The medical and surgical management of chronic anal fissure

Clinical, functional and morphologic evaluation of patients undergoing lateral sphincterotomy for chronic anal fissure treatment. Identification of factors that can interfere with fecal continence

Objective Evaluate clinical, functional and morphologic outcomes of lateral sphincterotomy for chronic anal fissure treatment, and correlate the findings with factors that influence in the anal continence.

Method In a prospective study, female patients treated by lateral sphincterotomy for chronic anal fissure were assessed using Wexner's incontinence score and grouped according to score: group I (score = 0) and group 2 (score ≥1) and evaluated with anal manometry and anorectal 3D ultrasonography.

Results Thirty-six womens were included, 33% had vaginal delivery. Seventeen patients were included in group I and 19 in group II. We found no difference in age, parity and mode of delivery between groups. A significant difference with respect to percentage reduction in resting pressures was noted, when comparing group 1 versus group 2. The anal sphincter muscle length was similar in both groups. However, the length and percentage of transected internal anal sphincter was significantly greater in group II.

Conclusion There was a correlation between fecal incontinence symptoms after sphincterotomy with the percentage of resting pressure reduction, length and percentage of transected internal anal sphincter.

Innovations in chronic anal fissure treatment: A systematic review

A chronic anal fissure is a common perianal condition. This review aims to evaluate both existing and new therapies in the treatment of chronic fissures. Pharmacological therapies such as glyceryl trinitrate (GTN), Diltiazem ointment and Botulinum toxin provide a relatively non-invasive option, but with higher recurrence rates. Lateral sphincterotomy remains the gold standard for treatment. Anal dilatation has no role in treatment. New therapies include perineal support devices, Gonyautoxin injection, fissurectomy, fissurotomy, sphincterolysis, and flap procedures. Further research is required comparing these new therapies with existing established therapies. This paper recommends initial pharmacological therapy with GTN or Diltiazem ointment with Botulinum toxin as a possible second line pharmacological therapy. Perineal support may offer a new dimension in improving healing rates. Lateral sphincterotomy should be offered if pharmacological therapy fails. New therapies are not suitable as first line treatments, though they can be considered if conventional treatment fails.

The house advancement anoplasty for treatment of anal disorders

OBJECTIVES

Anal advancement flaps treat a variety of anal disorders. In recent years the "House" advancement flap has been used with good success, the term referring to the shape of the flap used. It is simple with few shortcomings. We reviewed a single centre's experience of this procedure.

METHODS

All patients who underwent a house advancement flap between 1996 and 2001 were identified. The case notes were examined and data collected on indication for surgery, complications, follow-up and outcome.

RESULTS

Thirteen consecutive patients were identified, mean age of 44 years. Indications for surgery were chronic anal fissure, fistulous disease and post surgical deformity or stenosis of the anal canal. Median follow-up was 37 months (25-84). In 9 patients the flaps healed within 4 weeks. In the remaining 4 patients the flaps healed by secondary intention over a median of 14 weeks (8-20). Postoperative complications occurred in 5 patients (3 donor site separation and 2 flap retraction). Two patients developed recurrence of their original disorder. Eleven patients have relief of pre-operative symptoms with fully healed flaps.

CONCLUSION

This procedure is simple, easy to construct and robust. It can be performed for a variety of anal disorders with satisfactory results and few complications and should be in every Coloproctologist's armamentarium.