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

Abstract

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.

Outcomes of Fissurectomy and Advancement Flap in Management of Chronic Anal Fissure

“…Delayed healing process was observed only in about 12% of the patients, it took about 40-45 days for healing.Based on study done byPatti et. al.2012 and another study in the same year,refer that all their patients healed within 30 days6,14 . Furthermore, Fissurectomy with advancement flap is known as sphincter saving procedure, since the sphincter remains intact14 .Consistently, Fissurectomy alone without flap might rais the risk of keyhole deformity that leads to stool soiling.…”

“…Fissure has been known as a painful, linear tear in the mucocutaneous junction of the distal part of the anal canal, which usually involves the epithelial layer only in acute stage and involves the full thickness of mucosa in chronic stage 1 .It develops with equal frequency in both males and females, butit tends to have predilection for younger and middle age group 1,2 .Anal fissurecausing severe pain may last even hours after defecation and it is accompanied either with constipation or diarrhea 1 .The exact etiology is not understoodyet, but physical trauma stands at the top list (2,3) .Anal fissure mainly occurs in the midline either posteriorly or anteriorly, if it presents off the midline, other pathology might be associatedsuch as crohn'sdisease, sexually transmitted disease, granulomatous disease and neoplasms 4,5 . Unhealed anal fissure after 6-8 weeks is considered chronic, with the presence of other criterialike skin tag, hypertrophied papilla,raised margin and exposed internal sphincter muscle fibers 4,5,6 .…”

“…Chronic anal fissure wasunlikely healed with medical treatment and surgery is mandatory after pharmacological treatment failure 5 .Lateral internal sphincterotomy was first described in 1835, it was the treatment of choice, with high healing rate, but unfortunately risk of incontinence may reach to 30% based on previous studies 7,8 .In fact, this increased the need for new surgical procedure that preserve the anal sphincter integrity.Notably, Fissurectomy is the most commonly practiced procedure, however a possible drawback is keyhole defect and guttering that may lead to fecal soiling 4 . So, Fissurectomy either with pharmacological agent like botulinum or with advancement flap introduced to overcome this complication 6 . Fissurectomyhas been defined as a complete excision of the fissure keeping the internal anal sphincter (IAS) intact, while anal advancement flap (AAF) is the transfer of well vascularized tissue to cover the base of fissure to improve healing.…”

Novas perspectivas terapêuticas no tratamento da fissura anal

“…Em conclusão, embora alguns estudos tenham mostrado excelentes resultados para o tratamento de fissura anal crônica independente da localização, sexo e tônus do esfíncter, até o momento parece oportuno oferecer fissurectomia combinada com retalho de avanço anal apenas em pacientes com fissura anal crônica anterior, em pacientes do sexo feminino e/ou em o caso de recidiva após esfincterotomia e após operação cirúrgica no ânus (Patti, et al, 2012).…”

Fissure-In-ANO

“…This procedure has been shown to have good healing rates (81-100%) [53,72]. Anal advancement flaps have been utilised as a subsequent therapy to LIS or BTA injection resulting in less postoperative pain and improved healing [73,74].…”