Treatment Of Anal Fissure Research Articles

Results of surgical treatment in chronic anal fissure complicated by abscess or fistula in a retrospective cohort of patients

We report the results of the surgical treatment of anal fissures complicated by abscess or fistula and formulate hypotheses about their nature. Among patients operated between 2012 and 2020 for anal fissure resistant to medical therapy, those affected by septic complications were selected for our inquiry. Surgical treatment consisted in the drainage of the sepsis, fissurectomy, posterior sphincterotomy and anoplasty. Intra-sphincteric fistulas were removed with the fissure, whereas low trans-sphincteric tracks, including horseshoe fistulas, were partially opened and curetted. Patients were followed on post-operative days 7-10 and then until healing. Pre- and post-operative Visual Analog Scale (VAS) and Cleveland Clinic Incontinence Score (CCIS) scores were compared. Recurrence rates of disease were recorded. We operated 988 patients and 55 of them showed local sepsis (5.5%) complicating anal fissures. There were 23 abscesses and 32 fistulas. Of these latter, 17 were intra or inter-sphincteric (2 anterior) and 15 low trans-sphincteric (6 horseshoes). Pre-operative VAS score was 7.6 ± 0.9 (mean ± sd), CCIS was 0.1 ± 0.5. Complete healing occurred after a median of 6weeks (range 3-14weeks). Mean VAS score dropped to 2.3 ± 0.6 at first follow-up visit and CCIS rose to 0.4 ± 0.2. After a mean of 56.4months, 41 patients agreed to a visit and 14 were interviewed by phone. At office visit no disease recurrences were observed; pain and continence scores were within normal ranges in all patients. Abscess and fistula in anal fissures are not frequent and may represent a different disease from cryptoglandular fistulas. Surgical treatment achieves higher success than that reported for cryptoglandular fistulas.

Herbal medicine AnoSpray suppresses proinflammatory cytokines COX-2 and RANTES in the management of hemorrhoids, acute anal fissures and perineal wounds.

Hemorrhoids, anal fistula and fissure are common anorectal complications. Anorectal diseases are associated with severe pain, inflammation, swelling, itching and bleeding. These diseases may be managed with different medical treatments or surgical procedures, depending on their severity. Surgical procedures, however, are highly invasive and are associated with higher costs and the possibility of recurrence. In addition, surgical removal of fistula-in-ano leads to the formation of perineal wounds. Therefore, developing therapeutic interventions that are effective in alleviating inflammation and pain are desirable for the effective management of anorectal diseases. Herbal compounds have previously been indicated to suppress inflammation and pain in different pathological conditions. The aim of the present study was to examine the effects elicited by a polyherbal formulation, AnoSpray®, on the migration of inflammatory cells and on the expression of inflammatory cytokines in anorectal diseases. The effect of AnoSpray on cell viability and migration was studied using MTT and wound-migration assays, respectively. Furthermore, the effects of AnoSpray on the expression of the inflammatory cytokines regulated upon activation, normal T cell expressed and presumably secreted (RANTES) and VEGF, as well as on cyclooxygenase-2 (COX)-2, were investigated using western blot analysis. The expression of RANTES and COX-2 in human hemorrhoid specimens was also analyzed to corroborate the in vitro findings. The results obtained revealed that AnoSpray did not exhibit any cytotoxic effects; however, it did lead to a significant suppression in the migration of RAW 264.7 and BJ cells. Furthermore, the results suggested that AnoSpray suppressed the expression of the inflammatory cytokines RANTES and VEGF, and also the expression of COX-2. In addition, RANTES and COX-2 were significantly downregulated in the clinical specimens of AnoSpray-treated hemorrhoids compared with the controls. Taken together, the results of the present study suggested that AnoSpray may be a potential therapeutic agent in the treatment of bleeding hemorrhoids, anal fissures and perineal wounds.

Possibilities of medical relaxation of the internal anal sphincter for anal fissures

An anal fissure is a longitudinal tear defect in the skin of the anal canal distal to the dentate line. Anal fissure is a socially significant disease that worsens the quality of life of patients. The spasm of the internal sphincter is a guiding pathogenetic mechanism in the development of chronic anal fissures. It leads to circulatory disorder in the anoderm and non-healing wounds. Treatment of chronic anal fissure, as a rule, is based on a decrease in the tone of the internal anal sphincter and in the modern arsenal of coloproctologists there are both surgical and pharmacological ways to eliminate spasm. Lateral internal sphincterotomy is still the gold standard for the definitive treatment of anal fissure, but anal incontinence is a serious complication of the procedure. This article presents an overview of the available modern means for drug relaxation of the internal anal sphincter and the authors' experience in using the first fixed-dose combination of 0.3% nifedipine and 2.0% lidocaine topical gel authorized for use in Russia in patients with the chief complaint of pain during and after a bowel movement that requires the use of analgesics. A spontaneous wave activity in the resting phase, which indicated the presence of anal sphincter spasm, was recorded in all patients. According to our observation, the complete healing of the anal fissure and the anal sphincter relaxation was instrumentally confirmed in 70% of patients.

Pelvic floor physical therapy in the treatment of chronic anal fissure (PAF-study): Study protocol for a randomized controlled trial

BackgroundChronic 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. MethodsThe 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. DiscussionCurrently, 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.

Botulinum toxin associated with fissurectomy and anoplasty for hypertonic chronic anal fissure: A case-control study.

BACKGROUNDLateral internal sphincterotomy is still the approach of choice for the treatment of chronic anal fissure (CAF) with internal anal sphincter (IAS) hypertonia, but it is burdened by high-risk postoperative faecal incontinence (FI). Sphincter saving procedures have recently been reconsidered as treatments to overcome this risk. The most employed procedure is fissurectomy with anoplasty, eventually associated with pharmacological sphincterotomy. AIMTo evaluate whether fissurectomy and anoplasty with botulinum toxin injection improves the results of fissurectomy and anoplasty alone.METHODSWe conducted a case-control study involving 30 male patients affected by CAF with hypertonic IAS who underwent fissurectomy and anoplasty with V-Y cutaneous flap advancement. The patients were divided into two groups: Those in group I underwent surgery alone, and those in group II underwent surgery and a botulinum toxin injection directly into the IAS. They were followed up for at least 2 years. The goals were to achieve complete healing of the patient and to assess the FI and recurrence rate along with manometry parameters.RESULTSThe intensity and duration of post-defecatory pain decreased significantly in both groups of patients starting with the first defecation, and this reduction was higher in group II. Forty days after surgery, we achieved complete wound healing in all the patients in group II but only in 80% of the patients in group I (P < 0.032). We recorded 2 cases of recurrence, one in each group, and both healed with conservative therapy. We recorded one temporary and low-grade postoperative case of “de novo” FI. Manometry parameters reverted to the normal range earlier for group II patients.CONCLUSIONThe injection of botulinum toxin A in association with fissurectomy and anoplasty with a V-Y advancement flap improves the results of surgery alone in patients affected by CAF with IAS hypertonia.

The Effect of Anti-anxiety Medications on the Clinical Symptoms of Anal Fissure: A Randomized Clinical Trial

Background: Fissure is a common chronic anorectal disease that causes symptoms such as pain, burning, bleeding, and psychiatric problems. One of the psychiatric complications is anxiety, which might be an etiologic factor or secondary to the disease. Materials and Methods: A total of 160 patients with anal fissure were randomly divided into two groups (80 patients treated with anti-anxiety medications along with standard anal fissure treatment and 80 patients with standard anal fissure treatment alone) after obtaining patient consent and demographic data. Then, the symptoms have recorded after treatment. Results: The results of our study indicated that the administration of anti-anxiety medications in patients with anal fissures relieved pain and anxiety scores among all patients. The anti-anxiety medications were more effective on patients younger than 40 years, men with less than two weeks duration of illness, and baseline anxiety greater than 26. Conclusion: A high prevalence of anal fissures affects the quality of life of patients. Besides the lack of effective treatment that shortens the pain and recovers patients faster, anti-anxiety medications such as benzodiazepines can use along with standard anal fissure treatment to reduce pain and anxiety in patients with acute anal fissure.

Centella Asiatica in the Conservative Treatment of Anal Fissure and Hemorrhoids in Comparison with Flavonoids

In this review we report effects Centella asiatica (Ca) in comparison with Flavonoids (Fs) to find out which best deals with healing time, bleeding and pain in the treatment of outpatients with chronic Anal Fissure (AF) on one hand. On the other hand, we report also the time-to-stop bleeding, and the anal irritation in patients who complained of Hemorrhoidal Disease (HD). Ninety-eight outpatients with AF were divided randomly into treated (either Fs or Ca) and control group. The control group (Group C, n=32) received the traditional treatment along with the other two subgroups which were treated, additionally, with Fs (Group A, n=30) or Ca (Group B, n=36). Patients were observed once weekly over 8 consecutive weeks. In another study, 130 patients with HD were studied for bleeding and pain after hemorrhoidectomy (31 patients) and hemorrhoidal thrombosis (34 patients) in the short time (II). The treated group (both conservative and surgical) was divided into two subgroups: one treated with Fs (Group A, n = 73), the other with Ca (Group B, n = 66). Sixty patients were randomized to receive the routine treatment (both conservative and surgical) (control Group C). Time-to-stop bleeding was checked at baseline and checkups (0 up to day 42).

Injection of botulinum toxin significantly increases efficiency of fissurectomy in the treatment of chronic anal fissures.

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. 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. The majority of patients undergoing fissurectomy were women (65%, mean age 45.0years vs. 35% men, mean age 48.3years), 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). Injection of botulinum toxin significantly increases the efficiency of fissurectomy in the treatment of chronic anal fissures without additional complications.

WAYS OF IMPROVE THE TREATMENT EFFECTIVENESS OF PATIENTS WITH SACROCOCCYGEAL SINUS AND ANAL FISSURE

The anal fissure and the sacrococcygeal sinus in the structure of coloproctological pathology take third and fourth places after hemorrhoids and paraproctitis. The results of their treatment do not satisfy coloproctologists: the frequency of postoperative complications and relapses of the disease is high, rough scars and discomfort in the area of surgical intervention are formed. Aim - to improve the treatment results of patients with sacrococcygeal sinus and anal fissure. Materials and methods: 152 patients were operated on: 79 (52.0%)-with a sacrococcygeal sinus in the stage without clinical manifestations and 73 (48.0%) – with a chronic anal fissure. In addition to the standard laboratory and instrumental examination, the following were studied: predisposition to the development of excessive scarring; anal sphincter contractility. The importance of acute-phase inflammatory proteins in predicting the pathological scars formation was studied; measures were taken to prevent their occurrence. Surgical treatment methods of the sacrococcygeal sinus using an intradermal suture are proposed. Result. Long-term results comparison of traditional treatment patients with uncomplicated sacrococcygeal sinus and an integrated approach, a decrease was revealed: the development of gross scar deformation in the surgical intervention area – by 2.7 times; discomfort in the sacrococcygeal region - by 3.7 times, the number of relapses of the disease – by 2.4 times. In the chronic anal fissure treatment, the relapses number of the disease was reduced by 3.3 times. Conclution. 1. To predict the pathological scarring formation after proctological operations, it is necessary to study the changes dynamics in the concentrations of acute-phase inflammatory proteins in the patients peripheral blood sample. 2. To improve the treatment of patients with a tendency to excessive scarring it is necessary to include anti-scar therapy in the complex of postoperative measures

The Mechanism of Action of Huai-Hua Powder in the Treatment of Anal Fissures: A Study Based on Network Pharmacology and Molecular Docking Techniques

The Mechanism of Action of Huai-Hua Powder in the Treatment of Anal Fissures: A Study Based on Network Pharmacology and Molecular Docking Techniques

A systematic review and meta-analysis of the efficacy of topical sphincterotomy treatments for anal fissure.

Anal fissure is a common condition that can be treated medically or surgically. Chemical sphincterotomy is often used before surgical intervention. This study aims to evaluate the effectiveness of topical agents for chemical sphincterotomy on healing of anal fissures and side-effects. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) compliant systematic review was performed using MEDLINE, EMBASE, Scopus, and CENTRAL databases. Eligible studies included randomized controlled trials which compared topical sphincterotomy agents with topical placebo agents or each other. Studies that included surgical treatments were excluded. Overall evidence was synthesized according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Thirty-seven studies met the study selection criteria. Seventeen studies show that glyceryl trinitrate (GTN) was significantly more likely to heal anal fissure than placebo (relative risk (RR) = 1.96, 95% confidence interval (95%CI) = 1.35-2.84, I2 = 80%). Eleven studies showed a marginally significant difference between healing rates for diltiazem vs GTN, RR = 1.16, (1.01-1.33) I2 = 48%. There was no significant difference in healing between diltiazem and placebo, RR = 1.65, (0.64-4.23), I2 = 92%. GTN significantly reduced pain on the visual analog scale compared to the placebo group, MD-0.97 (-1.64 to -0.29) I2 = 92%. There was high certainty of evidence that GTN was significantly more likely to cause headache than placebo (RR = 2.73 (1.82-4.10) I2 = 58%) and diltiazem RR = 6.88 (2.19-21.63) I2 = 17%. There is low certainty evidence topical nitrates are an effective treatment for anal fissure healing and pain reduction compared to placebo. Despite widespread use of topical diltiazem, more evidence is required to establish the effectiveness of calcium channel blockers compared to placebo.

Outcome of Bilateral Segmental Internal Anal Sphincterotomy for Treatment of Chronic Anal Fissure

Background: Chronic anal fissures are harder to treat, and surgery may be the best option. The goal of surgery is to help the anal sphincter muscles relax which reduces pain and spasms, allowing the fissure to heal. Objective: The aim of the present study was to assess the improving outcome of patients of chronic anal fissure. Patients and methods: This study included 18 patients with chronic anal fissure admitted at Department of General Surgery, Faculty of Medicine, Zagazig University. All patients were subjected to full history taking, proper local examination and baseline investigations. Anorectal manometry was performed for all patients preoperatively and bilateral segmental internal sphincterotomy was done for all patients. Results: The present study showed that 88.9% had constipation, 100.0% had pain and 77.8% had bleeding defecation. Duration was distributed as 7.55 ±2.68 with minimum 4 and maximum 14 months and the majority were between 6-12 months. Complete healing was distributed as 5.16 ±1.09 with maximum 8 weeks. Visual Analogue Scale (VAS) significantly decreased from pre to 1st 24 hours tell the end of follow up . Incontinence score significantly decreased from pre to 1st week tell the end of follow up. Conclusion: It could be concluded that bilateral segmental internal sphincterotomy takes some extra time for the procedure and significantly a good procedure in treatment of chronic anal fissures in terms of early pain relief, reduction of resting anal pressure and complete healing rate in 5 weeks. The risks of incontinence and recurrence of fissure are negligible with superior patients’ satisfaction.

What is the optimum treatment of chronic anal fissure?

Aim: To compare the efficacy of topical Glyceryl trinitrate 0.2% (GTN) with Lateral internal spincterotomy (LIS) for treating chronic anal fissure (CAF). Methodology: A randomized control trial was carried out in the general surgery department, Lady reading hospital, LRH MTI, Peshawar (January 2018 to July 2018). All consecutive patients 18 to 60 year old presenting to OPD with a clinical diagnosis of chronic anal fissure were enrolled after informed consent. A total of 60 patients were enrolled. The patients were assigned two groups, including treatment group A (lateral internal spinterotomy) or treatment group B (use of Topical GTN ointment 0.2%). Results: Out of the 60 patients, 30 were enrolled into each group. The female had majority of 57% (group A) and 60% (group B). Mean duration regarding symptoms in group A was 1 year with SD ± 3.51 vs 1 year ± 2.98 in group B. Majority of patients in both groups were in the 20 to 40 years age group (74% in group A vs 83% in group B). Complete fissure healing and resolution of symptoms was observed in 27(91%) in group A vs 20(66%) in group B. Conclusion: In conclusion, we derive that lateral internal spincterotomy is more effectual than Topical Glyceryl trinitrate 0.2% for treating chronic anal fissure. Keywords: Chronic anal fissure, lateral internal spincterotomy, Glyceryltrinitrate

Fissurectomy Versus Lateral Internal Sphincterotomy in the Treatment of Chronic Anal Fissure: A Randomized Control Trial.

IntroductionAn anal fissure is defined as a longitudinal split in the distal anoderm which extends from the anal verge to the dentate line. Fissures can be of primary or secondary type. The posterior midline is the most common location for primary fissures, while, anterior primary fissures, though rare, are more common in females. The cause of primary fissure is idiopathic. But secondary fissures are associated with other systemic diseases and can occur at an abnormal position anywhere in the anoderm. A high percentage of acute fissures heal spontaneously within three weeks with conservative medical management comprising of a high fiber diet, warm sitz bath, and topical analgesic with steroids. Secondary anal fissures will not heal in any form of treatment until the primary cause is addressed. These fissures often need surgical treatment. The lateral internal sphincterotomy (LIS) is one of the most practiced treatments for chronic anal fissure. Nonetheless, anal incontinence is one of the worrisome complications of LIS. Fissurectomy is one of the options among those techniques which address the issues with LIS. Some studies showed that patients with chronic fissures who are refractory to medical treatment responded well to fissurectomy. Hence, this study was conducted to compare the outcomes of fissurectomy and lateral internal sphincterotomy in the treatment of chronic anal fissure and compare recurrence and postoperative complications among both the procedures.MethodsAll consecutive patients attending the department of surgery with chronic fissure and age above 18 years were included in the study. All the included patients were randomized into two groups (fissurectomy and LIS) using the serially numbered opaque-sealed envelope (SNOSE) technique. The patients were discharged on the third day. The first visit was scheduled after two weeks and subsequent visits on the first and second months. Then the patients were followed up by telephonic conversation for the next six months. At the end of the follow-up, post-surgical complications were enquired, recorded, and interpreted.ResultsIn the present study, out of a total of 87 patients, 80 patients were included in the study. Among all the patients, 16 patients (20%) developed retention of urine. Four patients in the LIS group showed retention of urine whereas in the fissurectomy group it was twelve. The difference was not statistically significant (p-value: 0.025). A total of 10 patients required catheterization postoperatively. More patients in the fissurectomy group developed incontinence to flatus (p-value: 0.02). Incontinence to liquid and solid was significantly higher in the fissurectomy group (p-value: 0.03 and 0.002, respectively).ConclusionIn the present study, it was found that LIS was a better treatment option for chronic anal fissure than Fissurectomy. The postoperative complications were less in LIS than in fissurectomy. But the recurrence was higher in the LIS group while there was no recurrence in the fissurectomy group.

Safety and effectiveness of saving sphincter procedure in the treatment of chronic anal fissure in female patients

IntroductionLateral internal sphincterotomy (LIS) is still the approach of choice for the treatment of chronic anal fissure (CAF) regardless to the internal anal sphincter tone but it is burdened by high risk post-operative faecal incontinence (FI). In female patient there are some anatomical and functional differences of the sphinteric system which make them more at risk of FI and vaginal birth could cause sphinteric lesions affecting the anal continence function. The aim of our study is to evaluate the results of saving sphincter procedure as treatment for female patients affected by CAF.MethodsWe studied 110 female patients affected by CAF undergone fissurectomy and anoplasty with V–Y cutaneous flap advancement associating pharmacological sphincterotomy in patients with hypertonic IAS. The follow up was at least for 2 years. The goals were patient’s complete healing, the evaluation of FI, recurrence rate and manometry parameters.ResultsAll wounds healed within 40 days after surgery. We recorded 8 cases of recurrences 6 healed with medical therapy and 2 with dilatation. We recorded 2 “de novo” temporary and low grade post-operative cases of FI. Post-operative value of MRP were unmodified in patient with normotonic IAS but significantly lower at 12 months follow up as compared with the pre-operative ones in patients with hypertonic IAS; after 24 months from surgery MRP values were within the normal range.ConclusionThe fissurectomy and anoplasty with V–Y cutaneous flap alone or in association with a pharmacological sphincterotomy in patients with hypertonic IAS may represent an effective approach for the treatment of CAF in female patients.

Do obstetric factors have an effect on success of medical treatment of anal fissure seen in women?

Objective: The aim of this study is to examine the effect of obstetric factors on the medical treatment success of anal fissure in women.&#x0D; Material and methods: A total of 324 women, who were diagnosed with anal fissure, who applied to the General Surgery outpatient clinic between 2015 and 2020, were included in the study. The patients were divided into two groups; group I (medical treatment was successful) and group II (medical treatment failed - surgery performed). Both groups were compared in terms of age, body mass index (BMI), number of births, delivery type, birth weight, breastfeeding rate, constipation, diarrhea, smoking and anal fissure symptoms.&#x0D; Results: Medical treatment was applied to all of the 324 patients we included in our study, and it was observed that 45.7% of them had successful medical treatment and 54.3% had undergone surgical treatment (lateral internal sphincterotomy) because of unsuccessful medical treatment. It was found that age, BMI, number of births, number of vaginal births, breastfeeding rate, constipation rates were higher in those who failed medical treatment (p 0.05). While gas incontinence was observed in 44.1% of those who underwent surgical treatment, this rate was found to be 1.4% in those who benefited from medical treatment.&#x0D; Conclusion: In our study, it was found that while maternal age, number of births, vaginal delivery and breastfeeding rates had a negative effect on the success of anal fissure medical treatment, cesarean delivery and baby birth weight were not effective.

Botulinum toxin injection is an effective alternative for the treatment of chronic anal fissure

Objectives There are few published data on the optimized use of botulinum toxin A (BTA) for the treatment of chronic anal fissure (CAF). The aim of this study was to investigate the effect of injection of 100 IU BTA into the internal anal sphincter (IAS) at the side opposite of the fissure, using an anal retractor, sedation, and perianal transcutaneous pudendal nerve block. Methods The prospectively maintained data of 132 patients who underwent BTA injection for CAF were retrospectively analyzed. Demographic data, symptom duration, fissure location, post-procedure pain, complications, continence status, response to treatment, and follow-up period were investigated. Postoperative analgesic requirements of patients who did and did not receive pudendal nerve block were compared. Results Eighty-two patients were male and the median age was 40 (18–74) years. Sixty-six patients required no, 46 required oral, and 20 required parenteral analgesics. No complications were observed. Complete response was observed in 105 patients (79.5%). Symptomatic improvement was observed in 67.4% of patients within 3–7 d. Median follow-up was 24 (18–42) months. The median Wexner’s incontinence score was 0 (0–8) at 1 month. In all, 104 patients had no, 22 patients had minor, and 6 patients had non-minor incontinence. All patients with incontinence recovered fully within 4 (2–13) weeks. Conclusions BTA injection using an anal retractor under sedation and perianal transcutaneous pudendal nerve block is an effective and safe alternative to partial lateral internal sphincterotomy (LIS) for the treatment of CAF.

Postoperative Outcome Comparison between Manual Dilatation and Lateral Internal Anal Sphincterotomy in the Treatment of Chronic Anal Fissure

Postoperative Outcome Comparison between Manual Dilatation and Lateral Internal Anal Sphincterotomy in the Treatment of Chronic Anal Fissure

Outcomes of Fissurectomy and Advancement Flap in Management of Chronic Anal Fissure

Chronic anal fissure is a painful linear tear in the mucocutaneous junction of the distal part of the analcanal and involves the full thickness of mucosa, causing severe pain may last even hours after defecation.Usually,it occurs along the midline either anterior or posterior,if it presents off the midline, other pathologymight be associated with. Unhealed anal fissure after 6-8 weeks is defined chronic, with the presence of othercriteria,it unlikely heals with medical treatment, and surgery is mandatory after pharmacological treatmentfailure. Lateral internal sphincterotomy had high healing rate, but unfortunately, with risk of incontinence.Fissurectomywithcomplete excision of the fissure keeping the internal anal sphincter intact,and anadvancement flap of well vascularized tissue is transferred to cover the base of fissure and improve healing.This study mainly aiming to analyze the outcome of fissurectomy with advancement flap procedure in thetreatment of chronic anal fissure and highlight its advantage in terms of healing rate and complicationsespecially anal incontinence.During a period of about 5 years 345 patients (260 males and 85 females), havebeen included in this study and were diagnosed as cases of chronic anal fissure. After administration of localanesthetic,fissurectomywith advanced flap was performed. Patients had been followed up regularly for 6-24months. Data collected and statistical analysesby using SPSS. About 75% ofpatients were males while, 25% were females, their ages were between 20-59 year, most of the patients werein thirties, nevertheless most of the females were in twenties.Mean time for wound healing was 10 days.Whilst complete fissure healing process lasting approximately one month. About 11.9% of the patients takemore than one month to complete healing process. Healing rate was 100% after the follow up period of 6-24months. Recurrence developed only in 2% of the patients. None of the patients developed incontinence,anal stenosis, key hole deformity, necrosis or urine retention. From this study concluded Fissurectomy withadvancement flap in the treatment of chronic anal fissure is cost effective procedure, can be done under LAwith least time-off work, with low complication, low recurrence,and no incontinence.

A comparative study between lateral internal anal sphincterotomy and botulinum toxin injection in the treatment of chronic anal fissure

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 &gt;0.999).Three months after treatment, 4% of the lateral internal sphincterotomy group had bleeding, while none of the botulinum toxin group (P &gt;0.999). None of the lateral internal sphincterotomy group had pain while one (4%) of the botulinum toxin group (P &gt;0.999). Regarding healing, 96% of the lateral internal sphincterotomy group healed, while 92% in the botulinum toxin group (P &gt;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. Keywords: Chronic anal fissure; Lateral internal sphincterotomy; Botulinum toxin; Complications.