Comparing closed versus open lateral internal sphincterotomy for management of chronic anal fissure: systematic review and meta-analysis of randomised control trials.

Chronic anal fissure is one of the most common benign anorectal health conditions, causing significant morbidity, quality of life, and economic loss. Eight randomized controlled trials with a total population size of 1035 were eligible for analysis. Seven studies included both males and female, while one only included females. The majority of randomized controlled trials involved female dominance [54.9% (43.5-66.3)] and posterior midline location [86.1% (95% CI 81.5-90.8%)]. This meta-analysis of randomised control trials found that overall postoperative healing was 90.2%, recurrent anal fissure was 3.7%, and postoperative incontinence was 8.9% after LIS. Even though there was no statistically significant difference, closed lateral internal sphincterotomy (LIS) had higher rates of recurrent anal fissure (RR = 1.73 (95% CI 0.86-3.47, p = 0.90, I2 = 0%) and lower rates of postoperative incontinence rate (RR = 0.60 (95% CI 0.37-0.96, p = 0.76, I2-0) as compared with open LIS. We recommended that closed lateral internal sphincterotomy (LIS) is a safe and effective surgical treatment option for chronic anal fissures.

Fissurectomy versus lateral internal sphincterotomy in the treatment of chronic anal fissures: no advantages in terms of post-operative incontinence.

PURPOSE: The standard treatment for chronic anal fissures that have failed non-operative management is lateral internal sphincterotomy. Surgery can cause de novo incontinence. Fissurectomy has been proposed as a sphincter/saving procedure, especially in the presence of a deep posterior pouch with or without a crypt infection. This study investigated whether fissurectomy offers a benefit in terms of de novo post-operative incontinence. METHODS: Patients surgically managed with fissurectomy or lateral internal sphincterotomy for chronic anal fissures from 2013 to 2019 have been included. Healing rate, changes in continence and patient satisfaction were investigated at long-term follow-up. RESULTS: One hundred twenty patients (55 females, 65 males) were analysed: 29 patients underwent fissurectomy and 91 lateral internal sphincterotomy. Mean follow-up was 55 months [confidence interval (CI) 5-116 months]. Both techniques showed some rate of de novo post-operative incontinence (> +3 Vaizey score points): 8.9% lateral internal sphincterotomy, 17.8% fissurectomy (p = 0.338). The mean Vaizey score in these patients was 10.37 [standard deviation (sd) 6.3] after lateral internal sphincterotomy (LIS) and 5.4 (sd 2.3) after fissurectomy Healing rate was 97.8% in the lateral internal sphincterotomy group and 75.8% in the fissurectomy group (p = 0.001). In the lateral internal sphincterotomy group, patients with de novo post-op incontinence showed a statistically significant lower satisfaction rate (9.2 ± 1.57 versus 6.13 ± 3; p = 0.023) while no differences were present in the fissurectomy group (8.87 ± 1.69 versus 7.4 ± 1.14; p = 0.077). CONCLUSIONS: Lateral internal sphincterotomy is confirmed as the preferred technique in term of healing rate. Fissurectomy did not offer a lower rate of de novo post-operative incontinence, but resulted in lower Vaizey scores in patients in whom this occurred. Satisfaction was lower in patients suffering a de novo post-operative incontinence after lateral internal sphincterotomy.

Clinical Outcome of 0.2% Glyceryl Trinitrate Topical Ointment Compared to Lateral Internal Sphincterotomy in the Treatment of Patient with Chronic Anal Fissure: A Randomized Control Trial.

The objective of study was to evaluate the clinical outcome of topical 0.2% Glyceryl trinitrate topical (GTN) ointment in the treatment of chronic anal fissure. This randomized control trial was carried out in the Colorectal Surgery Unit, Department of Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh from May 2015 to April 2016. Total 94 patients were included in this trial, where 47(50.0%) patients were treated by 0.2% GTN ointment as Trial group 12 hourly for 8 weeks and 47(50.0%) patients by lateral internal sphincterotomy (LIS) as Control group in this study. Patients were randomized in two groups by lottery following purposive sampling. Post-procedural outcome variables with 6 months follow up were evaluated. Majority of the patients were found in between 20 to 40 years of age in both groups. The mean age was 34.6±10.4 years and 33.2±8.6 years in GTN and LIS respectively. Overall male female ratio was 0.88:1. All (100.0%) patients presented with pain in anus and 86.15% patients presented with per rectal bleeding. Pain relief in GTN arm versus LIS arm in 2nd and 6th week was 55.31% vs. 76.6%, 74.5% vs. 87.23% with no significant difference between two groups. But at 6 month it was 57.44% vs. 93.6% respectively. The fall in pain relief at 6th month in GTN arm was due to recurrence of fissure. At the end of 2nd, 6th week and 6month, cessation of bleeding improved gradually in both groups after treatment but the improvement was significantly better in LIS group than in GTN group indicating sphincterotomy stops bleeding better. Healing after 2nd week in both groups was minimum but equal 2(4.26%) patients. After 6 weeks LIS group had significant better healing than GTN 40(85.1%) versus 26(55.3%) with p value <0.001. In 6 month time GTN group had increased healing but LIS group had significant better healing than GTN group 42(89.36) vs. 32(68.08) with p value 0.004. Transient flatus and liquid incontinence were 8.51% and 6.4% respectively in LIS group with 0.0% in GTN group. Headache and recurrence were significantly higher in GTN group 61.7% and 34.04% with p<0.001. Lateral internal anal sphincterotomy is superior to the topical application of 0.2% nitroglycerin ointment in the treatment of chronic anal fissure with the advantages of good symptomatic relief, high rate of healing and a very low rate of transient continence disturbances.

Long-term fecal incontinence after lateral internal sphincterotomy for anal fissure.

<b>Introduction:</b> Anal fissure is a common benign anal condition. The gold standard treatment is lateral internal sphincterotomy (LIS), and this procedure carries a risk of incontinence. </br></br> <b> Aim:</b> The aim of this study is to determine the long-term risk of fecal incontinence after LIS. </br></br> <b> Method:</b> All patients who had LIS for chronic anal fissure between the years 2004-2010 were interviewed by phone and assessed for sphincter function (incontinence) using Wexner fecal incontinence score (WIS). </br></br> <b>Results:</b> Fifty-nine patients (34 females, 57.6%) with a mean follow-up duration of 10.6 years (range 8-15 years) were interviewed. Twelve patients (20.3%) had a WIS score of one or more. The majority of the patients noticed a change in sphincter function years after the operation. There was no association between vaginal delivery and the WIS score. </br></br> <b>Conclusion:</b> The long-term risk of abnormal sphincter function after LIS appears to be higher than expected, especially in the presence of multiple vaginal deliveries or systemic diseases such as diabetes mellitus. A larger prospective study is required to establish a correct risk of incontinence in the long term.

Subcutaneous incision of the fistula tract and internal sphincterotomy (SIFT-IS): a novel surgical procedure for transsphincteric anal fistula.

AIM: The aetiology of anal fistula has not been fully clarified. One of the causes of anal fistulas may be the markedly deep crypts that characterize the primary openings. We developed subcutaneous incision of the fistula tract and internal sphincterotomy (SIFT-IS) to eradicate these deep crypts. The aim of this study was to evaluate outcomes in patients with anal fistula treated with SIFT-IS. METHOD: A retrospective study was performed over a 2-year period. Patients with transsphincteric anal fistula who underwent SIFT-IS were enrolled. The primary endpoint was the anal fistula healing rate at 16 weeks postoperatively. The secondary endpoints were healing time, postoperative complications and clinical continence status. RESULTS: One hundred and fifty one patients were enrolled. Primary healing was accomplished in 129 patients (85%). There were 17 patients (11%) with a remnant fistula and five (3%) with a recurrence. The remnant fistulas healed spontaneously at more than 16 weeks postoperatively in seven patients. The median healing time was 6 (3-96) weeks. Surgical intervention was required in seven patients with a remnant fistula and four with recurrence. At the final follow-up, the wounds had healed in 148 patients (98%). No significant postoperative complications or incontinence were observed. CONCLUSION: Subcutaneous incision of the fistula tract and internal sphincterotomy is a promising surgical option for transsphincteric anal fistulas, with a satisfactory healing rate.

Prospective, Randomized, Controlled Trial of Ultra-modified Internal Sphincterotomy vs Closed Lateral Internal Sphincterotomy for Chronic Fissure-in-Ano.

BACKGROUND: Currently, the lateral internal sphincterotomy is the treatment of choice for a chronic anal fissure (CAF). However, the length of the internal sphincter incision varies, due to lack of standardization. Insufficient length increases the risk of recurrence. To compare a new ultra-modified internal sphincterotomy (UMIS) to the closed lateral internal sphincterotomy (CLIS) for treating CAF, based on internal anal sphincter function and postoperative complications. The primary endpoint was continence after UMIS. The secondary outcomes were CAF healing complications, visual analog scale pain scores, and sphincter pressures. METHODS: This was a prospective, randomized, controlled trial (block randomization method). 200 patients with CAFs were randomly assigned to receive either UMIS (n = 100) or the closed lateral internal sphincterotomy (CLIS) (n = 100). Follow-up was 2 years. RESULTS: All (100%) patients in both groups showed clinical improvement at 1 month post-surgery. Recurrences were accompanied by deteriorations in Cleveland Clinic Florida Fecal Incontinence scores at 12 months and 2 years (P < .05). The groups showed significant differences in fissure healing rates and pain scores. After 1 and 2 years, incontinence rates were significantly higher, and patient satisfaction scores were significantly lower in the CLIS group than the UMIS group (P < .05). CONCLUSION: UMIS provided a faster healing rate and fewer side effects than the CLIS for treating CAFs. These results might lead to a standardized treatment among surgeons.

Real world outcomes of lateral internal sphincterotomy vs botulinum toxin for the management of chronic anal fissures.

BACKGROUND: Lateral internal sphincterotomy (LIS) remains the gold standard surgical approach for the management of chronic anal fissures (CAF). The procedure however, is complicated by the risk of postoperative incontinence. Intrasphincteric Botulinum Toxin (BT) has gained popularity as an alternative approach, despite being inferior to LIS with regards to cure rates. In the real world, patients at high risk for postoperative incontinence are likely to be offered BT as a preliminary procedure. The aim of this study was to explore the real-world outcomes of LIS and BT for a cohort of CAF patients. METHODS: 251 consecutive patients treated with either BT or LS for CAF by a single surgeon were reviewed. Patients were offered BT as a preliminary procedure if they had risk factors for faecal incontinence, whereas all other patients underwent LIS. Primary outcomes included rates of recurrence and faecal incontinence. RESULTS: LIS was superior to BT with regards to recurrence rates throughout the mean follow up period of five years (5% vs 15%, p = 0.012). A total of 17 patients experienced a minor degree of flatal incontinence at the 6-week follow up, although there was no difference between LIS and BT (7% vs 6%, p = 1.000). Four LIS patients (2%) continued to experience some minor incontinence to flatus at the 12-month follow up and were managed with biofeedback. CONCLUSION: For patients with CAF, individualizing the treatment approach according to risk factors for incontinence could mitigate this risk in LIS. High risk patients should be offered BT as a preliminary procedure.

Modified open posterior internal sphincterotomy with sliding skin graft for chronic anal fissure and anal stenosis: Low recurrence rate and no serious faecal incontinence postoperative complication.

AIM: Lateral internal sphincterotomy (LIS) remains a standard for chronic anal fissure even though other surgical techniques have shown high efficacy. Faecal incontinence is a well-documented complication of LIS. We devised modified open posterior internal sphincterotomy (m-OPIS) with sliding skin graft (SSG), which is a combined procedure of OPIS and anal advancement flap. The aim of this study is to evaluate m-OPIS+SSG. METHODS: This was a retrospective, observational, single-arm study. m-OPIS+SSG was performed for chronic anal fissure and anal stenosis. m-OPIS involved incision of the internal sphincter muscle at the posterior midline until four fingers could be passed. The incision wound was closed by anastomosis of the anoderm and skin. Then, an arcuate skin incision was created and the skin graft was advanced into the anal canal. Follow-up was conducted by clinical consultation and telephone interview. Faecal continence was assessed by Cleveland Clinic Faecal Incontinence (CCFI) score. RESULTS: m-OPIS+SSG was performed in 143 patients. The mean patient age was 50±16 years. The success and overall recurrence rates after m-OPIS+SSG were 99% and 0.7%, respectively, with a median follow-up period of 16.3 years. One patient developed incontinence with liquid stools once during the 6-month period. None of the other patients suffered permanent faecal incontinence postoperatively. The postoperative CCFI score was 0.5±0.9. CONCLUSIONS: We consider m-OPIS+SSG as one of the efficacious options of procedure for chronic anal fissure and anal stenosis, owing to its high success rate, low recurrence rate and no postoperative complication of serious faecal incontinence.

A randomised controlled study: the effects of internal sphincterotomy of the anus on defecation disorders in patients with outlet obstructive and mixed constipation.

BACKGROUND: This study sought to investigate the effects of internal sphincterotomy of the anus in the treatment of defecation disorders in patients with outlet obstructive and mixed constipation. METHODS: This study included 250 patients, who met the Rome III criteria for functional defecation disorder-associated constipation and were admitted to the Proctology Department in the People's Hospital of Dazu District between July 2014 and June 2016. The patients were randomly divided into the traditional medical treatment group (n=125) and the surgical treatment group (n=125), and received traditional treatment and internal anal sphincterotomy, respectively. All patient clinical data were retrospectively analyzed. Indices relating to anorectal pressure, electromyographic indices of abdominal muscles, sleep quality, anxiety and depression, defecography and anal healing before and after treatment were measured, and the effects of the different treatment modalities on defecation disorders were analyzed. RESULTS: The total treatment effective rate was significantly higher in the surgical treatment group than in the traditional treatment group (P<0.05). The Constipation Scoring System scores at time points 1, 2 and 3 were significantly lower in the surgical treatment group than in the traditional treatment group (P<0.001). After treatment, the Hospital Anxiety and Depression Scale and Pittsburg Sleep Quality Index scores were significantly lower in the surgical treatment group than in the traditional treatment group (P<0.001). After treatment, the rectal resting pressure and 10SR were significantly lower in the surgical treatment group than in the traditional treatment group (P<0.001). After treatment, the negative conversion rate of the balloon expulsion test was significantly higher in the surgical treatment group than in the traditional treatment group (P<0.05), while the rectocele, perineum descending distance, and anorectal angle of the efforts phase were significantly lower in the surgical treatment group than in the traditional treatment group (P<0.001). CONCLUSIONS: Internal anal sphincterotomy can significantly relieve defecation disorders and clinical symptoms, improve sleep quality, eliminate psychological disorders, and promote patient recovery. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2100048818.

Identification of a new syndrome: ASS-SSA or anal sphincter syndrome.

AIM: The author proposes a new, original Syndrome, observing the relationship between some of the most frequent anal pathologies, apparently different from each other in terms of morphological aspect and symptomatologic expression, but united by the same pathogenic cause, represented by the hypertonicity of the anal sphincter apparatus. There are already descriptions of other "syndromes" of the pelvic floor, inaccurate and subject to different interpretations. The proposed syndrome, instead, called Anal Sphincter Syndrome - ASS (in Italian SSA - Sindrome dello Sfintere Anale) presents clarity on the determining cause (sphincter hypertonicity) and descriptive simplicity, including only two welldefined pathological conditions: anal fissure and anal thrombosis; other ancillary conditions or symptoms are inconstantly possible, but not decisive. The author will present, as soon as possible, in subsequent works, a retrospective study (still to be completed) on a wide personal case history, dating back to the 1990s. KEY WORDS: Anal sphincter hypertonia, Anal thrombosis, Anal fissure, Syndrome, Proctology, Somatization.

Partial Division of Puborectalis Muscle with Lateral Internal Sphincterotomy: A Novel Surgical Technique for Management of Anal Hypertonia-Associated Anismus.

BACKGROUND: Treatment of anismus usually starts with biofeedback therapy and injection of botulinum toxin in the puborectalis muscle (PRM). Patients refractory to conservative treatment may require surgery. The present cohort study aimed to assess a combined technique of partial division of PRM and tailored lateral internal sphincterotomy (LIS) in treatment of anismus. METHODS: Patients with anismus who failed conservative treatments were assessed clinically and with high-resolution anal manometry (HRAM), EMG, defecography, and underwent combined partial division of PRM on one side and tailored LIS on the contralateral side. Main outcome measures were improvement in symptoms and quality of life, changes in HRAM and defecography postoperatively, complications, and patient satisfaction. RESULTS: A total of 73 patients (61 male) of a mean age of 37 years were included to the study. In total, 89% of patients showed a significant improvement in symptoms at 12 months postoperatively. The mean modified Altomare score decreased significantly (p < 0.0001) from 16.4 ± 1.7 to 6.6 ± 1 at 12 months postoperatively. There was a significant increase in the mental and physical components of quality of life at 12 months postoperatively. The numbers of patients with positive findings of anismus in postoperative defecography, EMG, and balloon expulsion test were significantly less than before surgery. The mean total satisfaction score was 86.5 ± 8.7. Five (6.5%) patients developed minor complications. CONCLUSION: Partial division of puborectalis muscle combined with LIS is an effective technique in the management of anal hypertonia-associated anismus with satisfactory results and low incidence of complications.