Surgery for Anal Fissure
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An anal fissure is a tear of the squamous epithelium that usually extends from the dentate line to the anal verge. In 90% of cases, the fissure manifests as a painful linear ulcer lying in the posterior midline of the anal canal. The fissure may occur in other areas as well, such as the anterior midline (more commonly in female patients), or laterally. Lateral or multiple fissures are considered to be atypical, and should warrant investigation for HIV infection, Crohn disease, syphilis, tuberculosis, or hematologic malignancies.
Patients describe the pain of anal fissures as feeling like “passing broken glass,” and they commonly mention a burning pain that can remain for several hours after defecation. [1] Many patients report having a lower quality of life because of the pain. [2] Bleeding can be an associated symptom that sometimes leads to the misdiagnosis of symptomatic hemorrhoids. [3]
The exact cause of anal fissures is currently unknown. Historically, an anal fissure was thought to be a result of mechanical trauma caused by a hard stool tearing the anoderm as it was passed. [4] In addition, anal fissures have been associated with increased anal tone for many years. [5]
A proposed mechanism for increased anal tone in a study by Lund showed reduced nitric oxide (NO) synthase and, consequently, decreased nitric oxide synthesis in the internal sphincters of patients with anal fissures as compared with control subjects. [6] NO has been known to facilitate smooth-muscle relaxation of the internal anal sphincter. [7]
Schouten et al proposed that anal fissures were ischemic ulcers and found that patients with anal fissures had significantly higher resting anal sphincter tone and decreased anodermal blood flow in comparison with healthy volunteers. [8] Other studies confirmed that blood supply to the posterior midline of the anodermis is relatively poor when compared with blood supply to the other quadrants. [9, 10]
This combination of increased tone and poor blood supply likely contributes to the relative ischemia of the posterior midline of the anoderm; however, not all patients with anal fissures have anal sphincter hypertrophy or insufficient blood supply to the anoderm.
Proctosigmoidoscopy may be performed prior to the procedure to fully inspect the colon, rectum, and anus to rule out concomitant pathology.
It should be kept in mind that the fissure itself does not necessarily require treatment.
Indications for sphincterotomy include the following:
Treatment of anal fissures is divided into two categories: nonsurgical and surgical. Nonsurgical treatment is considered first-line therapy and includes modalities such as the following:
It is estimated that half of all patients with an acute anal fissure will have resolution of their symptoms with nonsurgical treatment. [11]
When nonsurgical methods fail to heal the anal fissures or relieve symptoms, however, surgical treatment may be necessary. The surgical treatment options are as follows:
Although fissurectomy is still performed by some surgeons, the authors do not recommend it, because patients may end up with keyhole deformities. Two randomized trials found that lateral internal sphincterotomy had superior healing rates when compared with fissurectomy.
The V-Y advancement flap is a sphincter-preserving surgical approach for anal fissures. Retrospective results show decreased rates of incontinence with a V-Y flap as compared with lateral internal sphincterotomy, but more prospective data are needed in order to define the role of the V-Y flap in the treatment of anal fissures.
Lateral internal sphincterotomy is currently the procedure of choice for surgical treatment of chronic anal fissures. [3] It is indicated in the presence of persistent pain, bleeding, and lack of response to medical management. [12, 13] More than 90% of fissures heal after lateral internal sphincterotomy. The incidence of recurrence is lower with this procedure than with other available options, including fissurectomy and botulinum injection. Insufficient internal anal sphincterotomy is the most common reason for a nonhealing fissure after treatment.
Fissures associated with decreased sphincter tone are a contraindication for surgical treatment.
The anal canal is the most terminal part of the lower gastrointestinal (GI) tract, or large intestine. It lies between the anal verge (anal orifice, anus) in the perineum below and the rectum above. The perianal skin is keratinized, stratified squamous epithelium with skin appendages (eg, hair, sweat glands, sebaceous glands, somatic nerve endings that are sensitive to pain).
The anatomic anal canal skin (anoderm) is also keratinized, stratified squamous epithelium; it has somatic nerve endings that are sensitive to pain, but without skin appendages. The surgical anal canal mucosa is cuboidal in the transition zone and columnar above this zone; it is insensitive to pain. The rectal mucosa above the anorectal ring is lined by pinkish red, insensitive columnar epithelium. For more information about the relevant anatomy, see Anal Canal Anatomy.
Collins EE, Lund JN. A review of chronic anal fissure management. Tech Coloproctol. 2007 Sep. 11 (3):209-23. [Medline].
Griffin N, Acheson AG, Tung P, Sheard C, Glazebrook C, Scholefield JH. Quality of life in patients with chronic anal fissure. Colorectal Dis. 2004 Jan. 6 (1):39-44. [Medline].
[Guideline] Stewart DB Sr, Gaertner W, Glasgow S, Migaly J, Feingold D, Steele SR. Clinical Practice Guideline for the Management of Anal Fissures. Dis Colon Rectum. 2017 Jan. 60 (1):7-14. [Medline]. [Full Text].
Hananel N, Gordon PH. Re-examination of clinical manifestations and response to therapy of fissure-in-ano. Dis Colon Rectum. 1997 Feb. 40 (2):229-33. [Medline].
Brodie BC. Lectures on diseases of the rectum: III; Preturnatural contraction of the sphincter ani. London Medical Gazette. 1835. 16:26-31.
Lund JN. Nitric oxide deficiency in the internal anal sphincter of patients with chronic anal fissure. Int J Colorectal Dis. 2006 Oct. 21 (7):673-5. [Medline].
O’Kelly TJ. Nerves that say NO: a new perspective on the human rectoanal inhibitory reflex. Ann R Coll Surg Engl. 1996 Jan. 78 (1):31-8. [Medline]. [Full Text].
Schouten WR, Briel JW, Auwerda JJ, De Graaf EJ. Ischaemic nature of anal fissure. Br J Surg. 1996 Jan. 83 (1):63-5. [Medline].
Lund JN, Binch C, McGrath J, Sparrow RA, Scholefield JH. Topographical distribution of blood supply to the anal canal. Br J Surg. 1999 Apr. 86 (4):496-8. [Medline].
Klosterhalfen B, Vogel P, Rixen H, Mittermayer C. Topography of the inferior rectal artery: a possible cause of chronic, primary anal fissure. Dis Colon Rectum. 1989 Jan. 32(1):43-52. [Medline].
Gough MJ, Lewis A. The conservative treatment of fissure-in-ano. Br J Surg. 1983 Mar. 70 (3):175-6. [Medline].
Engel AF, Eijsbouts QA, Balk AG. Fissurectomy and isosorbide dinitrate for chronic fissure in ano not responding to conservative treatment. Br J Surg. 2002 Jan. 89 (1):79-83. [Medline].
Lindsey I, Cunningham C, Jones OM, Francis C, Mortensen NJ. Fissurectomy-botulinum toxin: a novel sphincter-sparing procedure for medically resistant chronic anal fissure. Dis Colon Rectum. 2004 Nov. 47 (11):1947-52. [Medline].
Littlejohn DR, Newstead GL. Tailored lateral sphincterotomy for anal fissure. Dis Colon Rectum. 1997 Dec. 40 (12):1439-42. [Medline].
Barnes TG, Zafrani Z, Abdelrazeq AS. Fissurectomy Combined with High-Dose Botulinum Toxin Is a Safe and Effective Treatment for Chronic Anal Fissure and a Promising Alternative to Surgical Sphincterotomy. Dis Colon Rectum. 2015 Oct. 58 (10):967-73. [Medline].
Brisinda G, Cadeddu F, Brandara F, Marniga G, Vanella S, Nigro C, et al. Botulinum toxin for recurrent anal fissure following lateral internal sphincterotomy. Br J Surg. 2008 Jun. 95 (6):774-8. [Medline].
Nelson RL, Thomas K, Morgan J, Jones A. Non surgical therapy for anal fissure. Cochrane Database Syst Rev. 2012 Feb 15. 2:CD003431. [Medline].
Brisinda G, Cadeddu F, Brandara F, Marniga G, Maria G. Randomized clinical trial comparing botulinum toxin injections with 0.2 per cent nitroglycerin ointment for chronic anal fissure. Br J Surg. 2007 Feb. 94 (2):162-7. [Medline].
Vassiliki Liana Tsikitis, MD, MCR, FACS, FASCRS Associate Professor of Surgery, Medical Director of Digestive Health Center, Department of Surgery, Division of Gastrointestinal and General Surgery, Oregon Health and Science University School of Medicine
Vassiliki Liana Tsikitis, MD, MCR, FACS, FASCRS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society of Clinical Oncology, American Society of Colon and Rectal Surgeons, Association for Academic Surgery, European Society of Coloproctology, International Society for Digestive Surgery, International Society of Surgery, Pacific Coast Surgical Association, Society for Surgery of the Alimentary Tract, SWOG
Disclosure: Nothing to disclose.
Ragavan V Siddharthan, MD General Surgery Resident, Department of Surgery, Oregon Health and Science University
Ragavan V Siddharthan, MD is a member of the following medical societies: American College of Surgeons
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine
Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.
Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine
Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.
Nicole EK Wieghard, MD Resident Physician, Department of Surgery, Oregon Health and Science University School of Medicine
Nicole EK Wieghard, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, Association of Women Surgeons
Disclosure: Nothing to disclose.
Atanu Biswas, MD Resident Physician, Department of Surgery, University of Arizona College of Medicine
Atanu Biswas, MD is a member of the following medical societies: American College of Surgeons
Disclosure: Nothing to disclose.
Surgery for Anal Fissure
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