A review of chronic anal fissure management

Abstract

Anal fissure management has rapidly progressed in the last 15 years as our understanding of fissure pathophysiology has developed. All methods of treatment aim to reduce the anal sphincter spasm associated with chronic anal fissures. Surgical techniques have been used for over 100 years with success. Lateral internal sphincterotomy remains the surgical treatment of choice for many practitioners. Postoperative impairment of continence remains controversial. Recently, less invasive methods of treatment have been explored. Topical nitrates, calcium channel blockers and botulinum toxin are established treatments. These and other non-surgical treatments are described in this review. Various guidelines and treatment algorithms for anal fissure are also discussed.

Comparison of Lateral Internal Sphincterotomy with Topical Nitroglycerine Treatment in Patients with Chronic Anal Fissure: A Prospective Randomised Study

“…After incision was made parallel to intersphincteric groove at hour three position, LIS was carried out in accordance with the length of the fissure under general or spinal anaesthesia in lithotomic position. Sphincterotomy was made along the length of fissure so that the rate of postoperative incontinence would not increase [5,6] 0.4% topical nitroglycerine (15 gm lanoline +15 gm vaseline+150 mg nitroglycerine 1%) treatment was administered to the patients in Group II for 8 ± 2 weeks 1.5 mg two times a day. Patients were informed that topical nitroglycerine should be applied as much as half of a pea at each application.…”

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

“…In 1969, Notaras proposed lateral internal sphincterotomy. This technique is associated with fewer complications than posterior sphincterotomy, with immediate improvement of pain and success rate above 95 % [2]. However, it is associated with significant incidence of postoperative incontinence ranging between 0 and 35 % for flatus, 0 and 21 % for liquid, and 0 and 5 % for solid stools [4] with an overall incontinence risk as high as 10 % [3].…”

“…The sphincterotomy was described in 1951 by Eisenhammer; partial division of the internal sphincter muscle posterior has been a popular treatment for anal fissure for nearly two decades. However, several studies have reported prolonged healing times, postoperative pain and keyhole deformity [2]. Therefore, today this procedure is used rarely.…”

“…Only recently, a mucosal advancement flap has been used [29,30]. The rationale of advancing flaps of skin and fat is based on introducing fresh blood supply to the ischaemic area of the fissure [2], reducing the time required for perianal wound healing and avoiding the risk of anal stenosis that follows healing by scarring [16]. This procedure has been performed selectively on patients with CAF without hypertonia of IAS [5,6,[31][32][33] or extensively, independently of CAF side and sphincter tone [13,14,[34][35][36].…”

“…After pharmacological sphincterotomy, the healing rate of CAF ranges from 30 to 96 %, whereas transitory minor incontinence for flatus and soiling has been reported in a few cases. Surgical treatment generally recommended is anal lateral sphincterotomy that seems to be the manoeuvre of choice after the failure of conservative treatment resulting in success rates above 95 % [2]. However, it may cause incontinence.…”