Chronic anal fissure

Chronic anal fissure is a common condition usually treated by maximal anal dilatation or lateral subcutaneous sphincterotomy. The following method is based on a common surgical principal; to widen a stenosed tube a longitudinal incision is made across the stenosed area and this is sutured transversely as in pyloroplasty. This method of anoplasty is simple and appears to have no resultant complications. Further studies are necessary before its value can be established compared to the presently accepted methods of treatment.     

Chronic anal fissure

Opinion statement Today, chronic anal fissure can be treated and often cured by nonsurgical therapy. Both topical application of glyceryl tri nitrate and intra-sphincteric injection of botulinum toxin appear to be safe and effective in relieving symptoms and in healing the anal fissure in 70% to 90% of patients. These drugs should now be regarded as the mainstay of therapy for chronic fissure-in-ano. Surgery should only be performed in refractory cases and should no longer be the first-line approach, largely because of the unpredictable and unacceptable adverse effects. It is important to emphasize that although the aforementioned therapies can heal fissure-in-ano, simpler lifestyle measures may be effective in the majority of patients with acute anal fissure. These include avoiding excessive straining, consuming a high fiber diet, using stool softeners, and taking warm sitz baths, together with local emollients with or without local anesthetics and steroids.     

Lateral subcutaneous internal anal sphincterotomy for anal fissure

Summary Lateral subcutaneous internal anal sphincterotomy is recommended as the primary operation for anal fissure. The technique of the procedure is presented and results in 21 patients are reviewed. Read at the meeting of the American Proctologic Society, June 10 to 14, 1973, Detroit, Michigan.     

Botulinum toxin and chronic anal fissure

Lateral internal sphincterotomy is widely used in the treatment of chronic anal fissure. However, it is associated with a high rate of irreversible incontinence. For this reason the botulinum toxin has become a medical means of reversible sphincterotomy. Indeed, this neurotoxin induces relaxation of the smooth internal anal sphincter lasting one to three months after one injection. We reviewed the published studies about the use of this technique in the management of chronic anal fissure. Healing occurred in more than 70% of fissures without irreversible incontinence. Although further studies are needed to determine the best modalities of administration, especially due to the remaining significant recurrence rate, this toxin may be a valuable treatment for chronic anal fissure in the future.     

Different anal pressure profiles in patients with anal fissure

Abstract Background A consistent debate exists about the association between anal fissure and hypertonic anal canal. The aim of this study was to determine if the manometric findings in patients with chronic anal fissures varied according to the topography of the fissure. Patients and methods Seventy-three outpatients (52 men, 71%) with chronic anal fissures and nine healthy volunteers (5 men, 55%) were examined. Patients were classified according to the topography of the anal fissures: posterior midline (group A), anterior midline (group B), and lateral position (group C). We use computerized anorectal manometry to evaluate anal resting pressure, maximal voluntary contraction, recto-anal inhibitory reflex, rectal sensations and rectum compliance. Results In Group A, the mean pressure was higher than that of controls (p<0.05), and the resting pressure 2 cm from anal verge was higher than that of other groups and controls (p<0.05). Normotonic anal canal was found in 49.1% of patients in group A, in 66% of those in group B and in 57.1% of those in group C. Four elderly patients (7%) of group A had a hypotonic anal canal. No differences were found regarding maximal voluntary contraction, recto-anal inhibitory reflex, rectal sensations and rectum compliance between patients and controls. Conclusions Patients with chronic anal fissures may have several anal pressure profiles. The anal canal is often normotonic. Fissures with hypertonic or normo-hypotonic anal canal need different therapies.     

Long-term follow-up (42 months) of chronic anal fissure after healing with botulinum toxin

BACKGROUND & AIMS: Botulinum toxin is an effective treatment in idiopathic chronic anal fissure, but the long-term outcome after healing is not well documented. We analyzed the long-term outcome of patients in whom an anal fissure had healed after botulinum toxin injection and the factors contributing to recurrence. METHODS: Fifty-seven patients who had completely healed 6 months after injection of botulinum toxin were reassessed every 6 months. The follow-up was 42 months in all patients. Clinical and manometric differences between the permanently healed and the relapsed group were statistically analyzed. RESULTS: Four patients were lost to follow-up. A fissure recurrence was shown in 22 patients (41.5%). Statistical differences between the permanently healed and the relapsed group were detected when analyzing the anterior location of the fissure (6% vs. 45%), a longer duration of the disease (38% vs. 68%), the need for reinjection (26% vs. 59%), a higher total dose injected to achieve definitive healing (13% vs. 45%), and the percentage decrease of maximum squeeze pressure after injection (-28% vs. -13%; P < 0.05). CONCLUSIONS: The late recurrence rate of chronic anal fissure is high when the effect of botulinum toxin disappears. The highest risk of recurrence is associated with anterior location of the anal fissure, prolonged illness, the need for reinjection and for high doses to achieve healing, and a lower decrease of maximum squeeze pressure after treatment.     

Tailored lateral sphincterotomy for anal fissure

PURPOSE: Most surgical texts describe the length of division of the internal sphincter during closed lateral sphincterotomy as to just above the dentate line, resulting in significant rates of incontinence. This study reviews our experience using a tailored lateral sphincterotomy by selecting the height of sphincter to be divided with the aim of preserving more sphincter. METHODS: From 1976 to March 1996, the files of 440 patients who had sphincterotomies were reviewed by an independent research assistant. After exclusions, a residual group of 352 patients had undergone tailored left lateral sphincterotomy for chronic anal fissure that had failed conservative treatment or for acute anal fissure requiring surgical intervention. RESULTS: A total of 287 patients from the group who had tailored left lateral sphincterotomy returned for review (81.5 percent). Of these, four complained of imperfect control of flatus (1.4 percent), one of minor staining (0.35 percent), and two of urgency (0.7 percent). None had incontinence of feces or leakage of stool. Five patients had repeat sphincterotomies, four for recurrence and one for a persistent fissure. CONCLUSION: The technique of tailored lateral sphincterotomy is safe, effective, and preserves more anal sphincter. It might be argued that a controlled trial comparing tailored sphincterotomy with the standard height of incision (with preprocedure and postprocedure manometry) should be performed, but the clinically significant reduction in incontinence rates using the tailored approach would seem to support its use.     

Total lateral sphincterotomy for anal fissure

Background and aims Initial experience with the posterior sphincterotomy for treating anal fissures was unsatisfactory, with a significant rate of recurrences and anal incontinence. This report describes the lateral approach to complete section of the internal sphincter.Patients and methods Between 1997 and 2001 we surgically treated 164 patients for anal fissure. Preoperative and postoperative anal manometries were recorded. Postoperative course and early and long-term results were recorded.Results No fissure failed to heal. Early complications included bleeding, hematoma, and pain. A transient, variable degree of incontinence occurred in 15 patients and persistent incontinence to flatus and soiling in 5. After total sphincterotomy no long-term complication was observed. Patient satisfaction was 96%.Conclusion Total subcutaneous, internal sphincterotomy is a safe, effective procedure for the treatment of chronic anal fissure.     

Surgical treatment of chronic anal fissure

This is a retrospective study of 1753 cases of chronic anal fissures treated by five varying methods over a five-year period from January 1976 to December 1980. Results showed that the incidence of recurrent fissures was higher in those treated by anal fissurectomy with sphincterotomy. There was also a significant difference in operative time, length of hospital stay, patient discomfort, and incidence of urinary retention among these operative methods. Generally, lateral anal sphincterotomy and multiple anal sphincterotomies showed a lesser incidence of these factors. A simpler procedure, such as lateral anal shipncterotomy or multiple anal sphincterotomies, is the treatment of choice for chronic anal fissure. However, a chronic anal fissure associated with symptomatic enlarged hemorrhoids may have a similar result when treated with hemorrhoidectomy and fissurectomy as a combined procedure. Read at the meeting of the American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 5 to 9, 1983.