anal%20fissure
ANAL FISSURE
An anal fissure is a disruption of the skin at the distal anal canal.
Most fissures are seen by separating the buttocks with opposing traction of the thumbs.
Majority of fissures are located in the posterior midline of the anus.
Acute fissures are simple splits or cracks in the anoderm while chronic fissures may show secondary changes eg sentinel tag, hypertrophied anal papilla, rolled edges, fibrosis of the edges or deep ulceration with exposure of the underlying internal anal sphincter muscle within the fissure's base.

Surgical Intervention

  • Surgery remains the gold standard of therapy for chronic anal fissure
    • Goal is to relax the internal anal sphincter
    • Several studies have shown that surgery achieves better rates of fissure healing compared with topical nitrates, calcium antagonists or Botulinum toxin injections
  • Surgery is recommended for acute anal fissures that do not resolve with 3-4 weeks of medical therapy
  • Surgery may also be considered after failure of 1st-line therapy even without a trial of 2nd-line medical therapy
    • Topical treatments often present problems with compliance and lower rates of healing, thus making surgery a valid option after failure of 1st-line or conservative medical therapy

Lateral Internal Sphincterotomy (LIS)

  • Considered the procedure of choice for refractory or chronic anal fissures
    • When done correctly, LIS appears to still be superior to medical therapy
  • Avoid in patients at high risk for incontinence, eg multiparous women and older individuals
  • Complications of surgery include incontinence, infection, bleeding and development of fistula
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