Anal Fissure Research Articles

The Association of Coloproctology of Great Britain and Ireland guideline on the management of anal fissure.

The management of anal fissure: ACPGBI position statement was written 15 years ago. [KLR Cross etal., Colorectal Dis, 2008]. Our aim was to update the guideline and provide recommendations on the most effective treatment for patients with anal fissures utilising a multidisciplinary, rigorous guideline methodology. The development process consisted of six phases. In phase 1 we defined the scope of the guideline. The patient population included patients with acute and chronic anal fissure. The target group was all practitioners (primary and secondary care) treating patients with fissures and, in addition, healthcare workers and patients who desired information regarding fissure management. In phase 2 we formed a guideline development group (GDG) including a methodologist. In phase 3 review questions were formulated, using a reversed PICO process, starting with possible recommendations based on the GDG's knowledge. In phase 4 a comprehensive literature search focused on existing systematic reviews addressing each review question, supplemented by more recent studies if appropriate. In phase 5 data were extracted from the included papers and checked by the GDG. If indicated, meta-analysis of systematic review data was updated by the GDG. During phase 6 the GDG members decided what recommendations could be made based on the evidence in the literature and strength of the recommendation was assessed using 'grade'. This guideline is divided into two sections: Primary care which includes (i) diagnosis; (ii) basic treatment; (iii) topical treatment; and secondary care which includes (iv) botulinum toxin therapy; (v) surgical intervention and (vi) special situations (including pregnancy and breast-feeding patients, children, receptive anal intercourse and low-pressure fissures). A total of 23 recommendations were formulated. A new term clinically healed was described by the GDG. This guideline provides an up-to-date evidence-based summary of the current knowledge of the management of anal fissure and may serve as a useful guide for clinicians as well as a potential reference for patients.

Comparative study of laser versus open lateral internal sphincterotomy in the treatment of anal fissure

Background: Anal fissure is a common proctological problem that causes anal pain during and after defecation. An anal fissure is a linear ulcer that presents at the anal verge. It is more common in females than males and can be seen either in the anterior or posterior midline, just distal to the dentate line. Aims and Objectives: Comparison of Laser versus Open lateral internal sphincterotomy (LIS) in the treatment of anal fissures. Materials and Methods: The study was conducted in 50 cases of Open LIS compared with 50 cases of laser LIS (LLIS) in patients admitted to the Department of Surgery, M.L.B. Medical College, Jhansi (UP), India, between January 2021 and June 2022. Results: Out of 50 cases of open LIS, 10 patients presented with bleeding, 10 patients presented with hematoma/perianal swelling and 5 patients presented with pain as compared to 50 cases of LLIS, hematoma/perianal swelling (1 patient) and pain (2 patients) were found as an early post-operative complication. Mean hospital stay was 2.84±1.128 days in Open LIS as compared to 1.02±0.141 days in LLIS. The pain was presented in 1 patient as the only late post-operative complication in LLIS as compared to pain (25 patients), bleeding (10 patients), infection (2 patients), and flatus incontinence (1 patient) in Open LIS, at 2 weeks follow-up and recurrence in 1 patient in laser and in 3 patients in open LIS at 6 weeks follow up. Conclusion: LLIS significantly reduces early postoperative complications such as postoperative pain, bleeding, and hematoma as compared to open LIS. The duration of hospital stay was significantly less in LLIS in comparison to open LIS. None of the patients presented with the flatus or stool incontinence who had undergone LLIS while in Open LIS, 12% of patients presented with flatus incontinence, and 2% of patients presented with stool incontinence during follow-up in 2–6 weeks.

Pudendal block effect on pain perception after lateral sphincterotomy for chronic anal fissure done under general anesthesia: a randomized controlled trial

Pudendal block effect on pain perception after lateral sphincterotomy for chronic anal fissure done under general anesthesia: a randomized controlled trial

Modern Possibilities of Using Lactulose in Clinical Practice

Aim of the publication. To present an overview of current literature data on the possibilities of application of lactulose in clinical practice.Key findings. Lactulose is a synthetic disaccharide belonging to the class of osmotic laxatives. Officially permitted indications for its appointment in Russian Federation are functional constipation (including in children, the elderly and senile, pregnant women and women in postpartum period), an obstipation type of irritable bowel syndrome, the need to soften the consistency of feces in hemorrhoids and anal fissures, after operations on the colon and anorectal area, as well as hepatic encephalopathy. Other indications include preparation for colonoscopy, treatment and prevention of disorders of the intestinal microbiota, prevention of constipation in oncological patients receiving narcotic analgesics, as well as patients on artificial lung ventilation.Conclusion. Lactulose is a highly effective and safe drug, which combines osmotic laxative effect with expressed prebiotic action and is used in a wide clinical practice.

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

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. 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. 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. 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.

Topical Sucralfate for Treatment of Chronic Anal Fissure.

Topical Sucralfate for Treatment of Chronic Anal Fissure.

EFFECTIVENESS OF DWIHARIDRA RASAKRIYA PICHU IN CHRONIC FIS-SURE-IN-ANO - A SINGLE GROUP CLINICAL STUDY

Fissure-in-ano is an elongated ulcer in the long axis of the lower anal canal. One in every ten people is affected by anal fissure in their lifetime. It occurs equally in both sexes and is mostly seen between 30-50 years of age. Sometimes it occurs in children also. Constipation is the primary and sole cause of initiation of a fissure-in-ano. Passage of hard stool, irregularity of diet, consumption of spicy and pungent food, faulty bowel habits, and lack of local hygiene can contribute to initiation of the pathology. Fissure-in-ano is of two types, acute and chronic. If a fissure is present for more than six weeks, it is termed a chronic fissure. In Ayurveda it may be correlated with Parikaṛthika. Pichu dhārana was found to be effective in chronic fissure-in-ano. The aim of this study is to find out the effectiveness of Dwiharidra rasakriya pichu in the management of chronic fissure-in ano.

The Italian Unitary Society of Colon-proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of anal fissure

IntroductionThe aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colon-Proctologia) on the diagnosis and management of anal fissure, with the purpose to guide every physician in the choice of the best treatment option, according with the available literature.MethodsA panel of experts was designed and charged by the Board of the SIUCP to develop key-questions on the main topics covering the management of anal fissure and to performe an accurate search on each topic in different databanks, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in different rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to the PICO criteria, and the statements developed adopting the GRADE methodology.ConclusionsIn patients with acute anal fissure the medical therapy with dietary and behavioral norms is indicated. In the chronic phase of disease, the conservative treatment with topical 0.3% nifedipine plus 1.5% lidocaine or nitrates may represent the first-line therapy, eventually associated with ointments with film-forming, anti-inflammatory and healing properties such as Propionibacterium extract gel. In case of first-line treatment failure, the surgical strategy (internal sphincterotomy or fissurectomy with flap), may be guided by the clinical findings, eventually supported by endoanal ultrasound and anal manometry.

Surgeons' practice and preferences for the anal fissure treatment: results from an international survey.

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 6weeks 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.

Efficacy of Yashtimadhu ghrit matra basti in post-operative management of Ano-rectal Cases – A case Series

Background- Exploitation of analgesics is becoming an advent scenario in the current practice of both medical and surgical cases. Adopting a less complicated and a wholesome beneficial modality for post operative analgesia is the need of the hour. In this case series, focus has been placed on yashti ghrit matra basti as the intervention for pain and wound management of post-operative cases of chronic fissure in ano associated with internal haemorrhoids. Objective- The current study was aimed at post operative analgesia and wound management with yashti ghrit matra basti in ano-rectal cases. Material &amp; Methods-The method adopted here was Lord’s anal dilatation followed by excision of sentinel tags or ligation haemorrhoidectomy according to the case presentation, followed by yashti ghrit mastra basti as primary ayurvedic intervention for post operative analgesia and wound healing. Results -It is found that the planned treatment gave a positive response as post operative analgesia and also played an adjuvant role in wound healing. Conclusion-This case series provides the successful pain and wound management of post-operative ano-rectal cases with a promising ayurvedic intervention.

S231 Rectal and Anal Ulceration: Analysis of Demographic Trends, Comorbidity Measures, and Outcomes from the National Inpatient Sample Database

S231 Rectal and Anal Ulceration: Analysis of Demographic Trends, Comorbidity Measures, and Outcomes from the National Inpatient Sample Database

Nigam’s standardization of manual anal dilatation (Lord’s procedure)

Background: Standardisation of manual anal dilatation. It was a quality improvement study. Patients were admitted in various hospitals of Gurgaon, Haryana, India. Methods: Two hundred thirty-six patients of fissure in ano were treated by manual anal dilatation (Lord’s procedure) as per Nigam’s standardization between January 2010 and January 2022. Informed consent was obtained from each patient. All patients were evaluated for post procedure for complications. Two hundred thirty-six patients of fissure in ano were treated by manual anal dilatation (Lord’s procedure). Results: No patient developed faecal incontinence. Pain subsided immediately in all patients. No patient had non healing of anal fissure. Two patients had mild gas incontinence which resolved after 3-4 days. None of the patients required lateral sphincterotomy or fissurectomy. Most of the patients healed completely within three weeks. Conclusions: If manual anal dilatation is performed slowly, gently with controlled force for four minutes, as per Nigam’s standardisation then results are very good. This study includes patients of acute and chronic fissure in ano. The study excludes cases of anal cancer, stage III and IV haemorrhoids and inflammatory bowel disease.

Early outcomes of chronic anal fissure treatment using the lateral internal sphincterotomy method without excision (randomized trial NCT05117697)

PURPOSE OF THE STUDY: improvement of the treatment of chronic anal fissure results.PATIENTS AND METHODS: the study included 70 patients randomized by random number generation into 2 groups: 30 patients underwent lateral internal sphincterotomy (main group, LIS), and 40 patients underwent LIS in combination with the excision of the fissure (EF) (control group, LIS + EF).RESULTS: the pain intensity both after stool and during the daytime in the main group (LIS) has been significantly lower than in the control group (LIS + EF) (p &lt; 0.05). The median duration of the patients’ temporary disability in the LIS group was 6 (4; 9) days, in the LIS + EF group — 17 (9; 23.5) days (p = 0.04). On day 15, the defect has epithelialized in 12/30 (40%) patients of the main group (LIS) and none (0/40) in the control group (LIS + EF) (p = 0.00001), on day 30 — in 22/30 (73.3%) and 2/40 (5%) (p = 0.00001), on day 45 — in 26/30 (87%) and 20/40 (50%) (p = 0.002), and on day 60 — in 28/30 (93.3%) and 38/40 (95%) (p = 1.0), respectively. On the day 30 after surgery, 3/30 (10%) patients of the main group and 15/40 (37.5%) of the control group had complaints regarding passing gas (p = 0.01), on day 60 — anal sphincter insufficiency (ASI) persisted in 1/30 (3%) patients in the LIS group and in 3/40 (7.5%) patients in the LIS + EF group (p = 0.63). Excision of the fissure in 5.4 (1.4–20.9) times increases the chance of developing ASI on day 30 of the postoperative period (p = 0.015) and 52 (10.2; 268.3) times increases the chance of non-healing of the defect during this period (p = 0.000002) and 6.5 (1.9; 22) times on the day 45 (p = 0.003), in comparison with the LIS only.CONCLUSION: refusal to excise the anal fissure during its surgical treatment and perform the lateral internal sphincterotomy only can reduce the intensity of postoperative pain syndrome, the rate of postoperative complications and reduce the time of epithelialization of the anoderm defect.

Open or closed sphincterotomy for treatment of the chronic anal fissure? (systematic review and meta-analysis)

INTRODUCTION: up to the present time, both open and closed lateral internal sphincterotomy (LIS) are considered by surgeons as fully comparable methods for eliminating the spasm of the internal sphincter in patients with chronic anal fissure. However, each method has a number of advantages and disadvantages. AIM: determination of an effective and safe method of lateral subcutaneous sphincterotomy.MATERIALS AND METHODS: a systematic overview and meta-analysis of studies, which compare the results of treatment after an open and closed lateral sphincterotomy was performed. The following has been evaluated: the incidence of fissure epithelialization, the postoperative morbidity, the recurrence rate, the incidence of anal incontinence (AI). Statistical processing has been carried out in the Review Manager 5.3 program.RESULTS: the meta-analysis included 9 studies with the results of treatment of 452 patients after an open lateral sphincterotomy and 443 after a closed one. The groups were comparable in frequency of epithelialization of fissures (OR = 0.87; CI = 0.30; 2.53; p = 0.8), in terms of the number of postoperative complications (OR = 0.52; CI = 0.15; 1.76; p = 0.29), as well as the number of relapses of the disease (OR = 0.5; CI = 0.19; 1.31; p = 0.16). At the same time, the implementation of an open lateral sphincterotomy leads to the development of AI 2.05 times more often than the closed method (OR = 2.05; CI = 1.01; 4.16; p = 0.05).CONCLUSION: during the treatment of the chronic anal fissure, in order to eliminate the spasm of the internal sphincter, it is advisable to use a closed method, in which the chance of AI is 2.05 times lower.

The Role of Fitostimoline Proctogel in Symptoms Relief and Healing in Patients Affected by Anal Fissure

The Role of Fitostimoline Proctogel in Symptoms Relief and Healing in Patients Affected by Anal Fissure

Anal Fissures: A Case Series Study On How Yoga Prana Vidya (YPV) HealingProtocols Treated This Condition And Associated Symptoms

Introduction: An anal fissure manifests as a painful longitudinal tear in the anoderm distal to the dentate line with symptoms of pain during defecation, rectal bleeding, tremendous emotional stress, and declined quality of life. Anal fissures are found more frequently in women. Several treatment options are available with or without medication and/or surgery. This paper presents 4 cases of patients affected by anal fissures healed by one healer and cured successfully by the application of Yoga Prana Vidya (YPV) healing protocols as alternative medicine. Method: This paper uses the case study method by collecting medical data from the 4 patients (3 female and 1 male), YPV healer’s records, and patient feedback. Results: Patient in case 1 became normal after 37 healing sessions of 20 minutes each in 1 ½ months of YPV healing. The patient in case 2 became normal after 25 sessions of 20 minutes of YPV healing conducted in 17 days. The patient in case 3 became normal after 35 sessions of 20 minutes each within a period of about 7 weeks of healing. The patient in case 4 became normal after 10 sessions of 20 minutes of healing within 11 days. Conclusions: This paper presented multiple cases of anal fissures suffered by patients over many years that have been cured successfully by the application of the integrated and holistic system of Yoga Prana Vidya (YPV) healing protocols. Further research is recommended. Recommendations include training Healthcare workers for applying YPV techniques complementary to their respective professions for treating patients holistically and as a preventive modality boosting immunity.

The Assessment of Marcaine Versus Meperidine for Spinal Anesthesia in Anorectal Surgery: A Randomized Clinical Trial.

Spinal anesthesia (SA) for the surgical management of chronic anal fissures is favored by surgeons as it provides an early return to daily activities; however, the agents applied for SA to achieve the best outcomes with minimized adverse effects are a matter of debate. This study aimed to assess the utility of Marcaine versus meperidine for SA induction of anoderm surgery. This randomized clinical trial (RCT) was conducted on 138 patients with chronic anal fissures who were candidates for surgical management in 2020. The patients were randomly assigned to two groups of SA using 2.5 mL of hyperbaric Marcaine 0.5% (n = 69) or 1 mg/kg of meperidine (n = 69). Pain severity (measured via Numerical Rating Scale (NRS)), anal sphincter tone manometry (measured at baseline and the end of the sphincterotomy), and drug-related adverse effects were compared between the groups. Both agents led to significant pain relief within 24 hours after SA (P < 0.05); nevertheless, pain severity was remarkably lower in meperidine-treated patients in different measurements performed during the first 24 hours after SA (P < 0.05). The sphincteric tone significantly decreased in both groups (P < 0.001), while the postoperative tone was significantly less in the Marcaine-treated patients (65.22 ± 3.02 versus 46.04 ± 1.97, P < 0.001). The two groups did not differ regarding the adverse effects (P > 0.05). Meperidine for SA in anal fissure surgical management was relatively superior to Marcaine, as postoperative pain control was remarkably better achieved with meperidine. However, anal sphincter tone reached a normal range in Marcaine-treated cases, and the average tone in those anesthetized with meperidine was slightly above the normal limits.

Trends in Management of Anal Fissures.

It is unclear how patients with anal fissures are treated in real-world settings, particularly since patients may not see colorectal surgeons. This study describes trends in treatment with medical therapies (calcium-channel blockers [CCBs], nitroglycerin [NTG], and narcotics) and surgical treatments. Cohorts were created within the TriNetX database platform using codes for anal fissures and surgical interventions. Demographics were compared between patients that received surgical intervention within 1year of diagnosis, CCB or NTG within 1year (or preoperatively), or narcotics within 30days or postoperatively vs those who did not. 121,213 patients were included of which 4.0% had surgical intervention. Factors associated with surgical intervention were male sex (OR 1.40), White race (OR 1.17), and Hispanic ethnicity (OR 1.11). Male patients were more likely to undergo sphincterotomy (OR 1.49). Female (OR 1.27), non-Hispanic (OR 1.34), and White patients (OR 1.41) were more likely to have chemodenervation. Regarding nonoperatively managed patients, non-Hispanic (OR .91) and White patients (OR .89) were less likely to receive CCB/NTG. Male (OR 1.21), non-Hispanic (OR 1.08), and Black patients (OR 1.20) were more likely to receive narcotics. Male patients that required surgery were more likely to be prescribed CCB/NTG preoperatively (OR 1.27). Non-Hispanic surgical patients were more likely to receive narcotics (OR 1.84). Male fissure patients were more likely to undergo surgical intervention other than chemodenervation. Differences in the rates of surgery and medical therapy (especially narcotics) between races and ethnicities require exploration to enhance the care of patients with anal fissures.

Clinical-Epidemiological Characterization of Human anal Papilloma Virus Infection Coloproctology Unit. Central University Hospital Dr. “Antonio Maria Pineda”

AbstractHuman papillomavirus (HPV) infection is one of the most common sexually transmitted viral diseases. A descriptive cross-sectional study was conducted with the purpose of clinically and epidemiologically characterizing anal HPV infection in patients who attended the Benign Orificial Pathology Consultation of the Coloproctological Unit at the Dr. “Antonio María Pineda” Central University Hospital, during the period March 2022 - February 2023, by selecting 288 patients whose average age was 47.09 ± 14.61 years, being the 41-50 years old group (29.17%) and the 51-60 years old group (19.44%) the most affected groups by pathologies of the anal region, with a predominance of male (54.17%). The sociodemographic characteristics with the highest frequency included married (48.61%) and single (47.22%); secondary level of education (44.44%) and traders (18.05%) and housewives (15, 28%) as predominant occupations. The risk factors were represented by onset of sexual intercourse between 16-20 years of age (65.28%), heterosexuality (91.67%), 22.22% reported having anal sex and 5.56% oral sex. Likewise, 5.56% were reported with a history of genital HPV and 4.17% were HIV positive. In addition, 48.61% stated not to use condoms. The initial clinical diagnosis included hemorrhoidal disease (30.55%), anal fistula (25%) and anal fissure (18.05%), and one patient (1.39%) with anal HPV infection. Anal cytology results showed 8.33% flat epithelial cells with cytopathic changes suggestive of HPV infection and 1.39% squamous cells with cytopathic changes suggestive of HPV infection: 50% mild inflammatory negative for malignancy and 33.33% flat epithelial cells without atypia. In conclusion, the anal cytology investigation should continue to determine the actual frequency of anal HPV infection.

Combined mucopexy & Milligan-Morgan's technique in circumferential 4th degree haemorrhoids: Prospective observational cohort study

BackgroundIt is well known that a large excisional haemorrhoidectomy could be certain cause of post-operative severe complications like incontinence, ectropion or anal stenosis. ObjectiveOur aim is to reduce post-operative complications avoiding a large haemorrhoidectomy in patients suffering of a circumferential 3-4th degree prolapsed haemorrhoids. DesignThis was a prospective, single institution study with propensity score matching performing a classic stapled mucopexy followed by the excision of the internal mucosae prolapse combining at the same operative time a concomitant classic Milligan and Morgan's technique of the remnant external piles. PatientsThe study population were 54 eligible patients, study included 32, to demonstrate feasibility and safety of our proposals. 20 males, 12 females, mean age 51.9 years (range 21–84) underwent combined mucopexy and haemorrhoidectomy in one single surgical procedure between January 2017 and December 2019. ResultsA total of thirty-two patients were included prospectively and consecutively; 18 patients (33.4% of the universe) presented anatomical variations on the CMHP and variations on the IHED (10), associated anal fissures (2), modified piles with HPV condylomata (2), non-stoppable anticoagulation treatment (2), immunity treated disease (1), no evidence of a haemorrhoidal mucosal prolapse and minor pile's components (1) and they were definitely excluded of the study. There were no significant differences in the postoperative complication rates. The length of the operation was (48, 05 min +/- 5, 30 min). Some special bleeding had required at the end of the procedure a supplementary haemostasis with absorbable single suture in six patients (18, 8%), men (12, 5%) women (6, 3%). The stapled haemorrhoidal mucopexy allowed a faster functional recovery with shorter time off work (weighted mean difference 9.45 days; p < 0.00001), earlier return to normal activities (weighted mean difference, 15.85 days; P = 0.03), and better wound healing (odds ratio, 0.1; P = 0.0006). No stenosis, neither ectropion. LimitationsBecause of a single limited study including a single operative group. ConclusionsOur results confirm the strategy, demonstrating that the combined technique drastically reduces the risk of anal stenosis, ectropion, incontinence or recurrence of the prolapse. By the restoration of the anal canal anatomy under visual control and preservation of the required mucosal and cutaneous bridges results are reproducible and sure.