Skip to main content

Advertisement

SpringerLink
Log in

Safety and effectiveness of minimal sphincterotomy in the treatment of female patients with chronic anal fissure

  • Original Article
  • Published:
Updates in Surgery Aims and scope Submit manuscript

Abstract

To evaluate the outcome of a left lateral internal sphincterotomy extended for 20% of total sphincter length in female patients with chronic anal fissure, high anal resting pressure and normal preoperative anal continence. Between January 2014 and January 2018 all the female patients with chronic anal fissure showing failure of medical therapy, perfect anal continence (Cleveland Clinic Florida incontinence score = 0) and high anal resting pressure underwent a lateral internal sphincterotomy extended for 1/5 of total lateral sphincter length, basing on the preoperative measurements by three-dimensional endoanal ultrasound. Postoperative follow-up included clinical assessment at 3, 6 and 12 months associated with manometric and ultrasonographic evaluation at 6 months. Thirty-two patients, [median age 45 (range 19–68)] were included and, of these, 2 (6.2%) were lost to follow-up. At 6 month follow-up success rate was 93.3% (28/30) and continence score was 0 in all the patients. Two patients (6.2%) with poor outcome showed incomplete sphincterotomy at EAUS and underwent re-surgery. At three-dimensional endoanal ultrasound the median length of sphincterotomy was 6 mm (5–8.2). At 12 month follow-up the success rate was 100% and Cleveland Clinic Florida incontinence score remained 0 in all the cases. Open left lateral internal sphincterotomy extended for about 20% of total left lateral internal sphincter length seems to be safe and effective in the treatment of chronic anal fissure in suitable female patients achieving a high success rate without compromising anal continence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

Abbreviations

LIS:

Lateral internal sphincter

CAF:

Chronic anal fissure

CCF-S:

Cleveland Clinic Florida incontinence score

VAS:

Visual analog scale

3D-EAUS:

Three-dimensional endoanal ultrasound

EAU:

Endoanal ultrasonography

References

  1. Nelson RL (2003) Treatment of anal fissure. BMJ 327(7411):354–355

    Article  Google Scholar 

  2. Sailer M, Bussen D, Debus ES, Fuchs KH, Thiede A (1998) Quality of life in patients with benign anorectal disorders. Br J Surg 85:1716–1719

    Article  CAS  Google Scholar 

  3. Madalinski MH (2011) Identifying the best therapy for chronic anal fissure. World J Gastrointest Pharmacol Ther 2(2):9–16

    Article  Google Scholar 

  4. Poh A, Tan KY, Seow-Choen F (2010) Innovations in chronic anal fissure treatment: a systematic review. World J Gastrointest Surg 2(7):231–241

    Article  Google Scholar 

  5. Altomare DF, Rinaldi M, Milito G, Arcanà F, Spinelli F, Nardelli N, Scardigno D, Pulvirenti-D'Urso A, Bottini C, Pescatori M, Lovreglio R (2000) Glyceryl trinitrate for chronic anal fissure-healing or headache? Results of a multicenter, randomized, placebo-controlled, double-blind trial. Dis Colon Rectum 43:174–179

    Article  CAS  Google Scholar 

  6. Lund JN, Scholefield JH (1997) A randomised, prospective, double blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure [published erratum appears in Lancet 349:656]. Lancet 349:11–14

    Article  CAS  Google Scholar 

  7. Renzi A, Brillantino A, Di Sarno G, D'Aniello F, Ziccardi S, Paladino F, Iacobellis F (2015) Myoxinol (hydrolyzed hibiscus esculentus extract) in the cure of chronic anal fissure: early clinical and functional outcomes. Gastroenterol Res Pract 2015:567920. https://doi.org/10.1155/2015/567920

    Article  PubMed  PubMed Central  Google Scholar 

  8. Brillantino A, Iacobellis F, Izzo G, Di Martino N, Grassi R, Renzi A (2014) Maintenance therapy with partially hydrolyzed guar gum in the conservative treatment of chronic anal fissure: results of a prospective, randomized study. Biomed Res Int 2014:964942. https://doi.org/10.1155/2014/964942

    Article  PubMed  PubMed Central  Google Scholar 

  9. Izzo D, Brillantino A, Iacobellis F, Falco P, Renzi A, Rea R (2014) Role of 0.4 % glyceryl trinitrate ointment after stapled trans-anal rectal resection for obstructed defecation syndrome: a prospective, randomized trial. Int J Colorectal Dis 29(1):105–110. https://doi.org/10.1007/s00384-013-1758-x

    Article  PubMed  Google Scholar 

  10. Yiannakopoulou E (2012) Botulinum toxin and anal fissure: efficacy and safety systematic review. Int J Colorectal Dis 27(1):1–9. https://doi.org/10.1007/s00384-011-1286-5

    Article  PubMed  Google Scholar 

  11. Renzi A, Brusciano L, Pescatori M, Izzo D, Napolitano V, Rossetti G, del Genio G, del Genio A (2005) Pneumatic balloon dilation for chronic anal fissure: a prospective, clinical, endosonographic, and manometric study. Dis Colon Rectum 48:121–126

    Article  CAS  Google Scholar 

  12. Karamanlis E, Michalopoulos A, Papadopoulos V et al (2010) Prospective clinical trial comparing sphincterotomy, nitroglycerin ointment and xylocaine/lactulose combination for the treatment of anal fissure. Tech Coloproctol 14(Suppl 1):S21–S23

    Article  Google Scholar 

  13. Garcia-Aguilar J, Belmonte C, Wong WD, Lowry AC, Madoff RD (1996) Open vs. closed sphincterotomy for chronic anal fissure: long-term results. Dis Colon Rectum 39:440–443

    Article  CAS  Google Scholar 

  14. Nelson RL, Chattopadhyay A, Brooks W, Platt I, Paavana T, Earl S (2011) Operative procedures for fissure in ano. Cochrane Database Syst Rev 11:CD002199

    Google Scholar 

  15. Alawady M, Emile SH, Abdelnaby M, Elbanna H, Farid M (2018) Posterolateral versus lateral internal anal sphincterotomy in the treatment of chronic anal fissure: a randomized controlled trial. Int J Colorectal Dis. 33(10):1461–1467. https://doi.org/10.1007/s00384-018-3087-6

    Article  PubMed  Google Scholar 

  16. Kiyak G, Korukluoğlu B, Kuşdemir A, Sişman IC, Ergül E (2009) Results of lateral internal sphincterotomy with open technique for chronic anal fissure: evaluation of complications, symptom relief, and incontinence with long-term follow-up. Dig Dis Sci 54(10):2220–2224

    Article  Google Scholar 

  17. Renzi A, Izzo D, Di Sarno G, Talento P, Torelli F, Izzo G, Di Martino N (2008) Clinical, manometric, and ultrasonographic results of pneumatic balloon dilatation vs. lateral internal sphincterotomy for chronic anal fissure: a prospective, randomized, controlled trial. Dis Colon Rectum 51(1):121–127

    Article  Google Scholar 

  18. Stewart DB Sr, Gaertner W, Glasgow S, Migaly J, Feingold D, Steele SR (2017) Clinical practice guideline for the management of anal fissures. Dis Colon Rectum 60(1):7–14

    Article  Google Scholar 

  19. García-Aguilar J, Belmonte Montes C, Perez JJ, Jensen L, Madoff RD, Wong WD (1998) Incontinence after lateral internal sphincterotomy: anatomic and functional evaluation. Dis Colon Rectum 41(4):423–427

    Article  Google Scholar 

  20. Levin A, Cohen MJ, Mindrul V, Lysy J (2011) Delayed fecal incontinence following surgery for anal fissure. Int J Colorectal Dis 26(12):1595–1599. https://doi.org/10.1007/s00384-011-1284-7

    Article  PubMed  Google Scholar 

  21. Murad-Regadas SM, Fernandes GO, Regadas FS, Rodrigues LV, Pereira JJ, Regadas Filho FS, Dealcanfreitas ID, Holanda EC (2013) How much of the internal sphincter may be divided during lateral sphincterotomy for chronic anal fissure in women? Morphologic and functional evaluation after sphincterotomy. Dis Colon Rectum 56(5):645–651. https://doi.org/10.1097/DCR.0b013e31827a7416

    Article  PubMed  Google Scholar 

  22. Garcea G, Sutton C, Mansoori S, Lloyd T, Thomas M (2003) Results following conservative lateral sphincteromy for the treatment of chronic anal fissures. Colorectal Dis 5(4):311–314

    Article  CAS  Google Scholar 

  23. Oliveira J, Pfeiffer J, Wexner SD (1996) Physiological and clinical outcome of anterior sphincteroplasty. Br J Surg 83:502–505

    Article  CAS  Google Scholar 

  24. Paul-Dauphin A, Guillemin F, Virion JM, Briançon S (1999) Bias and precision in visual analogue scales: a randomized controlled trial. Am J Epidemiol 150(10):1117–1127

    Article  CAS  Google Scholar 

  25. Brillantino A, Iacobellis F, Reginelli A, Monaco L, Sodano B, Tufano G, Tufano A, Maglio M, De Palma M, Di Martino N, Renzi A, Grassi R (2019) Preoperative assessment of simple and complex anorectal fistulas: tridimensional endoanal ultrasound? Magnetic resonance? Both? Radiol Med 124:339. https://doi.org/10.1007/s11547-018-0975-3

    Article  PubMed  Google Scholar 

  26. Brillantino A, Iacobellis F, Di Sarno G, D’Aniello F, Izzo D, Paladino F, De Palma M, Castriconi M, Grassi R, Di Martino N, Renzi A (2015) Role of tridimensional endoanal ultrasound (3D-EAUS) in the preoperative assessment of perianal sepsis. Int J Colorectal Dis 30(4):535–542. https://doi.org/10.1007/s00384-015-2167-0

    Article  PubMed  Google Scholar 

  27. Brillantino A, Iacobellis F, Reginelli A, Renzi A, Grassi R (2020) Three-dimensional endoanal ultrasound should be considered as first-line diagnostic tool in the preoperative work-up for perianal fistulas: the authors reply to the letter: Mathew RP, Patel V, Low G. Caution in using 3D-EAUS as the first-line diagnostic tool in the preoperative work up for perianal fistulas. Radiol Med 2020;125:155–156. Radiol Med 125(7):695–696. https://doi.org/10.1007/s11547-020-01160-8

    Article  PubMed  Google Scholar 

  28. Pinsk I, Brown J, Phang PT (2009) Assessment of sonographic quality of anal sphincter muscles in patients with faecal incontinence. Colorectal Dis 11(9):933–940. https://doi.org/10.1111/j.1463-1318.2008.01730.x

    Article  CAS  PubMed  Google Scholar 

  29. Menteş BB, Ege B, Leventoglu S, Oguz M, Karadag A (2005) Extent of lateral internal sphincterotomy: up to the dentate line or up to the fissure apex? Dis Colon Rectum 48:365–370

    Article  Google Scholar 

  30. Elsebae MM (2007) 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 31:2052–2057

    Article  Google Scholar 

  31. Ho KS, Ho YH (2005) Randomized clinical trial comparing oral nifedipine with lateral anal sphincterotomy and tailored sphincterotomy in the treatment of chronic anal fissure. Br J Surg 92:403–408

    Article  Google Scholar 

  32. Menteş BB, Güner MK, Leventoglu S, Akyürek N (2008) Fine-tuning of the extent of lateral internal sphincterotomy: spasm-controlled vs. up to the fissure apex. Dis Colon Rectum 51:128–133

    Article  Google Scholar 

  33. Brown CJ, Dubreuil D, Santoro L, Liu M, O'Connor BI, McLeod RS (2007) Lateral internal sphincterotomy is superior to topical nitroglycerin for healing chronic anal fissure and does not compromise long-term fecal continence: six-year follow-up of a multicenter, randomized, controlled trial. Dis Colon Rectum 50(4):442–448

    Article  Google Scholar 

  34. Ram E, Alper D, Stein GY, Bramnik Z, Dreznik Z (2005) Internal anal sphincter function following lateral internal sphincterotomy for anal fissure: a long-term manometric study. Ann Surg 242(2):208–211. https://doi.org/10.1097/01.sla.0000171036.39886.fa

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Funding

This research was not funded by any agency in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations

  1. Department of Surgery, “A. Cardarelli” Hospital, Via A. Cardarelli 9, 80131, Naples, Italy

    Antonio Brillantino, Mauro Maglio, Maurizio Grillo & Luciano Vicenzo

  2. Department of Surgery, CTO Azienda Ospedaliera dei Colli, Viale Colli Aminei 2, 80141, Naples, Italy

    Domenico Izzo

  3. Department of Radiology, “A. Cardarelli” Hospital, Via A. Cardarelli 9, 80131, Naples, Italy

    Francesca Iacobellis

  4. Department of Surgery, “Villa Betania” Hospital, Via Argine 604, 80147, Naples, Italy

    Vincenzo Bottino

  5. Department of Surgery, “Villa delle Querce” Hospital, Via B. Caracciolo 48, 80136, Naples, Italy

    Adolfo Renzi

Authors
  1. Antonio Brillantino
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Domenico Izzo
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Francesca Iacobellis
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Mauro Maglio
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Maurizio Grillo
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Luciano Vicenzo
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Vincenzo Bottino
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Adolfo Renzi
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

AB designed the study, drafted the manuscript, performed the endoanal ultrasound examinations and carried out statistical analysis. DI collected the data and took part in the drafting of manuscript. FI performed the ultrasound examinations in consensus with AB and collected the data. MM, MG, LV, VB and AR performed the surgical interventions and collected the data.

Corresponding author

Correspondence to Antonio Brillantino.

Ethics declarations

Conflict of interest

All the authors declare to not have financial interests related to the material in the manuscript.

Ethical approval

The ethical committee of our institution approved the study protocol. All patients gave informed written consent to participate and for publication.

Human and animal rights

The study involves Human participants and was conducted in conformity with ethical and humane principles of research according with the ethical guidelines of the 1975 Declaration of Helsinki.

Informed Consent

All patients gave informed written consent to be enrolled in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Brillantino, A., Izzo, D., Iacobellis, F. et al. Safety and effectiveness of minimal sphincterotomy in the treatment of female patients with chronic anal fissure. Updates Surg 73, 1829–1836 (2021). https://doi.org/10.1007/s13304-020-00874-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13304-020-00874-8

Keywords

Search

Navigation