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Anal fissure treatment
Fissures that don’t respond to the indicated medical treatment or don’t resolve on their own in about 6 weeks can be considered for surgical treatment. Both the patient and the physician should evaluate certain factors before proceeding. Failure of surgical treatment or recurrence of the fissure is possible. Impaired sphincter control after sphincterotomy is a major complication. Various procedures exist for the treatment of chronic or recurrent anal fissures. However, none of them can guarantee 100% results. These procedures include anal dilation, the classic excision of the fissure (fissurectomy), advancement flaps (anoplasty), and the lateral internal sphincterotomy (LIS).
Anal dilation (Lord’s procedure) for treatment of anal fissure
The procedure has been first described in the 60s by Lord. It utilizes manual dilation of the anus with several fingers. The goal is to stretch the sphincter and reproduce a temporary paralysis of the muscle fibers. The procedure is usually done with several fingers (4 to 8). The idea is that it will extend the sphincter stretch without causing any wounds to the anal canal.
Several complications following the anal dilation have attracted widespread criticism. The most concerning of them being the damage inflicted on the internal sphincter, which can lead to fecal incontinence. The reported disturbance of incontinence is in a range from 0% to as high as 20%. The incidence of recurrence of the anal fissure is rather high (10-50%).
Proponents of the procedure have suggested a modified technique that utilizes anal dilators to stretch the sphincter. There is not enough data available to support this method. But patients might find it uncomfortable, given that a cold foreign object has to be inserted into the anal canal on regular basis for several weeks. It has been suggested that the anal dilation may be done with other devices, such a retractor or rectosigmoid balloon. Limited data is available, but anal manometry and ultrasonography tests have shown that pneumatic balloon dilation yields similar results to lateral internal sphincterotomy.
To summerize, the anal stretch, at least in its classical form, carries a higher risk of fissure persistence or recurrence and of impaired continence compared with internal sphincterotomy.
There is no role for its continued use in the modern management of anal fissure.
Fissurectomy of anal fissure
The classic excision with or without division of the sphincter muscle is not frequently used procedure nowadays. The excision itself leaves the patient with a painful external wound that requires a long time to heal. Numerous studies report different complications after the procedure, including bleeding, abscess formation, anal stenosis, and fecal incontinence. The procedure is otherwise effective with low recurrence rate (<10%).
Advancement flaps technique for treatment of anal fissure
This method combines excision of the anal fissure with advancement flap of the anoderm (also called anoplasty). The anal fissure is excised and then covered with sliding skin graft with a broad base. The anoplasty has several advantages. It’s relatively painless and the postoperative wound care is uncomplicated. The wound will also heal faster. Complications are relatively rare, most of them involve postoperative bleeding. However, the procedure is less effective than lateral internal sphincterotomy (LIS) for patients with high-pressure fissures (about 80% efficiency versus nearly 100% for LIS). Advancement flaps should be therefore employed for patients with low-pressure fissure or as a second line of surgical treatment for patients who have failed lateral sphincterotomy.