. CONCLUSIONS: Chronic anal fissures can be simply and effectively treated medically without the risk of incontinence associated with sphincterotomy. Topical nifedipine and botulinum toxin injections are an excellent combination, associated with a low recurrence rate and minimal side effects.     

Botulinum toxin injection versus lateral internal sphincterotomy for the treatment of chronic anal fissure: randomized prospective controlled trial

Purpose

Lateral internal sphincterotomy has been the gold standard treatment for chronic anal fissure, but it still carries the risk of permanent damage of the anal sphincter, which has led to the implementation of alternative treatment like botulinum toxin injection. The aim of this randomized prospective controlled trial was to compare the efficacy and morbidity of botulinum toxin injection and lateral internal sphincterotomy in the treatment of chronic anal fissure.

Methods

Fifty consecutive adults with chronic anal fissure were randomly treated with either lateral internal sphincterotomy or botulinum toxin (BT) injection with 50 U BT into the internal sphincter. The complications, healing and recurrence rate, and incontinence score were assessed 2, 3, 6, 12 months after the procedure.

Results

Inspection at the 2-month visit revealed complete healing of the fissure in 11 (44?%) of the patients in the BT group and 22 (88?%) of the patients in the lateral internal sphincterotomy (LIS) group (p?=?0.001). At the 3-month visit, there was no significant difference between the two groups in healing. The overall recurrence rate after 6 months in the BT group was higher than in the LIS group (p?<?0.05). In the 3-month follow-up, the LIS group had a higher rate of anal incontinence compared to the BT group (p?<?0.05). The final percentage of incontinence was 4?% in the LIS group (p?>?0.05).

Conclusions

The treatment of chronic anal fissure must be individualized depending on the different clinical profiles of patients. Botulinum toxin injection has a higher recurrence rate than LIS, and LIS provides rapid and permanent recovery. However, LIS carries a higher risk of anal incontinence in patients.     

Results following conservative lateral sphincteromy for the treatment of chronic anal fissures

Introduction Lateral sphincterotomy is now the standard surgical treatment for fissure‐in‐ano. Healing is achieved in 90% of cases, however, sphincterotomy also carries a significant risk of incontinence. Traditional sphincterotomy comprises of division of the internal sphincter up to the level of the dentate line, a more conservative division could lead to a lower incontinence rate, with an equivalent healing rate. Materials and methods A total of 65 patients undergoing conservative lateral sphincterotomy under a single operator between January 1996 and January 2002 were reviewed. Specific questions were asked regarding overall success of the operation, leakage of fluid, faeces or flatus and recurrence of fissure symptoms. Supplemental data was obtained from a retrospective analysis of the patients' case notes to ascertain demographics, length of hospital stay and complication rate. Results Sixty of 65 patients responded to our postal questionnaire. The male to female ratio was 1 : 1 and the mean age 40.3 years of age. No complications were recorded and 97% of patients had achieved fissure healing by the time of their out‐patient follow‐up (mean 6.9 weeks). Two patients reported new incontinence following their procedure; one patient experienced incontinence of fluid and flatus (1.7%) and the remaining patient complained of incontinence to flatus only. No patients experienced incontinence of faeces. Eleven patients experienced persistent symptoms of pain and bleeding but only 6 of these patients required treatment from their general practitioner which consisted of stool softeners and topical analgesia. No patients required re‐operation. Conclusion A conservative division of the internal anal sphincter results in adequate fissure healing and a much lower incontinence rate than that previously recorded in the literature for more traditional divisions of the internal anal sphincter.     

Comparative Study of Glyceryl Trinitrate Ointment Versus Surgical Management of Chronic Anal Fissure

Chronic Anal Fissure (CAF) is common perineal condition and well-known painful entity. Standard surgical treatment even though available, may require long hospital stay and sometimes have worrying complications like anal incontinence. So non-surgical treatment, Glyceryl Trinitrate has been shown to be an effective for chronic anal fissure. It decreases anal tone and ultimately heals the anal fissure. The present study is the attempt to know the efficacy of 0.2% Glyceryl Trinitrate ointment in the treatment of chronic anal fissure and to compare the effectiveness of 0.2% Glyceryl Trinitrate ointment (GTN) versus fissurectomy with lateral internal sphincterotomy (LIS) and fissurectomy with posterior internal sphincterotomy (PIS) in the management of chronic anal fissure. This is a prospective comparative study of management of chronic anal fissure done in our hospital during the period of one and half year from October 2005 to March 2007. Thirty patients treated with 0.2% Glyceryl Trinitrate ointment and 30 patients treated with fissurectomy and lateral internal sphincterotomy and 30 patients treated with posterior internal sphincterotomy, for chronic anal fissure were selected for study. A single brand of 0.2% Glyceryl Trinitrate ointment (Nitrogesic) used for trial arm. Dose of administration was 1.5 cm to 2 cm in the anal canal with device provided by manufacturers of the proprietary preparation and applied twice a daily for 12 weeks. Patients were followed up for 12 weeks and thereafter evaluated for relief of symptoms in all three groups. Observations were recorded at 2 weeks; 6 weeks and 12 weeks of follow up period, regarding symptoms like pain and bleeding during defecation, healing of CAF and also for side effects like headache in GTN group and flatus, fecal incontinence in surgical groups. Data collected in proforma and analyzed. Study revealed CAF was more in male 59 patients (66%) than the female 31 patients (34%), the ratio being 1: 0.52. The maximum number of patients was encountered in the age group of 20 to 40 years with mean duration of age 34.14 years. In all three groups symptoms like pain, bleeding, constipation and sphincter spasm were present. Sentinel pile was present in 56% of the patients. Common site of fissure was found to be posterior in 94% of patients. Observations with respect to relief of pain, no bleeding and healing were recorded at 2, 6 and 12 weeks of duration. Lateral sphincterotomy remains effective but should be reserved for the patients who fail to respond to initial chemical sphincterotomy or GTN therapy. GTN is good alternative mode of therapy for patients who refuse surgery and prefer medical line of treatment.     

Internal anal sphincter function following lateral internal sphincterotomy for anal fissure: a long-term manometric study

BACKGROUND: Anal fissure is a common and painful disorder. Its relation to hypertonic anal sphincter is controversial. The most common surgical treatment of chronic anal fissure is lateral internal sphincterotomy. OBJECTIVE: The aim of this study was to evaluate long-term manometric results of sphincter healing following lateral internal sphincterotomy. PATIENTS AND METHODS: Between 2000 and 2003, 50 patients with anal fissure were included in this study and underwent sphincterotomy; 12 healthy patients served as controls. All patients with anal fissure underwent manometric evaluation using a 6-channel perfusion catheter. All patients were examined 1 month before surgery and 1, 3, 6, and 12 months following surgery. The control group had 3 manometric evaluations 6 months apart. RESULTS: The mean basal resting pressure before surgery was 138 +/- 28 mm Hg. One month after surgery, the pressure dropped to 86 +/- 15 mm Hg (P < 0.0001) and gradually rose to a plateau at 12 months (110 +/- 18 mm Hg, P < 0.0001). At 12 months, the manometric pressure was significantly lower than the baseline (P < 0.0001). However, manometric measurements in the fissure group were still significantly higher than in the control group (110 +/- 18 versus 73 +/- 4.8 mm Hg, P < 0.0001). All patients were free of symptoms at the 12-month follow-up. CONCLUSION: Lateral internal sphincterotomy caused a significant decline in the resting anal pressure. During the first year following surgery, the tone of the internal anal sphincter gradually increased, indicating recovery, but still remained significantly lower than before surgery. However, postoperative resting pressures were higher than those in the control, and no patient suffered any permanent problems with incontinence, so this decrease may not be clinically significant.     

控制性括约肌侧切术治疗陈旧性肛裂的临床疗效

为探讨控制性括约肌侧切术治疗陈旧性肛裂的疗效，将118例陈旧性肛裂患者随机分为两组，分别采用控制性内括约肌侧切术（治疗组）和传统的内括约肌侧切扩肛术（对照组）治疗，并对比分析两组治疗结果。结果显示，两组患者均一次性治愈，均无大便失禁发生。但治疗组和对照组分别有1例和6例肛门气体失禁。随访至今，治疗组无复发，对照组复发1例。结果表明，控制性括约肌侧切术减少了不必要的组织损伤，更好地保护了肛门功能，可～次性治愈陈旧性肛裂，且操作简单，适合基层医疗单位推广应用。     

Laterale, partielle Sphinkteromyotomie zur Therapie der chronischen Analfissur

AIM: We observed a relatively high rate of severe forms of anal incontinence in patients who had undergone lateral, partial, internal, open sphincterotomy for chronic fissure in ano years ago in our clinic. An explicit investigation of pre- and postoperative data for a representative patient group was undertaken to find out whether this incidental finding proved to be meaningful. PATIENTS AND METHODS: The perioperative data from 523 patients who underwent sphincterotomy (Parks) between 1986 and 1997 were analyzed by uni- and multivariate analysis. RESULTS: Of 209 patients included in the study, 94.7% could be considered healed after operation. Up until the 12th postoperative week, 14.8% of patients were incontinent in stage I and II (Parks). This increased up to 21% at the time of follow-up, mainly in stage II and III, which significantly differed from a healthy control group. CONCLUSION: Lateral sphincterotomy leads in most cases to quick healing of the chronic fissure in ano with a low recurrence rate. The added effect of degenerative changes was observed to be linked, however, with a higher long-term rate of anal incontinence.     

Long term outcomes after lateral anal sphincterotomy for anal fissure: a retrospective cohort study

Purpose

Lateral anal sphincterotomy is the gold standard of surgical treatment for anal fissure. Patients undergoing this procedure are warned about the risk of incontinence; however, there are few reports on long-term outcomes. We conducted this study to investigate long-term outcomes after lateral anal sphincterotomy, focusing specifically on postoperative incontinence.

Methods

Patients who underwent lateral anal sphincterotomy at a university teaching hospital between 1998 and 2004 were sent questionnaires to allow us to assess their continence according to the Cleveland Continence Score.

Results

The response rate was 58 % and the responders comprised 25 men and 13 women, with a median age of 49 years (range 16–82 years). The success rate for fissure healing following surgery was 92 %, being significantly more likely in patients with textbook symptoms (p = 0.016) and those with chronic disease (p = 0.006). The overall complication rate was 13.2 %. Long-term objective and symptomatic incontinence were reported by two (5.6 %) patients, one of whom required a colostomy.

Conclusion

Success rates after lateral anal sphincterotomy were satisfactory, but careful patient selection based on symptoms and disease chronicity may improve results further. Patients with predisposing risk factors for the development of incontinence, particularly multiparous women, are arguably better treated with non-surgical options.     

Fissure-in-ano, to divide or not to divide?

Anal fissure is one of the most common and painful proctological pathologies affecting mainly young individuals. The physiopathology in the development of a chronic anal fissure seems to be a combination of internal anal sphincter hypertonia and poor vascularization at the posterior midline. Treatment of acute fissures is conservative with supportive therapy, leading to healing in the majority of the patients. Open or closed lateral internal sphincterotomy is the treatment of choice for chronic anal fissures. In low pressure chronic fissures, sphincterotomy should be avoided and a V-Y island advancement flap may be an alternative procedure. Sphincterotomy can induce anal incontinence, a feared complication of this technique. Recent interest has developed in chemical sphincterotomy with local botulin toxin injections or glyceryl trinitrate application. Long-term follow-up is needed to evaluate these new therapeutic options.     

Surgical versus chemical (botulinum toxin) sphincterotomy for chronic anal fissure: long-term results of a prospective randomized clinical and manometric study

BACKGROUND: The aim of this prospective randomized trial was to compare the effectiveness and morbidity of surgical versus chemical sphincterotomy in the treatment of chronic anal fissure after a 3-year follow-up. METHODS: Eighty patients with chronic anal fissure were treated by whether open lateral internal sphincterotomy (group 1) or chemical sphincterotomy with 25 U botulinum toxin injected into the internal sphincter (group 2). Clinical and manometric results were analyzed. RESULTS: Overall healing was 92.5% in the open sphincterotomy group and 45% in the toxin botulinum group (P<.001). There is a group of patients with clinical (duration of disease >12 months and presence of a sentinel pile before treatment) and manometric factors (persistently elevated mean resting pressure, % of time presence of slow waves, and number of patients or the time presence ultra slow waves after treatment) associated with a higher recurrence of anal fissure. The final percentage of incontinence was 5% in the open sphincterotomy group and 0% in the botulinum toxin group (P>.05). CONCLUSION: We recommend surgical sphincterotomy as the first therapeutic approach in patients with clinical and manometric factors of recurrence. We prefer the use of botulinum toxin in patients older than 50 years or with risk factors for incontinence, despite the higher rate of recurrence, since it avoids the greater risk of incontinence in the surgical group.     

Chronic anal fissure: 1994 and a decade later--are we doing better?

BACKGROUND: Debate exists regarding whether the use of topical agents and Botox injections are as efficacious as sphincterotomy for the treatment of chronic anal fissure. METHODS: A retrospective review was performed to assess changes in management and outcomes of chronic anal fissure care in a community based colorectal practice between the individual years 1994 and 2003. RESULTS: Forty-seven patients in 1994 underwent lateral partial internal sphincterotomy and had a 100% healing rate. Thirty-nine patients were treated in 2003, with 32 undergoing Botox injection and 7 undergoing sphincterotomy initially. Of the Botox patients, 35% had recurrence, and 7 subsequently required sphincterotomy. Ultimate healing rates in 2003 were 97%. Time to heal was markedly prolonged in 2003 compared with 1994. Complication rates were similar, and there was no lifestyle-altering incontinence. CONCLUSIONS: Our review documents a significant change in the community approach to chronic fissure management. The addition of multiple treatment modalities prolongs time to healing from initial evaluation, but they allowed 72% of patients to avoid the need for permanent sphincter division while maintaining ultimate rates of healing.     

The Treatment of Chronic Anal Fissure with Botulinum Toxin

Background /Aims: The aim of this study was to evaluate the effectiveness of botulinum toxin for the treatment of uncomplicated dorsal chronic idiopathic anal fissure.

Material and Methods: Forty-five patients who reported post defecatory anal pain since two months or more were given a total of 20U botulinum toxin in the anal sphincter apparatus on both sides as well as below the anal fissure. Results: Thirty-seven patients received a second session of 25U botulinum toxin injection. Thirty-five patients (78%) presented completely healed anal fissure, while ten needed lateral internal sphincterotomy. All patients were followed up for 8-36 months. Two patients relapsed.

Conclusion: Local injection of botulinum toxin is a new and safe treatment; however, two sessions of injections are necessary to be effective and long-term follow-up to assess the recurrence rate of fissure is needed to evaluate further this method of treatment. Partial internal lateral sphincterotomy is no more the treatment of choice for chronic anal fissure.     

Treatment of anal fissure by lateral subcutaneous internal sphincterotomy]

50 patients have been followed up after lateral internal sphincterotomy for chronic anal fissure. The results are excellent. This operation has some advantages over against the posterior sphincterotomy or the sphincter stretching and should replace these latter procedures in the treatment of chronic anal fissure. The lateral internal sphincterotomy may probably be applied for other benign anal lesions.     

两种术式治疗肛裂前后肛管直肠压变化的比较

通过对两种术式治疗肛裂前后肛管直肠压的变化观察,探讨可能造成肛裂术后肛门失禁的原因,为寻找更优的手术方法提供依据。将确诊的100例肛裂患者随机分成治疗组和对照组,治疗组50例采用肛门内括约肌侧位切断术,对照组50例采用肛门内括约肌后位切断术。对两种治疗肛裂的术式手术前后肛管直肠压、疗程及术后并发症、术后疼痛、术后排便等指标进行观察统计。结果显示,治疗后两组患者症状评分均较治疗前降低,两组近期疗效、术后并发症（创13水肿、创口感染、肛门狭窄、术后排尿困难）、术后排便情况差异无统计学意义（P〉0．05）,在疗程、术后出血、术后疼痛及肛管直肠压方面治疗组优于对照组（P〈0．05）。结果表明,肛门内括约肌侧位切断术较肛门内括约肌后位切断术治疗肛裂具有创口小、愈合快、痛苦小、并发症少、安全性高等优点。     

Fistulotomy or seton in anal fistula: a decisional algorithm

Fistula in ano is a common proctological disease. Several authors stated that internal and external anal sphincters preservation is in the interest of continence maintenance. The aim of the present study is to report our experience using a decisional algorithm on sphincter saving procedures that achieved us to obtain good results with low rate of complications. From 2008 to 2011, 206 patients underwent surgical treatment for anal fistula; 28 patients underwent perianal abscess drainage plus seton placement of trans-sphincteric or supra-sphincteric fistula (13.6 %), 41 patients underwent fistulotomy for submucosal or low inter-sphincteric or low trans-sphincteric anal fistula (19.9 %) and 137 patients underwent partial fistulectomy or partial fistulotomy (from cutaneous plan to external sphincter muscle plan) and cutting seton placement without internal sphincterotomy for trans-sphincteric anal fistula (66.50 %). Healing rates have been of 100 % and healing times ranged from 1 to 6 months in 97 % of patients treated by setons. Transient fecal soiling was reported by 19 patients affected by trans-sphincteric fistula (11.5 %) for 4–6 months and then disappeared or evolved in a milder form of flatus occasional incontinence. No major incontinence has been reported also after fistulotomy. Fistula recurred in five cases of trans-sphincteric fistula treated by seton placement (one with abscess) (1/28) (3.5 %) and four with trans-sphincteric fistula (4/137) (3 %). Our algorithm permitted us to reduce to 20 % sphincter cutting procedures without reporting postoperative major anal incontinence; it seems to open an interesting way in the treatment of anal fistula.