Abstract
Background
Anal fissure is one of the most common proctological complaints. If the fissure persists for more than 6–8 weeks, it is termed a chronic fissure and will most likely need surgical intervention. Surgical partial transection of the internal sphincter muscle, lateral internal sphincterotomy (LIS), is still seen as the gold standard procedure for chronic anal fissure in many parts of the world, especially in the Anglo-American community. In contrast, the German-speaking surgical community favors fissurectomy ± application of Botox, as some studies report high postoperative incontinence rates after LIS.
Objective
This paper aims to give an overview of the literature on LIS and its outcomes and answer the question, “Is LIS still the gold standard surgical approach for chronic anal fissure?”
Material and methods
A literature search for “sphincterotomy,” “internal sphincter,” and “anal fissure” was performed in PubMed. For the purpose of this overview article, randomized controlled trials (RCTs), meta-analyses, up-to-date guidelines, and retrospective cohort studies were taken into account.
Results and conclusion
LIS produces excellent rates of fissure healing (~95%), quick symptom relief, and high patient satisfaction. Incontinence after LIS is mostly described as mild and transient. In the authors’ view, open LIS is therefore rightfully still the gold standard procedure for treatment of chronic anal fissure in the majority of patients. A conservative approach with limited division of internal sphincter muscle is preferred. For patients with preexisting sphincter weakness and an increased risk of incontinence, further preoperative diagnostic assessment (anal manometry, endoanal ultrasound) is recommended. In this high-risk group, alternative surgical options might be preferred.
Zusammenfassung
Hintergrund
Die Analfissur ist eine der häufigsten proktologischen Diagnosen. Besteht sie länger als 6–8 Wochen wird sie zur chronischen Fissur, welche in der Regel eine operative Intervention benötigt. Vor allem im englischsprachigen Raum wird die chirurgische Durchtrennung eines Teils des internen Sphinktermuskels, die laterale Internus Sphinkterotomie (LIS), nach wie vor als „Goldstandard“ in der chirurgischen Behandlung angesehen. Dies steht im Kontrast zur deutschsprachigen chirurgischen Gemeinschaft, welche der Fissurektomie ± Botoxinjektion den Vorzug gibt, da nach LIS zum Teil eine hohe Inkontinenzrate beschriebenen wird.
Ziel
Aufbereitung der aktuellen Literatur rund um LIS – ist der Status von LIS als Goldstandard-Therapie in der chronischen Analfissur nach wie vor vertretbar?
Material und Methoden
Aktuelle Literatur rund um LIS wurde in „pubmed“ identifiziert. Dabei wurden sowohl RCT, Metaanalysen, aktuelle Guidelines, sowie retrospektive Kohortenstudien berücksichtigt.
Ergebnisse und Diskussion
Die Vorteile von LIS bestehen in einer ausgezeichneten Heilungsrate (~95 %), einer prompten Symptomlinderung und dementsprechend hoher Patientenzufriedenheit. Postoperative Inkontinenz nach LIS wird meist als mild und transient beschrieben. Die Autoren vertreten daher die Meinung, dass eine offene, laterale Sphinkterotomie nach wie vor dem „Gold Standard“ der chirurgischen Fissurbehandlung entspricht. Dabei wird ein „konservativer Approach“ mit limitierter Muskeldurchtrennung bevorzugt. Bei Patienten mit Verdacht auf bereits bestehende Sphinkterschwäche werden weitergehende präoperative Abklärungen (Manometrie, endoanaler Ultraschall) empfohlen. Bei dieser „Risikogruppe“ kann ein Ausweichen auf alternative chirurgische Techniken sinnvoll sein.
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M. Holzgang and D. Jayne declare that they have no competing interests.
For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case.
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Holzgang, M., Jayne, D. Lateral internal sphincterotomy (LIS)—still top gun in chronic anal fissure treatment?. coloproctology 42, 478–484 (2020). https://doi.org/10.1007/s00053-020-00454-9
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DOI: https://doi.org/10.1007/s00053-020-00454-9
Keywords
- Postoperative incontinence
- Conservative sphincterotomy
- Anorectal surgery
- Fissurectomy
- Botulinum toxin injection