Search

The article discusses the current state of the problem and priorities in the treatment of chronic anal fissures according to literature data. We described consistently standard medical, surgical and other treatment methods with an assessment of their advantages and disadvantages. Based on the analysis of literature data, it is shown that fissure excision in combination with dosed form of subcutaneous sphincterotomy still remains the «gold standard» for the treatment of chronic anal fissure. Taking into account the revision of the traditionally established paradigm and the emerging trends towards a multidisciplinary approach to the problem, the use of combined and minimally invasive sphincter-sparing treatment methods is justified. The use of botulinum toxin, various options for anoplasty, transcutaneous neurostimulation, laser vaporization and pneumoballoon dilatation of the anal sphincter are described. The possibilities of using autologous plasma enriched with platelet growth factors and autologous cells of adipose origin used as cell (tissue) transplantation are presented.

Abstract Background Botulinum toxin type A is currently strongly recommended for the treatment of anal fissures (AFs). However, there is still no consensus on dosage or injection technique. This study provides further efficacy and safety evidence in a 2-year follow-up. Method Prospective, open-label, single-arm, single-center study carried out in adult patients with AFs non-responsive to previous treatments. Patients were treated with incobotulinumtoxinA (incoBoNT/A) injected in both laterals and posterior intersphincteric groove. Healing rate at 2 years was the primary endpoint. Secondary endpoints included internal anal sphincter pressures, incontinence, and safety. Results A total of 49 patients were treated with a mean incoBoNT/A dose of 40.5 U (spread across three locations). Healing rate at 2 years was 83.9% with a 24.5% of recurrence throughout the study. Only 7 patients (14.3%) reported adverse events (AEs) that were mild and temporary. Mean reduction in anal resting pressure was -9.1 mmHg at 3 months (p = 0.001). Mean reduction in voluntary squeeze pressure was -27.5 mmHg at 3 months (p

Introduction: Lateral internal sphincterotomy is the technique of choice for the management of chronic anal fissure. Botulinum toxin has lower complete cure rates, but with significantly lower risk of incontinence. Aim: To evaluate the healing rate, postoperative fecal incontinence and quality of life in patients with chronic anal fissure managed with botulinum toxin. Materials and Methods: Retrospective, prospective, observational and cross-sectional cohort study with consecutive patients. Patients with chronic anal fissure managed with injection of botulinum toxin at the Clinical Hospital of the University of Chile between March 2017 and September 2022 were included. Results: 19 patients, to whom botulinum toxin was administered. Complete healing of the fissure was achieved in all patients, with transient and exclusive fecal incontinence only to gas, which subsided during follow-up. There is a significant improvement in postoperative quality of life. Discussion: Botulinum toxin is a good alternative for the management of chronic anal fissure, with lower healing rates than standard treatment, but a lower proportion of fecal incontinence, generating a relevant benefit. There are no other publications that evaluate quality of life after treatment with botulinum toxin. Conclusion: The administration of botulinum toxin in patients with chronic anal fissure showed promising results in terms of healing, fecal incontinence and postoperative quality of life. In accordance with the recommendations of the American and British guidelines, it should be considered as a therapeutic alternative, especially in patients at high risk of permanent fecal incontinence [ABSTRACT FROM AUTHOR]

Objectives: Lateral internal sphincterotomy is a conventional surgical intervention for chronic anal fissures, yet the potential for postoperative anal incontinence underscores the need for an alternative approach. This study aimed to evaluate the outcomes of patients with chronic fissures who underwent a combination of fissurectomy, vertical non-full thickness midline sphincterotomy (VNMS), and mucosal advancement flap (MAF), as a means of mitigating the risk of incontinence. Methods: This retrospective analysis included forty-six consecutive patients with chronic anal fissures, unresponsive to topical diltiazem, who underwent fissurectomy combined with VNMS and MAF between April 2018 and May 2023. Primary outcome measures encompassed fissure healing rates. Continence was assessed using the Fecal Incontinence Severity Index (FISI), and manometric assessments were conducted before the procedure and three months postoperatively. Results: With a median follow-up of 27 months, there were no postoperative complications, and the overall fissure healing rate reached 96% (44/46). At three months post-procedure, FISI scores were reduced to 0, with no instances of fecal soiling. Anal resting pressure exhibited a significant reduction at 3 months [pre-op: 133 (95% CI, 128−150) vs. 3 mo: 109 (95% CI, 100−117) cmH2O; p = 0.01]. Similarly, maximum anal squeeze pressure showed a significant decrease three months post-surgery [pre-op: 317 cmH2O (95% CI, 294−380) vs. 3 mo: 291 cmH2O (95% CI, 276−359), p = 0.03]. Conclusions: The combination of fissurectomy, VNMS, and MAF proved to be an effective approach for chronic anal fissures, yielding favorable medium-term outcomes without postoperative anal incontinence.

BACKGROUND Enduring the disease and curing internal sphincter spasm while maintaining continence is the aim of treating the anal fissure. Although they can lead to issues like decreased anal continence, surgical techniques such as lateral internal sphincterotomy or manual anal dilatation have a positive healing impact. We wanted to study the effects of lateral internal sphincterotomy and the application of 2% diltiazem gel. METHODS At Government Vellore Medical College, 100 patients of both sexes, ages 20 to 60, who had recurrent symptoms of fissure in ano for longer than six weeks, participated in this two-year observational study. Patients were chosen at random for either surgery or diltiazem therapy. Patients who were chosen to get diltiazem therapy were told to implant the gel twice daily, up to a 1.5-2 cm length. Spinal anaesthesia was used for the internal sphincterotomy procedure. Post-surgery complications like haemorrhage and hematoma were noted. For a descriptive analysis, the results were tabulated. RESULTS 39% of the sample belonged to the 20-30 age group, and 31% to the 31-40 age group. 17% and 13% of those were between the ages of 41 and 50 and 51 and 60, respectively. 36% of people were female, and 64% of people were male. After four weeks, every patient in the internal sphincterotomy group had totally healed and was pain-free. After three months of follow-up, 10 (20%) patients in the diltiazem group reported having minor pain, while 39 (78%) reported being almost pain-free. Due to inadequate pain alleviation from diltiazem, four patients (8%) had internal sphincterotomies. Eight patients were lost to follow-up after receiving treatment with diltiazem gel, leaving 40 (80%) of the patients with fully healed fissures after 4-8 weeks. Out of the 50 patients who had an internal sphincterotomy, 45 (90%) fully recovered after 4 weeks, with six patients lost to follow-up. Both the internal sphincterotomy group and the diltiazem gel group reported no problems. CONCLUSION In treating chronic anal fissures, internal sphincterotomy works better than topical diltiazem. However, topical diltiazem is safe, simple to use, and has few side effects. It might be taken into consideration for people who are not surgical candidates or who refuse surgery. [ABSTRACT FROM AUTHOR]

Background and objective: Chronic anal fissure is a common health problem related to high morbidity. The chemical option for treating chronic anal fissures is highly preferred. Methods: A clinical prospective comparative study was carried out in the General Surgery Outpatient Department in Rizgary Teaching Hospital, Erbil, KRG, during the period from January 2019 to December 2021,on a sample of 100 patients randomly recruited patients with chronic anal fissures divided into two groups with 50 participants each: the DTZ group, who received 2% diltiazem ointment, and the GTN group, who used 0.2% glyceryl trinitrate ointment twice daily for 6 consecutive weeks. The aim of the study is to compare the efficacy and effects of topical Diltiazem (DTZ) and topical glyceryl trinitrate (GTN) in the management of chronic anal fissures. Results: There was a highly significant association between fissure healing at the 4th week and patients treated with DTZ (P

The best nonoperative or operative anal fissure (AF) treatment is not yet established, and several options have been proposed. Aim is to report the surgeons' practice for the AF treatment. Thirty-four multiple-choice questions were developed. Seven questions were about to participants' demographics and, 27 questions about their clinical practice. Based on the specialty (general surgeon and colorectal surgeon), obtained data were divided and compared between two groups. Five-hundred surgeons were included (321 general and 179 colorectal surgeons). For both groups, duration of symptoms for at least 6 weeks is the most important factor for AF diagnosis (30.6%). Type of AF (acute vs chronic) is the most important factor which guide the therapeutic plan (44.4%). The first treatment of choice for acute AF is ointment application for both groups (59.6%). For the treatment of chronic AF, this data is confirmed by colorectal surgeons (57%), but not by the general surgeons who prefer the lateral internal sphincterotomy (LIS) (31.8%) (p = 0.0001). Botulin toxin injection is most performed by colorectal surgeons (58.7%) in comparison to general surgeons (20.9%) (p = 0.0001). Anal flap is mostly performed by colorectal surgeons (37.4%) in comparison to general surgeons (28.3%) (p = 0.0001). Fissurectomy alone is statistically significantly most performed by general surgeons in comparison to colorectal surgeons (57.9% and 43.6%, respectively) (p = 0.0020). This analysis provides useful information about the clinical practice for the management of a debated topic such as AF treatment. Shared guidelines and consensus especially focused on operative management are required to standardize the treatment and to improve postoperative results. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to compare two surgical treatment methods for chronic anal fissures (CAF), mucosal advancement flap anoplasty (MAFA) and cutaneous advancement flap anoplasty (CAFA). Methods: A randomized, blinded clinical trial was conducted on patients with CAF refractory to medical treatment referred to a tertiary-level hospital between January 2021 and December 2022. The patients were assigned to two groups by block randomization and were compared in terms of outcome, pain reduction, and complications. Results: There were 30 patients (male to female ratio 2:3, median age 42 years [range 25–59 years]). Both techniques reduced anal pain significantly (p = 0.001); however, there were no significant differences between MAFA and CAFA groups in recurrence, duration of healing, postoperative pain, and postoperative bleeding. No patient suffered from fecal incontinence (Wexner score = 0) or flap necrosis postoperatively. Only two patients in the MAFA group (1 and 3 months after surgery) and one patient in the CAFA group (2 months after surgery) had recurrence (total recurrence rate = 10%, healing rate = 90%). All of the patients were satisfied with their surgical results. Conclusion: Mucosal and cutaneous anal advancement flap techniques are effective and comparable surgical procedures for the treatment of chronic anal fissures with minimal complications, fast healing process, and minimal postoperative pain and complications. Clinical trial ID: IRCT20120129008861N4 (www.irct.ir). [ABSTRACT FROM AUTHOR]

Introduction: Anal fissure is a linear ulcer usually found in the midline distal to the dentate line in highly sensitive anoderm. This condition causes severe pain and if not adequately treated can lead to severe consequences. Until now due to it's comparatively harmlessness it hasn't garnered the interest of researchers to much greater extent. Aims: To compare the effect of local application of diltiazem 2% ointment and nitroglycerin 0.2% ointment in the treatment of anal fissure. Materials and Methods: The present study was a Prospective study. This Study was conducted from procedure was carried out for two year from at Department of General surgery, AGMC& GBP Hospital. Result: In our study, It was observed that, all patients [90 (100.0%)] had Pain in anal region. the study showed that, 51 (56.7%) patients had Bleeding while defecation. 79 (87.8%) patients were of mixed diet and 11 (12.2%) patients were of vegetarian diet. Conclusion: We concluded that most of the patients reported complete healing of fissures within 6--12 weeks in diltiazem. Diltiazem caused less side-effects particularly headache than glyceryltrinitrate ointment. Diltiazem may be the first-line treatment for chemical sphincterotomy for the chronic anal fissure. [ABSTRACT FROM AUTHOR]

We aimed to evaluate the efficacy and safety of endoanal ultrasound (EAUS)–guided botulinum toxin (BT) in the treatment of chronic anal fissure (CAF). All patients were classified into 2 groups: conventional and EAUS groups. In total, 90 units of BT were injected into the internal anal sphincter at the 3, 6, and 9 o'clock positions in the EAUS group. An injection was performed into the intersphincteric space at the 3, 6, and 9 o'clock positions in the conventional group. Adverse effects and efficacy were analyzed. There were 44 patients: 26 in the conventional group and 18 in the EAUS group. Pain and incontinence rates were similar between groups (P >.05). The efficacy rate was higher in the EAUS group (69.23%) than in the conventional group (81.82%), but this difference was not significant (P =.466). EAUS–guided BT injection is safe and effective in patients with CAFs. [ABSTRACT FROM AUTHOR]

Background: Anal fissure is an ulcer-like, longitudinal tear in the anal canal squamous epithelium. Nowadays the standard treatment for anal fissure is Lateral internal sphincterotomy (LIS). Anal advancement flap (AAF) procedure is accomplished by transfer of healthy well-vascularized tissue onto the base of the fissure combined with fissurectomy, this improves wound healing and decrease anal stenosis risk. So the aim of this study is to compare the outcome of lateral internal sphincterotomy and anal advancement flap in management of chronic anal fissure. Methods: Forty patients with chronic anal fissure and hypertonic anal sphincter detected by anal Manometry. Allocated randomly into two groups. Lateral internal sphincterotomy group (A) and anal advancement flap group (B). Results: A total number of 40 cases (20 cases in each groups). Manometry results showed no significant difference in the preoperative mean resting anal pressure was observed among the two groups. The Mean ± SD for group A was 104.3900 ± 12.93917 and for group B was 107.3900 ± 12.30241 as shown in. the operative time in Group A ranged from 8-12 minutes with a mean operative time 10.0 ± 1.3 minutes. In Group B, the operative time ranged from 25-41 minutes with a mean operative time 32.0 ± 6.01752 minutes. As regard hospital stay in this study, no difference was found between both groups. Conclusions: In conclusion, anal advancement flap is a comparable procedure for LIS for treatment of chronic anal fissure in hypertonic anal canal. [ABSTRACT FROM AUTHOR]

Background: Chronic anal fissure is one of the most common anorectal diseases and is associated with reduced quality of life. The aim of this study was to investigate the effects of pelvic floor physical therapy on quality of life in patients with chronic anal fissure using the Short-Form 36 Health Survey (RAND-36). Methods: Adult patients, with chronic anal fissure and concomitant pelvic floor dysfunction, such as dyssynergia and increased pelvic floor muscle tone, were recruited at the Proctos Clinic in the Netherlands, between December 2018 and July 2021 and randomly assigned to an intervention group, receiving 8 weeks of pelvic floor physical therapy or assigned to a control group receiving postponed pelvic floor physical therapy (PAF trial). Quality of life and pain ratings were outcomes of the study and were measured at 8- and 20-week follow-up. Results: One hundred patients (50 women and 50 men, median age 44.6 years [range 19–68 years]), completed the RAND-36 questionnaire and visual analog (VAS) pain scale score at admission. A significant improvement was found at 20-week follow-up in all domains of the RAND-36; physical functioning, pain, health change (p < 0.001); physical role, vitality, general health, social functioning, emotional role, mental health (p < 0.05). VAS pain was significantly reduced at 8 weeks (mean estimated difference 1.98; 95% CI 1.55–2.42, p < 0.001) and remained significant at 20-week follow-up (p < 0.001). The difference between the groups as regards change in the mean pain intensity scores at 8 weeks was 2.48 (95% CI − 3.20 to − 1.75; p < 0.001). Compared to the reference values of the general Dutch population, the patients in our study with a chronic anal fissure and pelvic floor dysfunction reported an impaired quality of life in 8 of 9 domains of the RAND-36. After treatment, significant lower scores were found in 2 out of 9 domains. Conclusions: The results of this study provide evidence that treatment by pelvic floor physical therapy improves quality of life and reduces pain, making it an important tool in management of chronic anal fissure and concomitant pelvic floor dysfunction. [ABSTRACT FROM AUTHOR]

Objective To study the effect of lateral internal partial sphincterotomy and ligation on chronic anal fissure. Methods A total of 160 patients with chronic anal fissure were randomly divided into two groups. Eighty cases both in study group treated with lateral internal partial sphincterotomy combined with ligation and in control group treated with internal sphincter resection were studied. Incision size, pain score, bleeding score, anal function, hospital stay and incision would healing day on different days after operation in two groups were analyzed. Results Treatment efficacy was 100% in both groups. Cure rates was 100% in study group and 97.50% in control group (P

Introduction. Sphincterotomy is a pathogenetically justified method of surgical treatment of chronic anal fissures with spasm of the sphincter, but the risk of anal incontinence can reach 44%. Therefore, other methods are being sought to eliminate spasm of the sphincter, and the greatest interest is the medical relaxation of the internal sphincter.Aim. To determine the efficacy and limitations of the use combined preparation in the form of a gel of 0.3% nifedipine and 2.0% lidocaine for the treatment of chronic anal fissure.Materials and methods. All patients included in the study were recommended to apply gel 2 times a day with an interval of 12 hours on the skin of the anus and inside the anal canal. In total, the results of treatment of 40 patients were analyzed.Results. Before the start of treatment, the average pain during defecation was 5 (4.5; 7), on the third day of treatment – 4 (4; 5), and on the 10th day – 2 (2; 3). By day 10, 80% (32) of patients refused to take painkillers. On day 21, complete epithelialization was observed in 31 (77.5%) patients. The average healing time of anal fissures was 17 ± 3 days. In patients with complete epithelization of anal fissures, according to the results of EMG on the 21st day of therapy, spontaneous wave activity was absent. In 9 patients, despite the reduction of pain, sphincter spasm persisted after therapy and cracks in the anal canal did not heal.Discussion. When analyzing the reasons that led to the ineffectiveness of the use of gel, it was revealed that in all cases, according to ultrasound studies, there were fibrous changes in the internal anal sphincter.Conclusion. Summarizing the above-mentioned, we can state that the use of a fixed-dose combination of 0.3% nifedipine and 2.0% lidocaine is effective for the treatment of chronic anal fissure with sphincter spasm.

Lateral internal sphincterotomy is increasingly used to treat chronic anal fissure. Since continence disorders are linked to excessive sectionning of the anal sphincter, it is now accepted that better control of the level of sectioning would reduce the occurrence of postoperative incontinence. The aim of this study was to evaluate the midterm results of the lateral internal sphincterotomy at Hopital de la Renaissance of Ndjamena. It was a prospective study of 121 cases of lateral internal sphincterotomy followed up at Hopital de la Renaissance of Ndjamena, during the period from december, 2013 to january, 2019. Lateral internal sphincterotomy was performed in all cases, 79 patients were males (65.3%) and 42 females (44.7%). The average age of our patients was 32 years. Two patients were operated under local anesthesia (1.65%). 113 patients had (93,4%) and 8 (6,6%) anterior anal fissure. 117 patients achieved complete healing at 3 weeks (96.7 %). Anal incontinence was not reported. After a follow-up of 6 months, no recurrence was noticed. Lateral internal sphincterotomy is an effective technique for the treatment of chronic anal fissure. A larger number of cases with a longer follow up could confirm these results. [ABSTRACT FROM AUTHOR]

Background: Patients having anal fissures present commonly to surgical opds. It is caused by linear tear in the anoderm distal to dentate line. Main presenting complaint in such patients is pain while defecation. Chronic anal fissures cause psychological changes in patients that lead to poor quality of life. chronic anal fissures are treated both by medical management and surgical methods. Lateral anal sphincterotomy has proved gold standard in treating CAF. Objectives: We aimed to assess outcome of lateral anal sphincterotomy, safety and efficacy in the management of chronic anal fissure. Materials Andf Methods: This study was done in a tertiary care hospital SKIMS MCH, Bemina Srinagar, Jammu and Kashmir for a period of two years 2020 to 2022. All patients above 18 years not having any other anorectal pathology were selected from opd for this procedure, who fulfill the criteria of chronic anal fissure clinically. Data of such patients in terms of age, gender, any comorbidity, complications of this procedure, satisfaction of patient were recorded. Results: Out of 80 patients 51 were males and 29 females. Most patients were in age of 35 years. Maximum number of patients have this problem over a duration of 7 to 12 weeks. Pain while defecation was chief complaints in almost all patients. Most common complication in our study was flatus incontinence, although recurrence rate of disease was negligible. The complete resolution of preoperative symptoms was 2 months. Conclusion: LIAS is quite cost effective, safe and having very least recurrence rate, and moreover is to be done as opd procedure with no hospitalization of patient. [ABSTRACT FROM AUTHOR]

Background: Chronic anal fissure is a common benign anorectal disease with a high recurrence rate. Pelvic floor physical therapy has been proven effective in the short-term management in patients with chronic anal fissure and pelvic floor dysfunction (PAF-trial). The aim of this study was to determine the outcomes of the PAF-trial and fissure recurrence in patients who completed the 2 months of pelvic floor physical therapy at 1-year follow-up. Methods: Electromyographic registration of the pelvic floor, digital rectal examination, visual analog scales, patient-related outcome measurements, and quality of life were assessed at baseline and at 1-year after inclusion. The primary outcome was muscle tone at rest during electromyographic registration of the pelvic floor at baseline and at 1-year follow-up. Secondary outcomes contained fissure recurrence, pain ratings, pelvic floor dysfunction, complaint reduction measured with a proctology specific patient-reported outcome measurement, and quality of life. Results: The treatment protocol was followed by 137 patients. Ninety-seven patients (71%) completed the 1-year follow-up, 48 women (49.5%) and 49 men (50.5%) with a mean age of 44.4 ± 11.6 years (range 19–68). In the total group of patients, mean resting electromyographic values of the pelvic floor significantly improved from baseline to follow-up at 1 year (mean estimated difference 2.20 μV; 95% CI, 1.79 to 2.61; p < 0.001). After 1 year, the fissure recurred in 15 patients (15.5%). VAS-pain significantly decreased from baseline to follow-up (mean estimated difference 4.16; 95% CI, 3.75 to 4.58; p < 0.001). Dyssynergia was found in 72.9% at baseline and decreased to 14.4% at 1-year follow-up (p < 0.001). Complaint reduction measured with the Proctoprom significantly improved from baseline to 1-year follow-up (p < 0.001). Quality of life (RAND-36) significantly improved in eight of nine domains at 1-year follow-up. No significant improvement was found in the domain vitality. Conclusions: In the PAF-trial, we demonstrated that pelvic floor physical therapy yields a significant and clinical benefit in the time course and therefore should be advocated as adjuvant conservative treatment in patients with chronic anal fissure. Trial registration: The trial is registered at the Dutch Trial registry (NTR7581) [ABSTRACT FROM AUTHOR]

Introduction An anal fissure is marked by a longitudinal tear in the mucosal lining of the lower anal canal, causing painful defecation and mild anal bleeding. The classical triad includes an anal ulcer, a sentinel tag, and a hypertrophic papilla. This study investigates the frequency of fecal incontinence in patients with anal fissure undergoing closed internal sphincterotomy, offering recent insights for treatment recommendations. Objective To determine the prevalence of fecal incontinence in individuals with chronic anal fissure undergoing closed internal sphincterotomy. Methodology The study design was a descriptive case series, conducted over a 6-month period (August 21, 2018 to February 21, 2019). It was carried out at the General Surgery Department, Lady Reading Hospital MTI, Peshawar, Pakistan. The participants included a total of 139 patients diagnosed with chronic anal fissures. Data collection To gather comprehensive information, a detailed approach was adopted. This included history taking, general physical examinations, and digital rectal examinations for all patients. All patients diagnosed with chronic anal fissure were prepared for lateral internal sphincterotomy (LIS). Variables The variable of interest was the occurrence of fecal incontinence, assessed during follow-up visits at the end of the 2nd and 6th week post-surgery. Ethical consideration The study received approval from the hospital's ethical committee and the College of Physicians and Surgeons of Pakistan (CPSP) research committee. Results In our study, the mean age was 30 years (SD ± 12.16). Forty-five percent of patients were male, and 55% were female. Fecal incontinence was observed in 10% of patients. Conclusion Our study reveals a fecal incontinence frequency of 10% in patients undergoing closed LIS for chronic anal fissure., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. College of Physicians and Surgeons Pakistan issued approval CPSP/REU/SGR-2015-022-7638. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Farid et al.)

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.

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. 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. 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. 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. [ABSTRACT FROM AUTHOR]

Background and objective: The gold standard for the treatment of chronic anal fissure is lateral internal sphincterotomy. Botulinum toxin injection provides temporary alleviation of sphincter spasm and allows the fissure to heal. This study aimed to compare the outcomes of lateral internal sphincterotomy and botulinum toxin injection treatments in patients with uncomplicated chronic anal fissure. Methods: A prospective comparative study was carried out at the surgical unit of Erbil teaching hospital, Erbil, Kurdistan Region of Iraq, from January 2017 to February 2018. Fifty-five patients were enrolled in this study. Five patients were excluded, and the remaining 50 patients were equally divided into two groups. Group A was managed with lateral internal sphincterotomy and group B with botulinum toxin. Postoperative pain relief, bleeding, fissure healing, incontinence, and relapse after six weeks and three months of follow-up were compared. Results: One month after treatment, 12% of the lateral internal sphincterotomy group had bleeding, while none of the botulinum toxin group (P = 0.234). Two patients (8%) of the lateral internal sphincterotomy group had pain while one (4%) of the botulinum toxin group (P >0.999).Three months after treatment, 4% of the lateral internal sphincterotomy group had bleeding, while none of the botulinum toxin group (P >0.999). None of the lateral internal sphincterotomy group had pain while one (4%) of the botulinum toxin group (P >0.999). Regarding healing, 96% of the lateral internal sphincterotomy group healed, while 92% in the botulinum toxin group (P >0.999). Conclusion: The outcome of lateral internal sphincterotomy and botulinum toxin were nearly the same, but lateral internal sphincterotomy required hospitalization, period off work, and risk of anesthesia. These risks were absent in botulinum toxin injection.

Objective: To compare the postoperative outcomes in Lateral Internal Sphincterotomy Group and in Botulinum toxin injection Group in patients managed for chronic anal fissure. Study Design: Quasi-experimental study. Place and Duration of Study: Department of Surgery, Combined Military Hospital, Rawalpindi Pakistan, from Aug 2021 to Feb 2022. Methodology: All patients of either gender, aged 30 to 70 years, who had presented to CMH, were included in this study. Block randomization was done to allocate half of them to Lateral Internal Sphincterotomy and half to Botulinum toxin injection. Patients in both Groups were followed for four weeks to assess and compare various short and long term post-surgical outcomes. Results: There were 82 patients in total with 41 in each treatment arm. In the Lateral Internal Sphincterotomy Group, 35 85(37%) of the patients reported postoperative pain relief at 24 hours, 39(95.12%) patients healed, only 2(4.88%) patients had a recurrence. In the Botulinum toxin Group, 29(70.73%) reported postoperative pain relief at 24 hours, 35(85.37%) patients healed, whereas 6(4.63%) had a recurrence. There was no statistical difference in any parameter between either Group. Conclusion: Both methods did not show any statistically significant difference in post-operative outcomes thus other parameters like patient's choice, cost and expertise may be considered in treatment of chronic anal fissure. [ABSTRACT FROM AUTHOR]

Background and Study aims Chronic anal fissures (CAF) are common and associated with reduced quality of life. Partial posterior internal sphincterotomy (PPIS) is frequently carried out and involves partial division of the internal anal sphincter. It carries a risk of anal incontinence, which can be as high as 14%. Anal advancement flap (AAF) combined with fissurectomy has emerged as an alternative, ‘sphincter-preserving’ procedure. Fissurectomy involves excision of the underlying fissure, effectively converting a chronic fissure to an acute one, whereas AAF involves the transfer of well-vascularized, healthy tissue onto the fissure base. The objective of this study was to compare the conventional PPIS and the AAF, using a V-Y advancement flap, regarding healing, anal continence, operative time, postoperative pain, and postoperative bleeding. Patients and methods Our study included 200 consecutive patients who presented at Kasr Al-Ainy colorectal outpatient clinic with CAF, who were randomized and divided into two groups. Group A underwent V-Y advancement flap, whereas group B underwent PPIS. Patients were followed up in the outpatient clinic at 1 week, 6 weeks, and 3 months postoperatively. Results The current study shows group A had lower healing rate (82%) compared with group B (96%). However, there were no recorded cases of anal incontinence postoperatively in group A compared with 14% in group B. Operative time was much less in group B. There were no significant differences regarding postoperative bleeding or pain. Conclusion We recommend the AAF for the surgical management of patients with CAF who are at high risk of developing anal incontinence. Further studies with bigger sample sizes are required to properly assess the rate of healing of the AAF compared with PIS. [ABSTRACT FROM AUTHOR]

Background: A chronic anal fissure is a common, painful condition with great impact on daily life. The exact pathogenesis has not been fully elucidated and treatment varies. A large percentage of patients experience pelvic floor dysfunction (dyssynergia and increased pelvic floor muscle tone). The aim of our study was to investigate the effect of pelvic floor physical therapy in patients with chronic anal fissure. Methods: Between December 2018 and July 2021, at the Proctos Clinic in the Netherlands, patients with chronic anal fissure and pelvic floor dysfunction were randomly assigned to an intervention group, receiving 8 weeks of pelvic floor physical therapy including electromyographic biofeedback or assigned to a control group receiving postponed pelvic floor physical therapy. The primary outcome was muscle tone at rest during electromyographic registration of the pelvic floor before and after pelvic floor physical therapy. Secondary outcomes contained healing of the fissure, pain ratings, improvement of pelvic floor function, and complaint reduction measured with a proctology-specific patient-reported outcome measurement. Endpoints were measured at 8- and 20-week follow-up. Results: One hundred forty patients were included in the study, 68 men (48.6%) and 72 women (51.4%) with a mean age of 44.5 ± 11.1 (range 19–79) years. Mean resting electromyographic values of the pelvic floor in the intervention group significantly improved from pre- to post-treatment (p < 0.001) and relative to controls (mean estimated difference between groups − 1.88 µV; 95% CI, − 2.49 to − 1.27 (p < 0.001) at first follow-up and remained significant from baseline at 20-week follow-up (p < 0.001). The intervention group performed better compared to the control group on all secondary outcomes, i.e., healing of the fissure (55.7% of the patients vs 21.4% in control, pain ratings (p < 0.001), diminished dyssynergia (p < 0.001), complaint reduction (p < 0.001), and decrease of pelvic floor muscle tone (p < 0.05) at first follow-up. Conclusions: The findings of this study provide strong evidence that pelvic floor physical therapy is effective in patients with chronic anal fissure and pelvic floor dysfunction and supports its recommendation as adjuvant treatment besides regular conservative treatment. [ABSTRACT FROM AUTHOR]

Copyright of Colo-Proctology is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Nitroglycerin, a vasodilator, is typically used to treat anginal chest discomfort. The FDA currently approves it for the acute prophylaxis of angina pectoris owing to coronary artery disease (CAD) as well as the acute alleviation of an episode. The treatment of hypertensive urgency/emergency, coronary artery spasm, cocaine-related angina, congestive heart failure (CHF), and chronic anal fissures are a few of the unapproved, off-label uses for this medication. In order for medical professionals to successfully direct patient therapy in circumstances where nitroglycerin is advantageous to patient care, the present review describes the indications, mechanism of action, routes of administration, significant adverse effects, contraindications, monitoring, and toxicity of nitroglycerin. [ABSTRACT FROM AUTHOR]

Background: Chronic anal fissure (CAF) is a common, bothersome condition frequently accompanied by pelvic floor complaints. Despite current guidelines, optimal management is challenging. The aim of this study is to evaluate current management of CAF among gastrointestinal surgeons in the Netherlands. Methods: Dutch gastrointestinal surgeons and residents were sent a survey invitation by email, which was available online between June 2021 and September 2021. The questionnaire consisted of 21 questions concerning work experience, physical examination, diagnostic and surgical techniques, and follow-up. Results: Overall, 106 (33%) respondents completed the survey. Most respondents (59%) had at least 10 years of experience in treating CAF. Only 23% always addressed pelvic floor complaints. Fifty-one percent performed digital rectal examination and 22% always, or almost always, examined the pelvic floor muscles. Most respondents started treatment with fibers and/or laxatives and ointment (96%). Diltiazem was in 90% the preferred ointment. Twenty-two percent referred patients for pelvic floor physical therapy. Botulinum toxin was in 54% performed under general or spinal anesthesia or sedation. The surgical procedure of choice was fissurectomy (71%) followed by lateral internal sphincterotomy (27%). Fissurectomy was in 51% always combined with botulinum toxin. Fifty-seven percent of the respondents preferred a physical follow-up appointment. Conclusion: Guideline recommendations are largely followed in the Netherlands, starting with conservative measures followed by surgical procedures. Surgeons do not consistently assess pelvic floor complaints, nor do they routinely examine the pelvic floor muscles. Awareness of pelvic floor dysfunctions is important to refer patients for pelvic floor physical therapy. [ABSTRACT FROM AUTHOR]

Background: The treatment of chronic anal fissure is predominantly conservative. However, failure of conservative measuresobliges the use of more potent treatments, such as Botulinum Toxin (BT) injections to relax the internal anal sphincter. Furthermore, surgical intervention represented by lateral internal sphincterotomy (LIS) is used to treat resistant cases but imposes the risk of faecal incontinence. The aim of our study is to assess the degree of post-operative pain, recovery time and the rate of postoperative faecal incontinence in patients where CO2 laser is used to perform LIS. Methods: 236 patients clinically diagnosed with chronic anal fissure through 2012-2014 were included in the study. The selected patients were those who did not benefit from conservative treatment. The approach we took starts with Examination Under Anaesthesia (EUA), followed by excision of the fibrotic anal fissure using CO2 laser on continuous mode with defocus technique for haemostasis. Wound healing was induced by secondary intention. The follow-up period extended for 2 years postoperatively. Results: The effectiveness of laser LIS was tested over two domains, pain score and post-operative complications. On a pain scale of 1-10, all patients had a pain score of one or less on day seven. Three patients (1.27%) hadrecurrent pain and bleeding within two years and were treated conservatively. No patients had incontinence at the last follow-up. Six patients (2.5%) developed minimal mucus discharge for three months post operatively. Conclusion: The treatment of resistant chronic anal fissure with CO2 laser shows promising outcomes when compared to conventional LIS. Laser surgery offers the advantage of being a minimal surgical intervention in addition to a reduced risk of incontinence and recurrence when compared to other methods such as BT injections and conventional LIS. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose: While acute anal fissures can be treated with topical therapy to reduce sphincter hypertonia (e.g., isosorbide dinitrate, glyceryl trinitrate, diltiazem), chronic fissures may require more invasive instrumental therapy. Currently, the golden standard remains lateral internal sphincterotomy; however, this carries the long-term risk of faecal incontinence. Fissurectomy can be a valuable alternative, but is less efficient because of absence of correction of underlying hypertonia. In this study, we aim to evaluate the additional effect of injection of botulinum toxin during fissurectomy in the treatment of chronic anal fissures. Methods: A single-centre retrospective analysis of 293 isolated superficial fissurectomies with or without injection of botulinum toxin was performed, with pain relief as primary endpoint. Results: The majority of patients undergoing fissurectomy were women (65%, mean age 45.0 years vs. 35% men, mean age 48.3 years), often because of ventral fissures (30% in women vs. 8% in men). Fissurectomy resulted in resolution of complaints in 81.1%, while additional injection of botulinum toxin resulted in resolution in 90.1% (p < 0.05). Complication rate was identical between the two groups, mainly (flatus) incontinence (4.5% vs 4.9% with botulinum toxin) and post-operative bleeding (1.8% vs 2.5% with botulinum toxin). Conclusion: Injection of botulinum toxin significantly increases the efficiency of fissurectomy in the treatment of chronic anal fissures without additional complications. [ABSTRACT FROM AUTHOR]

Background Chronic anal fissures are longitudinal tear in the anoderm below the dentate line, typically occurring in the midline, with visible sphincter fibers at the fissure base, anal papillae, sentinel piles, and indurated margins. The gold-standard method of treatment is lateral internal sphincterotomy, which can be done by either open or closed technique. Medical sphincterotomy refers to pharmacological manipulation of anal sphincter tone as an alternative modality to surgery. Objective To compare the efficacy of treatment among patients receiving glyceryl trinitrate (GTN) treatment for chronic anal fissure with that among patients receiving percutaneous posterior tibial-nerve stimulation and those undergoing closed lateral internal sphincterotomy. Patients and methods In total, 120 patients were randomly allocated into three groups: 40 patients treated with percutaneous posterior tibial-nerve stimulation, 40 patients treated with GTN ointment, and 40 patients treated with closed lateral internal sphincterotomy. Results This study showed that treatment with percutaneous posterior tibial-nerve stimulation had led to complete healing in 27.5% of patients in posterior tibial-nerve stimulation group, 70% of patients in the GTN group, and 95% of patients in closed lateral internal sphincterotomy group. Conclusion Closed lateral internal sphincterotomy remains the gold standard for treatment of chronic anal fissure. [ABSTRACT FROM AUTHOR]

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. 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. 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. 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. [ABSTRACT FROM AUTHOR]

Purpose: Anocutaneous advancement flap is a surgical procedure for the treatment of chronic anal fissures. This study aimed to assess the results of anocutaneous advancement flap in a consecutive cohort of patients. Methods: This is a retrospective, observational study. From 2000 to 2011, 481 patients had been operated for a single chronic anal fissure at the Maingau Clinic of the German Red Cross in Frankfurt am Main. The intention was to excise the fissure by fissurectomy (FIS) and then to cover the wound primarily with an anocutaneous advancement flap (AAF). The primary outcomes were resolution of symptoms and healing rates 1 month postoperatively. Secondary outcomes included incidences of early and late complications, postoperative incontinence, and recurrent fissure. Results: Anocutaneous advancement flap was performed in 455 (94.6%). In 26 (5.4%) patients, AAF failed due to lacking skin and the wound left open after FIS. One month postoperatively, half of the patients with AAF were free of symptoms (53.2%) with complete wound healing (47.9%). The incidence of early complications within 1 month postoperatively was 0.9% after AAF. From 1 month to 5 years after operation anal abscesses and fistula occurred in 2.9%. Mild symptoms of anal incontinence were recorded in 0.2% and recurrent chronic anal fissure in 3.3% of patients. Subgroup analysis revealed improved wound healing 1 month postoperatively in patients with AAF compared to FIS. Conclusion: Anocutaneous advancement flap is a very safe sphincter-sparing surgical option for CAF, provides a quicker cure than fissurectomy, and may be considered a good first-line surgical treatment option for chronic anal fissures if medical treatment failed. [ABSTRACT FROM AUTHOR]

Introduction: Surgery for chronic anal fissure is challenging for every proctologist. Solving the pain by guaranteeing rapid and effective healing is the objective, but what is the price to pay today in functional terms? Though this result is nowadays partially achievable through interventions that include the execution of an internal sphincterotomy among the procedures, it is necessary to underline the high rate of patients who can present faecal incontinence. The aim of this study is to explore the effectiveness of scanner-assisted CO2 laser fissurectomy.Methods: From April 2021 to September 2021, all consecutive patients who affected by chronic anal fissure suitable for surgery, meeting the inclusion and exclusion criteria, were evaluated. All planned data were recorded before surgery, then at 24 h, 1 week, and 1 month follow-up. A scanner-assisted CO2 laser was used in this study to achieve a smooth and dried wound with a minimal tissue thermal damage, to ensure good postsurgical pain control, rapid and functional, elastic and stable healing, and to prevent potential relapses. Paracetamol 1 g every 8 h was prescribed for the first 24 h and then continued according to each patient's need. Ketorolac 15 mg was prescribed as rescue.Results: Mean pain intensity ≤3, considered as the principal endpoint, was recorded in 26 out of the 29 patients who enrolled in the study with a final success rate of 89.7% at 1-month follow-up. Pain and anal itching showed a statistically significant reduction while bleeding, burning, and maximum pain, and REALIS score showed a reduction too at the end of the follow-up period. Reepithelisation proved to be extremely fast and effective: 22 of 29 (75.9%) showed a complete healing and 5 showed a partial reepithelisation at 1-month follow-up.Discussion: Outcomes of this study showed that it is undoubtedly necessary to change the surgical approach in case of anal fissure. The internal sphincterotomy procedure must be most of all questioned, where the availability of cutting-edge technological tools must be avoided and offered only in selected cases. Scanner-assisted CO2 laser showed great results in terms of pain control and wound healing, secondary to an extremely precise ablation, vaporisation, and debridement procedures with minimal lateral thermal damage.

Background: Chronic anal fissure (CAF) is a common cause of severe anorectal pain with a high incidence rate. Currently, a wide range of treatment options are available with recurrence rates varying between 7 and 42%. Pelvic floor physical therapy (PFPT) is a treatment option for increased pelvic floor muscle tone and dyssynergia which often accompanies CAF. However, literature on this subject is scarce. The Pelvic Floor Anal Fissure (PAF)-study aims to determine the efficacy and effectiveness of PFPT on improvement on pelvic floor muscle tone and function, pain, healing of the fissure, quality of life and complaint reduction in patients with CAF. Methods: The PAF-study is a single-centre, two armed, randomized controlled trial. Patients with CAF and pelvic floor dysfunction are eligible for inclusion. Exclusion criteria include abscess, fistula, Crohn's disease, ulcerative colitis, anorectal malignancy, prior rectal radiation, and pregnancy. A total of 140 patients will be randomized for either PFPT or postponed treatment of PFPT.The primary outcome is tone at rest during electromyographic registration of the pelvic floor before and after therapy. Secondary outcomes consist of healing of the fissure, pain ratings, improvement of pelvic floor function, complaint reduction and quality of life. Primary and secondary endpoints are measured at 8 and 20 weeks and at 1-year follow-up. Discussion: Currently, there is a gap in treatment modalities between conservative management and surgery. This manuscript prescribes the rationale, design, and methodology of a randomized controlled trial investigating PFPT as a treatment option for patients with CAF.

Objective: Surgical treatment of anal fissure can cause permanent incontinence in some patients. Topical medications have less adverse effects. The aim of this study was to compare the effectiveness of Diltiazem 2% topical with GTN 0.2% ointment in the treatment of chronic anal fissure with a view to establish which drug should be used as first line in conservative management. Material and Methods: This randomized clinical trial was carried out in Department of Surgery, Distric Headquaters Hospital (DHQ), Abbott abad from April 2020 to February 2021. Patients with chronic anal fissure above 18 years of age were treated with Diltiazem 2% (34 patients) and GTN 0.2% (34 patients) in the anal canal three times a day for 6 weeks duration. Age, symptoms, gender, location of ulcer, healing rate and adverse effect like headache were compared. SPSS 17 was used for calculation. X2 test used for comparing healing rate and incidence of headache. P value below 0.05 considered significant. Results: 68 patients were included in study. They were randomly allocated to two groups. Group-A (Diltiazem DTZ) comprised of 34 patients while group-B (GTN) contained 34 patients. Difference between healing rates was not significant between two groups. GTN group had more headache than DTZ group. Conclusion: Medical treatment is the initial treatment for chronic anal fissure. Both DTZ and GTN have comparable rate in healing chronic anal fissure although DTZ is superior to GTN in relation to headache. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: One of the most frequent distressing diseases which causes anal pain and bleeding after defecation is anal fissure. Despite a poorly understood pathogenesis, the internal anal sphincter spasm has been identified to play a central role in pathogenesis. Recently, botulinum toxin is being used increasingly for the treatment of chronic anal fissure to achieve chemical sphincterotomy and reduce internal sphincter tonicity. Based on the heterogeneity among the published studies, we aimed this study to evaluate its healing rate and for recognizing the factors of patients which may affect the outcome. Subjects and Methods: In a prospective case series medical research, 106 patients who suffer from chronic anal fissure were treated by botulinum toxin injections. All patients received 30 units of botulinum toxin and were physically examined every week for 2 months. They were evaluated for bleeding, pain, hematoma, thrombosis, infection, incontinence, and healing of the fissure. At the end of the follow-up period, the fissure healing rate and its relation to age, gender, prior topical therapy, duration of symptoms, and the position of the fissure were assessed. Results: At the end of the study (8 weeks), the healing rate was 84.9% (90 patients responded to injections). Healing rate was higher in females and in patients who experienced a shorter duration of symptoms before injection. The mean healing time was 4.68 weeks. In addition, patients with one fissure (anterior or posterior) demonstrated higher healing rate and shorter healing time compared to patients with two fissures (anterior and posterior). Conclusion: This study demonstrated that botulinum toxin injection is safe and effective for the treatment of chronic anal fissures, with a low complication rate. In addition, the healing rate was higher in females, patients with shorter duration of symptoms, and those with one fissure.

Background: Chronic anal fissure is a common condition which is classically treated by surgery which may lead to incontinence. Recently medical treatment in form of calcium channel blockers (CCB) has gained interest. Aims: The aim of this study is to compare the effectiveness of local Nifedipine and Diltiazem with lignocaine as control. We also aimed to observe the clinical pattern of chronic anal fissure. Material and Method: Patients of chronic anal fissure were divided into three groups. First group received topical Nifedipine, second received topical Diltiazem, and the control group received only local lignocaine for 1 month. Their clinical data was recorded. The intensity of pain and bleeding was assessed from a visual analogue score (VAS). On the 4th week patients were examined for healing. Statistical Analysis: Statistical analysis was done by Medcalc statistical software v14. Student's t-test and Chi-square test was used accordingly. Results: Mean age was 35.89 with a male female ratio of 1.7:1. Most common clinical feature was pain (100%), followed by constipation, bleeding, and pruritus. Most common location was posterior. VAS scores for pain of the Nifedipine group and Diltiazem group was significantly better than control group (P < 0.0001). VAS scores for bleeding in the Nifedipine group (P = 0.0091) and Diltiazem group (P = 0.0045) was significantly better than control group. The healing rate for NFD group was 93.33% (P < 0.0001), that of DTZ group was 86.67% (P = 0.0002), which was statistically better than control group (36.67%). There was no significant difference between the two CCBs. Conclusion: Adding topical Nifedipine or Diltiazem in the treatment of anal fissure is far superior to treatment with only topical Lignocaine.

Abstract Background: Conservative treatment of chronic anal fissure (CAF) is the first line of treatment. Patients who fail conservative treatment are offered surgical treatment in the form of lateral internal sphincterotomy (LIS) or V-Y anoplasty.Objective: This prospective study aimed to compare LIS and V-Y anoplasty in the treatment of CAF based on the baseline resting anal pressure of patients.Methods: Female patients with CAF were investigated with anal manometry. Patients with elevated resting anal pressure were treated with LIS and patients with normal or low resting anal pressure were treated with V-Y anoplasty. Data about healing of anal fissure, reduction in pain score, continence disturbance, and complications were recorded on follow-up.Results: Twenty-four female patients of a mean age of 37.6 years were included to this study. Sixteen patients underwent LIS (group I) and 8 underwent V-Y flap (group II). Both groups achieved comparable time to complete healing. Both groups showed significant decrease in pain score at 3 months of follow-up (Group I: 6.1±0.85 to 0.93±0.7, p

In the treatment of chronic anal fissure, both surgical and topical treatment methods are used. The purpose of this study was to research a combined topical treatment that we prepared and to compare the effectiveness of lateral internal sphincterotomy in chronic anal fissure with this topical treatment. A total of 183 patients with chronic anal fissure were divided into two groups. One hundred and four patients had topical medical treatment (group 1) and seventy-nine patients underwent lateral internal sphincterotomy (group 2). In the first group, a topical combination of ointments consisting of bacitracin-neomycin sulfate, dexpanthenol, and diltiazem was applied to the anal area. Four weeks after treatment, pain and bleeding during defecation, gas/fecal incontinence, treatment-related adverse events and recovery rates were evaluated in both groups. Also, patients were examined for recurrence between the 8th and 10th weeks. There was no significant difference in recovery rates between the groups. In group 1, recovery rate was 82.7%, while in Group 2 it was 92.4% (p = 0.054). In both groups, gas/fecal incontinence ratio was significantly different, supporting the medical treatment (p = 0.02). The severity of pain and bleeding during defecation were compared between the groups. Only the severe pain was significantly higher in the medical treatment group (p = 0.018). The recurrence rate was 5.8% in the medical treatment group, but no recurrence was detected in the surgical group. Due to possible complications of surgical treatment and similar recovery rates, medical treatment of patients with chronic anal fissure can be tried before surgical treatment. [ABSTRACT FROM AUTHOR]