ANAL FISSURE

Dr. Haluk Kerim Karakullukcu1
Prof. Dr. Ömer Faruk Özkan, FTBS, FEBS-c, FACS, PhD2

1İstanbul Sultan Abdulhamid Han Training and Research Hospital, Department of General Surgery, İstanbul, Türkiye
2İstanbul Sultan Abdulhamid Han Training and Research Hospital, Department of General Surgery, İstanbul, Türkiye

ABSTRACT

Anal fissure is defined as a painful tear in the epithelium distal to the dentate line. Although it commonly occurs in young adults, particularly in the second and third decades of life, it can also be seen in the elderly and pediatric populations. Typical symptoms include a sensation of ‘passing glass’ during defecation and bright red blood on the toilet paper post-defecation. Additionally, sphincter spasm and pain, which can last for several hours after defecation, can significantly affect the patient’s quality of life. Fissures are categorized into acute and chronic types. Acute anal fissures heal within less than six weeks, are considered superficial tears, and usually respond to conservative treatment. Chronic fissures, on the other hand, persist for more than six weeks, are characterized by sentinel pile and hypertrophic anal papilla, and are often resistant to treatment.

The most widely accepted mechanism for the development of anal fissures involves anoderm trauma caused by conditions such as hard stools or diarrhea, leading to an increase in internal anal sphincter (IAS) pressure and subsequent ischemia. Fissures are more frequently observed at the posterior and anterior midline, areas with relatively low blood flow. When sphincter pressure increases, ischemia worsens, leading to the chronicity of the fissure.

Treatment typically begins with conservative measures. Warm sitz baths, a fiber-rich diet, and stool softeners can be effective in acute fissures, providing healing in nearly half of the patients. Topical analgesics and agents like nitroglycerin also help reduce pressure and promote healing. While nitroglycerin is effective in relieving symptoms, it is often poorly tolerated due to side effects such as headaches. Calcium channel blockers serve as an alternative treatment option, offering similar efficacy with better tolerability. Botulinum toxin (BTX), which decreases IAS pressure, is effective in chronic fissures and is considered a minimally invasive treatment option.

Surgical options are considered for patients who do not respond to medical therapies. Lateral internal sphinc- terotomy (LIS) is the most effective surgical intervention, reducing IAS pressure and promoting fissure healing. However, in patients with a risk of fecal incontinence, alternative surgical methods such as fissurectomy or anocutaneous flap application are preferred. A tailored treatment approach should be adopted, considering the patient’s overall condition, the duration of the fissure, and its location when planning treatment.

Key words: Topical Glyceryl Trinitrate; Topical Diltiazem; Botulinum Toxin (BTX); Anal dilatation; Fissurectomy; Anocutaneous Flap; Lateral Internal Sphincterotomy

Keywords: Topical Glyceryl Trinitrate; Topical Diltiazem; Botulinum Toxin (BTX); Anal dilatation; Fissurectomy; Anocutaneous Flap; Lateral Internal Sphincterotomy

Referanslar

  1. Davids JS, Hawkins AT, Bhama AR, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anal Fissures. Dis Colon Rectum. 2023;66(2):190-199. [Link]
  2. Lu KC, Herzig DO. Anal fissure. In: Steele SR, Hull TL, Read TE, Saclarides TJ, Senagore AJ, Whitlow CB, eds. The ASCRS Textbook of Colon and Rectal Surgery. 3rd ed. New York: Springer; 2017. p. 205-212. [Crossref]
  3. Lund JN, Scholefield JH. Aetiology and treatment of anal fissure. Br J Surg. 1996;83(10):1335-1344. [Crossref]  [PubMed]
  4. Schouten WR, Briel JW, Auwerda JJ, De Graaf EJ. Ischaemic nature of anal fissure. Br J Surg. 1996;83(1):63-65. [Crossref]  [PubMed]
  5. Farouk R, Duthie GS, MacGregor AB, Bartolo DC. Sustained internal sphincter hypertonia in patients with chronic anal fissure. Dis Colon Rectum. 1994;37(5):424-429. [Crossref]  [PubMed]
  6. Shub HA, Salvati EP, Rubin RJ. Conservative treatment of anal fissure: an unselected, retrospective and continuous study. Dis Colon Rectum. 1978;21(8):582-583. [Crossref]  [PubMed]
  7. Zaghiyan KN, Fleshner P.Anal fissure. Clin Colon Rectal Surg. 2011;24(1):22-30. [Crossref]  [PubMed]  [PMC]
  8. Nelson RL, Thomas K, Morgan J, Jones A. Non surgical therapy for anal fissure. Cochrane Database Syst Rev. 2012;2012(2):CD003431. Published 2012 Feb 15. [PubMed]
  9. Scholefield JH, Bock JU, Marla B, et al. A dose finding study with 0.1%, 0.2%, and 0.4% glyceryl trinitrate ointment in patients with chronic anal fissures. Gut. 2003;52(2):264-269. [Crossref]  [PubMed]  [PMC]
  10. Bailey HR, Beck DE, Billingham RP, et al. A study to determine the nitroglycerin ointment dose and dosing interval that best promote the healing of chronic anal fissures. Dis Colon Rectum. 2002;45(9):1192-1199. [Crossref]  [PubMed]
  11. Agrawal V, Kaushal G, Gupta R. Randomized controlled pilot trial of nifedipine as oral therapy vs. topical application in the treatment of fissure-in-ano. Am J Surg. 2013;206(5):748- 751. [Crossref]  [PubMed]
  12. Nash GF, Kapoor K, Saeb-Parsy K, Kunanadam T, Dawson PM. The long-term results of diltiazem treatment for anal fissure. Int J Clin Pract. 2006;60(11):1411-1413. [Crossref]  [PubMed]
  13. Sajid MS, Whitehouse PA, Sains P, Baig MK. Systematic review of the use of topical diltiazem compared with glyceryltrinitrate for the nonoperative management of chronic anal fissure. Colorectal Dis. 2013;15(1):19-26. [Crossref]  [PubMed]
  14. Ruiz-Tovar J, Llavero C. Perianal Application of Glyceryl Trinitrate Ointment Versus Tocopherol Acetate Ointment in the Treatment of Chronic Anal Fissure: A Randomized Clinical Trial. Dis Colon Rectum. 2022;65(3):406-412. [Crossref]  [PubMed]
  15. Bobkiewicz A, Francuzik W, Krokowicz L, et al. Botulinum Toxin Injection for Treatment of Chronic Anal Fissure: Is There Any Dose-Dependent Efficiency? A Meta-Analysis [published correction appears in World J Surg. 2016 Dec;40(12):3063. World J Surg. 2016;40(12):3064-3072. [Crossref]  [PubMed]  [PMC]
  16. Lin JX, Krishna S, Su'a B, Hill AG. Optimal Dosing of Botulinum Toxin for Treatment of Chronic Anal Fissure: A Systematic Review and Meta-Analysis. Dis Colon Rectum. 2016;59(9):886-894. [Crossref]  [PubMed]
  17. Scholz T, Hetzer FH, Dindo D, Demartines N, Clavien PA, Hahnloser D. Long-term follow-up after combined fissurectomy and Botox injection for chronic anal fissures. Int J Colorectal Dis. 2007;22(9):1077-1081. [Crossref]  [PubMed]
  18. Pelta AE, Davis KG, Armstrong DN. Subcutaneous fissurotomy: a novel procedure for chronic fissure-in-ano. a review of 109 cases. Dis Colon Rectum. 2007;50(10):1662-1667. [Crossref]  [PubMed]
  19. Vitton V, Bouchard D, Guingand M, Higuero T. Treatment of anal fissures: Results from a national survey on French practice. Clin Res Hepatol Gastroenterol. 2022;46(4):101821. [Crossref]  [PubMed]
  20. Abe T, Kunimoto M, Hachiro Y, et al. Long-term Efficacy and Safety of Controlled Manual Anal Dilatation in the Treatment of Chronic Anal Fissures: A Single-center Observational Study. J Anus Rectum Colon. 2023;7(4):250-257. Published 2023 Oct 25. [Crossref]  [PubMed]  [PMC]
  21. Riboni C, Selvaggi L, Cantarella F, et al. Anal Fissure and Its Treatments: A Historical Review. J Clin Med. 2024;13(13):3930. Published 2024 Jul 4. [Crossref]  [PubMed]  [PMC]
  22. BENNETT RC, GOLIGHER JC. Results of internal sphincterotomy for anal fissure. Br Med J. 1962;2(5318):1500- 1503. [Crossref]  [PubMed]  [PMC]
  23. Notaras MJ. Lateral subcutaneous sphincterotomy for anal fissure--a new technique. Proc R Soc Med. 1969;62(7):713. [Crossref]  [PubMed]
  24. Menteş BB, Tezcaner T, Yilmaz U, Leventoğlu S, Oguz M. Results of lateral internal sphincterotomy for chronic anal fissure with particular reference to quality of life. Dis Colon Rectum. 2006;49(7):1045-1051. [Crossref]  [PubMed]
  25. Nelson RL, Chattopadhyay A, Brooks W, Platt I, Paavana T, Earl S. Operative procedures for fissure in ano. Cochrane Database Syst Rev. 2011;2011(11):CD002199. Published 2011 Nov 9. [Crossref]  [PubMed]  [PMC]
  26. Mousavi SR, Sharifi M, Mehdikhah Z. A comparison between the results of fissurectomy and lateral internal sphincterotomy in the surgical management of chronic anal fissure. J Gastrointest Surg. 2009;13(7):1279-1282. [Crossref]  [PubMed]
  27. Littlejohn DR, Newstead GL. Tailored lateral sphincterotomy for anal fissure. Dis Colon Rectum. 1997;40(12):1439- 1442. [Crossref]  [PubMed]
  28. Menteş BB, Ege B, Leventoglu S, Oguz M, Karadag A. Extent of lateral internal sphincterotomy: up to the dentate line or up to the fissure apex?. Dis Colon Rectum. 2005;48(2):365-370. [Crossref]  [PubMed]
  29. Elsebae MM. A study of fecal incontinence in patients with chronic anal fissure: prospective, randomized, controlled trial of the extent of internal anal sphincter division during lateral sphincterotomy. World J Surg. 2007;31(10):2052-2057. [Crossref]  [PubMed]
  30. Theodoropoulos GE, Spiropoulos V, Bramis K, Plastiras A, Zografos G. Dermal flap advancement combined with conservative sphincterotomy in the treatment of chronic anal fissure. Am Surg. 2015;81(2):133-142. [Crossref]  [PubMed]
  31. D'Orazio B, Geraci G, Martorana G, Sciumé C, Corbo G, Di Vita G. Fisurectomy and anoplasty with botulinum toxin injection in patients with chronic anal posterior fissure with hypertonia: a long-term evaluation. Updates Surg. 2021;73(4):1575-1581. [Crossref]  [PubMed]  [PMC]
  32. Sweeney JL, Ritchie JK, Nicholls RJ. Anal fissure in Crohn's disease. Br J Surg. 1988;75(1):56-57. [Crossref]  [PubMed]