Close lateral internal sphincterotomy versus open lateral internal sphincterotomy for chronic anal fissure: a systematic review and meta-analysis.

Background: Lateral internal sphincterotomy (LIS) has been the gold standard for treating chronic anal fissure (CAF) that persists despite other measures. The authors aim to evaluate the effects of the close method (CLIS) of performing LIS as compared to the open method (OLIS). Methods: Databases were searched for relevant studies and results were screened to identify eligible articles, and all concerned outcomes were pooled as odd ratio (OR) or mean difference (MD) with 95% CI in the meta-analysis models using RevMan 5.4. Results: Pooled data from 16 trials with 1,711 patients with idiopathic CAF showed that the CLIS has significant lower risk of delayed fissure healing [OR: 0.28, 95% CI (0.10, 0.77), P = 0.01], duration of hospital stay [MD: -0.82 with 95% CI (-1.07, -0.57), P < 0.00001] and postoperative visual analogue pain score (VAPS) at 24 h [MD: -0.30 with 95% CI (-0.39, -0.21), P < 0.00001]. Also, the risk of overall complications [OR: 0.33 with 95% CI (0.19, 0.55), P < 0.0001], incontinence [OR: 0.28 with 95% CI (0.20, 0.38), P < 0.00001], and postoperative pain [OR: 0.56 with 95% CI (0.35, 0.91), P = 0.02] was significantly lower with CLIS. Conclusion: CLIS is a safer option than OLIS for treating anal fissure. The risk of delayed fissure healing, incontinence, post-op pain and overall complication was significantly lower. However, the risk of surgical site infection, postoperative bleeding and recurrence did not differ. Future research with more prolonged follow-up is necessary to document recurrence reliably.

Long-term Efficacy and Safety of Controlled Manual Anal Dilatation in the Treatment of Chronic Anal Fissures: A Single-center Observational Study.

Objectives: Conventional anal dilatation for anal fissures has long been abandoned because of the high incidence of anal incontinence. However, less invasive and more precise dilation techniques have been developed that have shown high healing and low incontinence rates. This study aimed to evaluate the efficacy and safety of controlled anal dilatation (CAD) using a standardized maximum anal diameter. Methods: This study included 523 patients who underwent CAD for chronic anal fissures between January 2010 and December 2014. CAD was performed under sacral epidural anesthesia. The index fingers of both hands were placed in the anus and dilated evenly in various directions. CAD was completed when the anus was dilated to the sixth scale (35 mm in diameter) using a caliber ruler. Results: The mean anal scale size expanded from 3.1 to 5.8 (p<0.001). Non-healing was observed in nine patients (1.7%) at 1 month postoperatively, six of whom underwent additional CAD. The mean maximal anal resting pressure (mmHg) decreased from 90.2 to 79.7 at three months postoperatively (p<0.001). Postoperative complications were observed in 11 (2.1%) patients, of whom three patients with thrombosed hemorrhoids underwent resection. None of the patients complained of anal incontinence during the mean follow-up period of 16.6 months. The cumulative recurrence-free rates at three and five years were 87.9% and 69.2%, respectively. Conclusions: CAD is technically simple and safe and can achieve reasonable long-term outcomes. Thus, CAD appears to be the preferred procedure for patients with chronic anal fissures who do not respond to conservative treatments.

Platelet-rich plasma improves acute and chronic anal fissure, a randomized control trial.

Anal fissure is one of the most prevalent diagnosis in patients with anorectal symptoms. Depending on the chronicity, treatment choices vary, from topical and conservative management to operative ones. PRP is a blood-derived product with a three to five-fold platelet count and can be used for restorative purposes. The objective of this study is to assess the therapeutic effect of intralesional PRP in acute and chronic anal fissures and comparing it with the classic topical approach. We included 94 patients with acute and chronic anal fissures and divided them into intervention and control groups. Control patients were treated only with topical compounds, and the intervention group received one dose of intralesional autologous PRP plus the same classic treatment. We assessed patients 2 weeks, 1 month, and 6 months later. The mean pain score in the intervention group was significantly lower than control groups in all visits (p-value <0.001). During the follow-ups, the bleeding rate was significantly lower in the intervention group, so in the sixth month, the bleeding was 4% in the intervention group against 32% of the control (p-value <0.001). The healing rate assessed by examination was 96% in the intervention group against 66% in the control in the sixth month (p-value <0.001). Although there may be no significant difference in healing rate between groups in the acute anal fissure, the PRP group is significantly superior in the chronic setting. We concluded that in anal fissure treatment, PRP plus topical products are significantly superior to alone topical treatment.

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.

The Efficacy of Sitz Baths as Compared to Lateral Internal Sphincterotomy in Patients with Anal Fissures: A Systematic Review.

An anal fissure is a common condition that affects patients of all ages. Its clinical presentation is a sharp pain on defecation with or without blood. It is treated by conservative or surgical means. This study aims to assess the efficacy of a sitz bath as compared to lateral internal sphincterotomy in the treatment of anal fissures. The search strategy used keywords related to the topic of study. Three databases were used: PubMed, Google Scholar, and Science Direct. A total of 551 articles were screened. A quality assessment check was done on the articles leaving 11 articles. Four aspects of sitz bath outcomes were evaluated in the articles. In terms of analgesia, articles showed conflicting evidence. However, the overall evidence supports the use of sitz baths for their analgesic properties. In terms of healing, most articles had similar recovery rates of around 80%. Much of the research supported the use of sitz baths as the primary treatment to heal acute fissures. When compared to lateral internal sphincterotomy, the recovery rates of lateral internal sphincterotomy are superior to those of conservative treatment, including sitz baths. However, studies showed incontinence as a side effect of lateral internal sphincterotomy, and no studies reported side effects from the sitz baths. To conclude, the results of the articles support the use of sitz baths to treat anal fissures. Sitz baths have been found to have analgesic properties, as well as a good healing time. But, compared to lateral internal sphincterotomy, there is a significant difference in the healing rate at the end stage of treatment, lateral internal sphincterotomy is found to be superior. With regards to the side effects, none have been reported from using a sitz bath.

Botulinum toxin injection for the treatment of chronic anal fissure: uni- and multivariate analysis of the factors that promote healing.

PURPOSE: Anal fissure is caused by a pathological contraction of the internal anal sphincter. Lateral internal sphincterotomy remains the gold standard for the treatment of fissure. Botulinum toxin injections have been proposed to treat this condition without any risk of permanent injury of the internal sphincter. We investigate clinical and pathological variables and the effects of different dosage regimens of botulinum toxin to induce healing in patients with idiopathic anal fissure. METHODS: This is a retrospective study at a single center. The patients underwent a pre-treatment evaluation that included clinical inspection of the fissure and anorectal manometry. We collected and analyzed demographic data, pathological variables, associated pathological conditions, and treatment variables. Success was defined as healing of the fissure, and improvement of symptoms was defined as asymptomatic persistent fissure. RESULTS: The findings of 1003 patients treated with botulinum toxin injections were reported. At 2 months evaluation, complete healing was evident in 780 patients (77.7%). Resting anal tone (77.1 ± 18.9 mmHg) was significantly lower from baseline (P < 0.0001) and from 1-month value (P = 0.0008). Thirty-nine not healed patients underwent lateral internal sphincterotomy, and 184 were re-treated with 50 UI of botulinum toxin. In these patients, the healing rate was 93.9% (171 patients). Dose and injection site of toxin correlates with healing rate. There were no relapses during an average of about 71 months. CONCLUSION: Our data show that injection of botulinum toxin into the internal anal sphincter is a safe and effective alternative to surgery in patients with chronic anal fissure.

Efficacy of posterior median anal incision with incision and drainage of the anal sinus on chronic anal fissure.

BACKGROUND: To explore the efficacy of posterior median anal incision plus incision and drainage of anal sinus on chronic anal fissure (CAF), and its influence on incidence and recurrence of postoperative infection. METHODS: Altogether 130 patients with CAF treated during January 2017 and January 2021 were included and divided into a research group (RG) and control group (CG). Among them, 80 patients in the RG were treated with posterior median anal incision and expansion plus anal sinus incision and drainage, while 50 in the CG were treated with lateral internal sphincterotomy. Clinical indexes (wound healing time, recovery time of bowel sounds, intraoperative blood loss, length of stay), levels of inflammatory factors (IL-6, IL-8, CRP) before and one week after treatment, changes of psychological and emotional scores (SAS, SDS scores) before and 6 months after treatment, sleep and scores of daily activities after admission and 6 months after treatment, VAS scores at 1 day, 1 week and 2 weeks after operation, compliance, total effective rate, and incidence and recurrence rate of postoperative incision infection were compared between the groups. RESULTS: Compared with the CG, the wound healing time, recovery time of bowel sounds and length of stay were shorter, and intraoperative blood loss was lower in the RG; the levels of IL-6, IL-8 and CRP were lower in RG one week after treatment. Six months after treatment, the SAS, SDS and PSQI scores were lower, the ADL scores were higher, the compliance and total effective rate were higher, and the incidence and recurrence rate of postoperative incision infection were lower in the RG. CONCLUSION: Posterior median anal incision plus incision drainage of the anal sinus has better efficacy on CAF, and can effectively reduce the incidence of postoperative infection and recurrence.

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.

Minimal Lateral Internal Sphincterotomy (LIS): Is It Enough to Cut Less Than the Conventional Tailored LIS?

PURPOSE: Anal fissure is a common anorectal condition, yet its pathogenesis remains unclear. Lateral internal sphincterotomy (LIS) is the gold standard treatment for chronic anal fissures that do not respond to conservative treatment; however, it has a risk of anal incontinence. We believe that fibrosis of the internal anal sphincter is an important factor in the pathogenesis of chronic anal fissure. In this study, we describe the minimal LIS method, a minimally invasive method where only the fibrotic portion of the internal anal sphincter is cut. We also describe the outcomes of this method. METHODS: We performed a retrospective review of 468 patients (270 male and 198 female) who underwent minimal LIS for chronic anal fissure in 2017 at Seoul Song Do Hospital. We analyzed the patients' clinical characteristics, manometry data, complications, and outcomes of minimal LIS. The outcomes of the surgery were assessed via questionnaires during the postoperative outpatient visits, beginning 2 weeks postoperatively. RESULTS: The overall complication rate was 4.0% (19 patients). Delayed healing occurred in 14 patients (3.0%), perianal abscess was present in 3 patients (0.6%), and gas incontinence occurred in 2 patients (0.4%). All complications were improved with conservative treatment. Recurrence, defined as the recurrence of anal fissure more than 4 weeks after healing, was present in 6 patients (1.3%). CONCLUSION: Minimal LIS is a safe and effective treatment option for patients with chronic anal fissure. Postoperative complications, especially incontinence and recurrence, are rare.

The Role of Lateral Internal Sphincterotomy in Haemorrhoidectomy: A Study in a Tertiary Care Center.

Background Hemorrhoids are a common condition that presents with bleeding per rectum, pain at rest and defecation, mucosal discharge, and prolapse. Surgical hemorrhoidectomy is the treatment method of choice for Grade 3 and Grade 4 hemorrhoids. Hemorrhoidectomy is associated with postoperative pain and no single surgical technique has been proved to significantly reduce the pain. We analyzed in our study the effect of lateral internal sphincterotomy with hemorrhoidectomy on postoperative pain, anorectal function, and retention of urine after the Milligan and Morgan technique. Methods This randomized, prospective, and comparative study included 200 Grade 3 and Grade 4 hemorrhoids patients who were scheduled for surgical management. The patients were classified randomly into two groups with an equal number of participants: Group A underwent Milligan & Morgan open hemorrhoidectomy and Group B underwent lateral internal sphincterotomy (LIS) in addition to Milligan and Morgan open hemorrhoidectomy. Postoperative pain was recorded using the Visual Analog Scale (VAS) score for up to 48 hours. Postoperative bleeding, urinary retention, and bowel and gas incontinence were noted. Long-term follow-up at six and 24 months for anal stenosis, anal fissure, incontinence, and recurrence was also noted. Results Patients who underwent LIS showed a significant reduction in postoperative pain at 12 hours (p=0.0008*), 24 hours (p=0.000*), and 48 hours (p=0.003*); the time taken to request rescue analgesia was similar between the two groups (p=0.07). Side effects, such as postoperative bleeding and urinary retention, were significantly lower after LIS (p=0.001* and p=0.01*, respectively), and gas incontinence was significantly higher after LIS (p=0.002*). The long-term outcomes of anal fissure were significantly higher without LIS at six months (p=0.02*) and 24 months (p=0.04*) and those of anal stenosis were significantly higher without LIS at six months (p=0.04*). Conclusions From our study, we conclude that postoperative pain, bleeding, and urinary retention were significantly lower after LIS, and gas incontinence was transient. The long-term outcomes, which included anal stenosis and anal fissure, were significantly lower after LIS. However, bowel and gas incontinence and recurrence were not altered. Therefore, we conclude that the addition of LIS to hemorrhoidectomy improves patient outcomes in terms of postoperative pain and anorectal function.

Safety and effectiveness of minimal sphincterotomy in the treatment of female patients with chronic anal fissure.

To evaluate the outcome of a left lateral internal sphincterotomy extended for 20% of total sphincter length in female patients with chronic anal fissure, high anal resting pressure and normal preoperative anal continence. Between January 2014 and January 2018 all the female patients with chronic anal fissure showing failure of medical therapy, perfect anal continence (Cleveland Clinic Florida incontinence score = 0) and high anal resting pressure underwent a lateral internal sphincterotomy extended for 1/5 of total lateral sphincter length, basing on the preoperative measurements by three-dimensional endoanal ultrasound. Postoperative follow-up included clinical assessment at 3, 6 and 12 months associated with manometric and ultrasonographic evaluation at 6 months. Thirty-two patients, [median age 45 (range 19-68)] were included and, of these, 2 (6.2%) were lost to follow-up. At 6 month follow-up success rate was 93.3% (28/30) and continence score was 0 in all the patients. Two patients (6.2%) with poor outcome showed incomplete sphincterotomy at EAUS and underwent re-surgery. At three-dimensional endoanal ultrasound the median length of sphincterotomy was 6 mm (5-8.2). At 12 month follow-up the success rate was 100% and Cleveland Clinic Florida incontinence score remained 0 in all the cases. Open left lateral internal sphincterotomy extended for about 20% of total left lateral internal sphincter length seems to be safe and effective in the treatment of chronic anal fissure in suitable female patients achieving a high success rate without compromising anal continence.

Fisura anal: anatomía, patogenia y tratamiento / Anal fissure - anatomy, pathogenesis and treatment

RESUMEN La fisura anal es una patología proctológica frecuente caracterizada por un desgarro oval en el anoder mo que, si bien es pequeño, puede producir mucho dolor y angustia en el paciente. La etiología exacta aún se discute, pero está relacionada con una hipertonía del esfínter anal en la mayoría de los casos. El tratamiento inicial es médico, con fármacos que disminuyen el tono del esfínter anal. Las fisuras cróni cas generalmente requieren tratamiento quirúrgico. La esfinterotomía interna lateral tiene un elevado porcentaje de éxito y se considera el tratamiento de referencia. En este artículo haremos una revisión de la anatomía, fisiopatología y opciones terapéuticas actuales de las fisuras anales.

ABSTRACT Anal fissure is a common anorectal condition. While it often presents as a small oval tear in the anoderm, it can cause significant pain and anguish to the patient. The exact etiology is still debatable but increased anal tone is associated with most fissures. The initial management is medical with agents intended to reduce the anal tone. More chronic fissures usually require surgical intervention. Lateral internal sphincterotomy has a high success rates and is considered the gold standard of interventions. In this article we review the relevant anatomy, pathophysiology and contemporary treatment options for anal fissures.

Safety and efficacy of the treatment of chronic anal fissure by lateral internal sphincterotomy: A retrospective cohort study.

BACKGROUND: An anal fissure is one of the most common anorectal diseases resulting from a longitudinal tear in anoderm under the dentate line. It causes severe pain during defecation, and the resulting emotional stress leads to a reduction in the overall quality of life of a person. There are several medical and surgical treatment procedures that are employed to treat anal fissures. In the present retrospective study, we aimed to evaluate the safety and efficacy of lateral internal sphincterotomy (LIS) surgical procedure for the treatment of chronic anal fissure. Additionally, we also analyzed the complications arising after the surgery and the factors affecting the complications. METHODS: The present study is a retrospective study that included 691 patients treated for chronic anal fissure in a private sector setting, by a single Saudi female surgeon, starting from April 2004 to April 2020. RESULTS: Out of the 691 patients included in the study, all the patients were female, with an average age of 45.77 years (ranging from 17 to 82 years). Major complaints of the patients were as follows: pain, bleeding, constipation, pruritus, perianal discharge. Recurrence was reported in 2 patients (0.3%) while, 3 patients (0.4%) developed gas incontinence.The complaints of all patients with gas incontinence regressed over a period of time. CONCLUSION: This study reports that lateral internal sphincterotomy (LIS) is a safe surgical treatment for chronic anal fissure, leading to a reduction in recurrence, incontinence rate and substantially improves symptoms, especially pain.

Health and quality of life among a cohort of patients having lateral internal sphincterotomy for anal fissures.

AIM: The aim of this study is to report changes in health-related quality of life attributable to lateral internal sphincterotomy for treatment of anal fissure. There is very little evidence on whether the overall health-related quality of life of patients is detrimentally affected by the condition, or which aspects of self-perceived health status improve after lateral internal sphincterotomy. This study will articulate which aspects of health tend to improve and guide postoperative expectations appropriately. Knowledge gained from this study may also identify gaps in an individual patient's episode of care. METHOD: Patients were prospectively identified when they consented to surgical treatment of their anal fissure and were contacted by phone to participate. Participants completed a number of patient-reported outcomes preoperatively and 6 months postoperatively. Faecal incontinence-related quality of life, pain and depression were measured at both time points. The severity of faecal incontinence was measured at both times. RESULTS: Participants reported high levels of pain preoperatively. Postoperatively, improvement in pain exceeded the threshold of clinical relevance (P < 0.01). Thirty-five per cent of participants reported significant effects of faecal incontinence preoperatively, while 26% did so postoperatively. Participants with multiple comorbidities were more likely to report faecal incontinence postoperatively than preoperatively. CONCLUSION: This study reports that lateral internal sphincterotomy improved pain symptoms without adverse effects on continence. Not all domains of health-related quality of life were similarly positively affected by anal fissure repair.

La esfinterotomía lateral interna subcutánea cerrada en pacientes con fisura anal crónica / The closed subcutaneous internal lateral sphincterotomy in patients with chronic anal fissure diagnosis

RESUMEN Fundamento: las enfermedades benignas del recto son muy frecuentes en la práctica médica habitual en todos los niveles de atención de salud, pero en especial en los servicios especializados. Dentro de estos procesos se reconoce que la fisura anal es uno de los más comunes. En Cuba, representan alrededor de un 30-35 % de las consultas e intervenciones en los servicios de Coloproctología. Objetivo: determinar la efectividad de la esfinterotomía lateral interna subcutánea cerrada en pacientes con el diagnóstico de fisura anal crónica. Métodos: se realizó un estudio descriptivo, de corte longitudinal y prospectivo, en pacientes con el diagnóstico de fisura anal crónica, atendidos en los servicios de proctología del Hospital Universitario Manuel Ascunce Domenech de la provincia Camagüey, de septiembre 2016 a septiembre de 2017. El universo estuvo constituido por los 132 pacientes adultos que acudieron al servicio de Coloproctología de dicha institución con el diagnóstico de fisura anal crónica. A todos los pacientes se les aplicó una encuesta validada por criterios de expertos, previo consentimiento informado por parte de los mismos. Resultados: en la investigación existió una elevada incidencia de la fisura anal crónica en el grupo etareo de 40 a 49 años y en el sexo femenino, la sintomatología que predominó fue el dolor, seguido del sangramiento rectal con localización posterior, con una evaluación al final del tratamiento de curado. Conclusiones: la efectividad de la esfinterotomía lateral interna subcutánea cerrada es una técnica que tiene pocas reacciones adversas y derivación a otros tratamientos.

ABSTRACT Background: benign rectal diseases are very frequent in the usual medical practice at all levels of health care, but especially in specialized services. Within these processes it is recognized that Anal Fissure is one of the most common. In Cuba, they represent approximately 30-35 % of consultations and interventions in the services of Coloproctology. Objective: to determine the effectiveness of closed subcutaneous internal lateral sphyncterotomy in patients with chronic anal fissure diagnosis. Methods: a descriptive, longitudinal and prospective study was performed in patients with chronic anal fissure diagnosis, assisted in the services of proctology of the Teaching Hospital Manuel Ascunce Domenech from September 2016 to September 2017. The universe consisted of the 132 adult patients who came to the Coloproctology service of this institution with the diagnosis of chronic anal fissure. A validated survey was applied to all patients, based on expert criteria, with prior informed consent. Results: in the investigation there was a high incidence of chronic anal fissure in the age group of 40 to 49 years and in the female sex; the predominant symptomatology was pain, followed by rectal bleeding, located in the posterior area, with an evaluation at the end of the curing treatment. Conclusions: the effectiveness of closed internal lateral sphyncterotomy is given because this technique has few adverse reactions and referral to other treatments.

Comparison of the effectiveness of two treatment modalities for chronic anal fissure: Botox versus sphincterotomy.

OBJECTIVES: Anal fissure is a common health problem that affects the quality of life of young patients. The aim of our study was to benchmark results of lateral internal sphincterotomy (LIS) and botulinum toxin injection in the treatment of chronic anal fissure. MATERIAL AND METHODS: This multi-center, retrospective study used data from 135 chronic anal fissure patients. Patients' demographic features, clinical findings, fissure characteristics, post-defecation pain score, rectal bleeding or pruritus, and treatment satisfaction scores were recorded. Patients' data were collected from the hospital records and patients with all of this data available were called and invited to the hospital for examination. RESULTS: Seventy-four LIS and 61 botulinum toxin applied patients were included. Symptom duration, hospitalization period, and duration of remission of complaints after the treatment were significantly higher in the LIS group (p<0.001). However, pruritus in anus and relapses were found to be higher in the botulinum toxin group (p=¬ 0.04 and p= 0.043, respectively). Abscess and fistula were observed in one patient's perianal region in the LIS group, and an abscess was observed in one patient in the botulinum toxin group. There was no significant difference in treatment satisfaction rates and postoperative complications. CONCLUSION: Botulinum toxin yields satisfying results that are comparable to LIS. Patient selection may help mitigate this disease and allow it to be considered a good alternative option to surgery.

What predicts successful nonoperative management with botulinum toxin for anal fissure?

BACKGROUND: Botulinum toxin has been established as a non-surgical alternative for chronic anal fissures. There is a paucity of data regarding which patients benefit most from this intervention. METHODS: We retrospectively collected data from all cases of chronic anal fissures treated with botulinum toxin over seven years to identify predictors of success. Non-responders were defined as any subsequent surgery or reporting satisfaction as poor or fair. RESULTS: Of 91 patients, 60% (n = 55) were responders and 26% (n = 25) underwent subsequent surgery. There were significantly more females among responders (78% vs. 55%, p = 0.02). A higher body mass index tended towards significance among non-responders (30 ± 7 vs. 27 ± 6, p = 0.08). High satisfaction at the first visit was associated with no subsequent surgery (18% vs. 45%, p = 0.002). CONCLUSIONS: Botulinum toxin can be successfully used to treat anal fissures in a majority of patients. Primary predictors of success were female sex, satisfaction at the first post-procedure visit and there was a tendency towards a lower body mass index.

Apamarga Ksharasutra application and open lateral internal sphincterotomy in the management of Parikartika (chronic fissure­in­ano): A randomized controlled clinical trial.

INTRODUCTION: Parikartika resembles fissure­in­ano which is one of the common painful disease among the anorectal disorders. Ksharasutra which is a para­surgical procedure is effective in the management of Parikartika. AIM: To compare the efficacy of Apamarga Ksharasutra and open lateral internal sphincterotomy (OLIS) in the management of Parikartika (chronic fissure­in­ano). MATERIALS AND METHODS: Total 30 patients having signs and symptoms of Parikartika (chronic fissure­in­ano) were selected and randomly divided into two groups. In Group A (n = 15), Ksharasutra ligation after anal stretching was carried out while in Group B (n = 15), OLIS with excision of skin tag was carried out under local anesthesia or spinal anesthesia. Relief in postoperative symptoms and complications if any was recorded for 4 weeks and follow­up was done for the period of 1 month. RESULTS: In both the groups, significant results were obtained, but the difference among groups was statistically insignificant. Duration required for relief in postoperative pain, bleeding, swelling, and wound healing was found to be more in Group A (Ksharasutra) than Group B (OLIS). CONCLUSION: OLIS provided better results compared to Ksharasutra ligation in the management of Parikartika (chronic fissure­in­ano).

Operative and medical treatment of chronic anal fissures-a review and network meta-analysis of randomized controlled trials.

Anal fissures are a common problem and have a cumulative lifetime incidence of 11%. Previous reviews on anal fissures show inconsistent results regarding post-interventional healing and incontinence rates. In this review our aim was to compare the treatments for chronic anal fissures by incorporating indirect comparisons using network meta-analysis. The PubMed database was searched for randomized controlled trials (RCTs) published between 1975 and 2015. The primary outcome measures were healing and incontinence rates after lateral internal sphincterotomy (LIS), anal dilatation (DILA), anoplasty and/or fissurectomy (FIAP), botulinum toxin (BT) and noninvasive treatment (NIT). Random effects network meta-analyses were complemented by fixed effects and Bayesian models. The present analysis included 44 RCTs and 3268 patients. After a median follow-up of 2 months, the healing rates for LIS, DILA, FIAP, BT and NIT were 93.1, 84.4, 79.8, 62.6, and 58.6% and the incontinence rates were 9.4, 18.2, 4.9, 4.1, and 3.0%, respectively. Compared with NIT, the odds ratio (OR) [95% confidence interval (CI)] for healing after LIS, DILA, FIAP and BT was 9.9 (5.4-18.1), 8.6 (3.1-24.0), 3.5 (1.0-12.7) and 1.9 (1.1-3.5), respectively, on network meta-analysis. The OR (95% CI) for incontinence after LIS, DILA, FIAP and BT was 6.8 (3.1-15.1), 16.9 (6.0-47.8), 3.9 (1.0-15.1) and 1.6 (0.7-3.7), respectively. Ranking of treatments, fixed effects and Bayesian models confirmed these findings. In conclusion, based on our meta-analysis LIS is the most efficacious treatment but is compromised by a high rate of postoperative incontinence. Given the trade-offs between the risks and benefits, FIAP and BT might be good alternatives for the treatment of chronic anal fissures.

Chronic Anal Fissure: A Comparative Study of Medical Treatment Versus Surgical Sphincterotomy.

To determine whether the medical Treatment of anal fissure can be an effective alternative for surgery Methods: Retrospectively, we randomly selected 190 Patients being treated for anal fissure between the years 2005-2010 in 3 equal groups: group A: Patients who received medical treatment with topical nitroglycerin, group B: Patient treated with topical diltiazem, and group C: Patients underwent surgery. The results were then correlated with the statistical program SPSS using chi-square test. Main complaints of the patients were first anal pain and then bleeding. The response to treatments for relieving pain was: 77% in A, 83% in B, and 98% in group C. Response of treatments for fissure healing, in order of groups A, B and C was: 74%, 83%, and 94%. Despite good response to medical treatment, surgical treatment was more effective and medical treatment of choice in patients who are willing to have surgery.