Abstract
This study was designed to evaluate the healing and complications rates in surgically and conservatively treated patients with chronic anal fissure. Conservative treatment consisted of nitrate or diltiazem ointment. In case of surgery, fissurectomy was performed. In total, 340 patients were included in the study. Among them, 162 patients had surgery and 178 patients had conservative treatment. The healing rate at surgically treated group of patients varied between 95 and 98 % depending on previous treatment. Group treated with nitrate ointment and group treated with diltiazem ointment showed, respectively 62 % and 52 % healing rates. Difference between ointments was not statistically significant. Average healing time was between 105 and 123 days and complication rates were between 1.7 and 5.4 %. The surgical treatment showed much higher healing rates and thus should recommended as primary treatment option for the chronic anal fissure, especially if there are chronic secondary lesions already present. In case of conservative treatment, either nitrate or diltiazem ointment could be used with similar efficacy.
Similar content being viewed by others
References
Goligher JC, Duthie HL, Nixon HH (1984) Surgery of the anus, rectum and colon. Baillière Tindall, London
Lindsey I, Cunningham C, Jones OM, Francis C, Mortensen NJ (2004) Fissurectomy-botulinum toxin: a novel sphincter-sparing procedure for medically resistant chronic anal fissure. Dis Colon Rectum 47(11):1947–1952
Crapp AR, Alexander-Williams J (1975) Fissure-in-ano and anal stenosis. Part I: conservative management. Clin gastroenterol 4(3):619–628
Wienert V (1985) [Anal fissure]. Der Hautarzt; Zeitschrift fur Dermatologie, Venerologie, und verwandte Gebiete 36 (4):234–236
Lock MR, Thomson JP (1977) Fissure-in-ano: the initial management and prognosis. Br J Surg 64(5):355–358
McDonald P, Driscoll AM, Nicholls RJ (1983) The anal dilator in the conservative management of acute anal fissures. Br J Surg 70(1):25–26
Klosterhalfen B, Vogel P, Rixen H, Mittermayer C (1989) Topography of the inferior rectal artery: a possible cause of chronic, primary anal fissure. Dis Colon Rectum 32(1):43–52
Schouten WR, Briel JW, Auwerda JJ (1994) Relationship between anal pressure and anodermal blood flow. The vascular pathogenesis of anal fissures. Dis Colon Rectum 37(7):664–669
Soullard J (1975) Proctologie. Masson, Paris
Magee HR, Thompson HR (1966) Internal anal sphincterotomy as an out-patient operation. Gut 7(2):190–193
Arabi Y, Alexander-Williams J, Keighley MR (1977) Anal pressures in hemorrhoids and anal fissure. Am J Surg 134(5):608–610
Duthie HL, Bennett RC (1964) Anal sphincteric pressure in fissure in ano. Surg Gynecol Obstet 119:19–21
Hancock BD (1977) The internal sphincter and anal fissure. Br J Surg 64(2):92–95
Kuypers HC (1983) Is there really sphincter spasm in anal fissure? Dis Colon Rectum 26(8):493–494
Gibbons CP, Read NW (1986) Anal hypertonia in fissures: cause or effect? Br J Surg 73(6):443–445
Klug W (1998) Analfissur. Coloproctology 20(2):67–71
Gabriel WB The principles and practice of rectal surgery. 4th edn, Lewis, London
Oh C, Divino CM, Steinhagen RM (1995) Anal fissure. 20-year experience. Dis Colon Rectum 38(4):378–382
Abcarian H (1980) Surgical correction of chronic anal fissure: results of lateral internal sphincterotomy vs. fissurectomy—midline sphincterotomy. Dis Colon Rectum 23(1):31–36
Blessing H (1993) Late results after individualized lateral internal sphincterotomy. Helv Chir Acta 59(4):603–607
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(4):440–443
Khubchandani IT, Reed JF (1989) Sequelae of internal sphincterotomy for chronic fissure in ano. Br J Surg 76(5):431–434
Nyam DC, Pemberton JH (1999) Long-term results of lateral internal sphincterotomy for chronic anal fissure with particular reference to incidence of fecal incontinence. Dis Colon Rectum 42(10):1306–1310
Pernikoff BJ, Eisenstat TE, Rubin RJ, Oliver GC, Salvati EP (1994) Reappraisal of partial lateral internal sphincterotomy. Dis Colon Rectum 37(12):1291–1295
Pfeifer J, Berger A, Uranus S (1994) Surgical therapy of chronic anal fissure—do additional proctologic operations impair continence? Der Chirurg Zeitschrift fur alle Gebiete der operativen Medizen 65(7):630–633
Sultan AH, Kamm MA, Nicholls RJ, Bartram CI (1994) Prospective study of the extent of internal anal sphincter division during lateral sphincterotomy. Dis Colon Rectum 37(10):1031–1033
Usatoff V, Polglase AL (1995) The longer term results of internal anal sphincterotomy for anal fissure. Aust N Z J Surg 65(8):576–578
Keighley MR, Williams NS (1999) Surgery of the anus, rectum and colon, 2nd edn. Saunders, London
Lund JN, Scholefield JH (1997) A randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure. Lancet 349(9044):11–14. doi:10.1016/S0140-6736(96)06090-4
Altomare DF, Rinaldi M, Milito G, Arcana 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-controled, double-blind trial. Dis Colon Rectum 43(2):174–179 (discussion 179–181)
Gorfine SR (1995) Treatment of benign anal disease with topical nitroglycerin. Diseases of the colon and rectum 38(5):453–456 (Discussion 456–457)
Nelson R (2006) Non surgical therapy for anal fissure. The Cochrane database of systematic reviews (4):CD003431. doi:10.1002/14651858.CD003431.pub2
Nelson RL, Thomas K, Morgan J, Jones A (2012) Non surgical therapy for anal fissure. The Cochrane database of systematic reviews 2:CD003431. doi:10.1002/14651858.CD003431.pub3
Richard CS, Gregoire R, Plewes EA, Silverman R, Burul C, Buie D, Reznick R, Ross T, Burnstein M, O’Connor BI, Mukraj D, McLeod RS (2000) Internal sphincterotomy is superior to topical nitroglycerin in the treatment of chronic anal fissure: results of a randomized, controlled trial by the Canadian colorectal surgical trials group. Dis Colon Rectum 43(8):1048–1057 (Discussion 1057–1048)
Cook TA, Brading AF, Mortensen NJ (1999) Effects of nifedipine on anorectal smooth muscle in vitro. Dis Colon Rectum 42(6):782–787
Chrysos E, Xynos E, Tzovaras G, Zoras OJ, Tsiaoussis J, Vassilakis SJ (1996) Effect of nifedipine on rectoanal motility. Dis Colon Rectum 39(2):212–216
Bielecki K, Kolodziejczak M (2003) A prospective randomized trial of diltiazem and glyceryltrinitrate ointment in the treatment of chronic anal fissure. Colorectal Dis Off J Associ Coloproctol Gt Br Irel 5(3):256–257
Jonas M, Neal KR, Abercrombie JF, Scholefield JH (2001) A randomized trial of oral vs. topical diltiazem for chronic anal fissures. Dis Colon Rectum 44(8):1074–1078
Kocher HM, Steward M, Leather AJ, Cullen PT (2002) Randomized clinical trial assessing the side-effects of glyceryl trinitrate and diltiazem hydrochloride in the treatment of chronic anal fissure. Br J Surg 89(4):413–417. doi:10.1046/j.0007-1323.2001.02042.x
Maria G, Cassetta E, Gui D, Brisinda G, Bentivoglio AR, Albanese A (1998) A comparison of botulinum toxin and saline for the treatment of chronic anal fissure. N Engl J Med 338(4):217–220. doi:10.1056/NEJM199801223380402
Jost WH, Schimrigk K (1993) Use of botulinum toxin in anal fissure. Dis Colon Rectum 36(10):974
Lindsey I, Jones OM, Cunningham C, George BD, Mortensen NJ (2003) Botulinum toxin as second-line therapy for chronic anal fissure failing 0.2 percent glyceryl trinitrate. Dis Colon Rectum 46(3):361–366. doi:10.1097/01.DCR.0000049478.73020.39
Brisinda G, Maria G, Bentivoglio AR, Cassetta E, Gui D, Albanese A (1999) A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure. N Engl J Med 341(2):65–69. doi:10.1056/NEJM199907083410201
Pitt J, Craggs MM, Henry MM, Boulos PB (2000) Alpha-1 adrenoceptor blockade: potential new treatment for anal fissures. Dis Colon Rectum 43(6):800–803
Pitt J, Dawson PM, Hallan RI, Boulos PB (2001) A double-blind randomized placebo-controlled trial of oral indoramin to treat chronic anal fissure. Colorectal Dis Off J Assoc Coloproctol Gr Br Irel 3(3):165–168
Carapeti EA, Kamm MA, Evans BK, Phillips RK (1999) Topical diltiazem and bethanechol decrease anal sphincter pressure without side effects. Gut 45(5):719–722
Songun I, Boutkan H, Delemarre JB, Breslau PJ (2003) Effect of isosorbide dinitrate ointment on anal fissure. Dig Surg 20(2):122–126. doi:10.1159/000069387
Griffin N, Zimmerman DD, Briel JW, Gruss HJ, Jonas M, Acheson AG, Neal K, Scholefield JH, Schouten WR (2002) Topical l-arginine gel lowers resting anal pressure: possible treatment for anal fissure. Dis Colon Rectum 45(10):1332–1336. doi:10.1097/01.DCR.0000029763.63970.7F
Jones OM, Brading AF, Mc CMNJ (2002) Phosphodiesterase inhibitors cause relaxation of the internal anal sphincter in vitro. Dis Colon Rectum 45(4):530–536
Oettle GJ (1997) Glyceryl trinitrate vs. sphincterotomy for treatment of chronic fissure-in-ano: a randomized, controlled trial. Dis Colon Rectum 40(11):1318–1320
Evans J, Luck A, Hewett P (2001) Glyceryl trinitrate vs. lateral sphincterotomy for chronic anal fissure: prospective, randomized trial. Dis Colon Rectum 44(1):93–97
Libertiny G, Knight JS, Farouk R (2002) Randomised trial of topical 0.2 % glyceryl trinitrate and lateral internal sphincterotomy for the treatment of patients with chronic anal fissure: long-term follow-up. Eur J Surg 168(7):418–421. doi:10.1080/110241502320789113
Hancke E, Rikas E, Schwaner S, Voelke K (2009) Fissurexzision versus Fissurexzision und laterale interne Sphinkterotomie bei der chronischen Analfissur. Coloproctology 31:1–9
Hancke E, Scwaner S (2003) Chronische Analfissur—Operative Behandlung mit Analdilatation, Exzision der Analfissur versus laterale Sphinkterotomie. Coloproctology 25:95–105
Meier zu Eissen J (2001) Chronic anal fissure, therapy. Kongressband/Dtsch Ges fur Chir Dtsch Gesellschaft fur Chir Kongr 118:654–656
Schornagel IL, Witvliet M, Engel AF (2012) Five-year results of fissurectomy for chronic anal fissure: low recurrence rate and minimal effect on continence. Colorectal Dis Official J Assoc Coloproctol Gr Br Irel 14(8):997–1000. doi:10.1111/j.1463-1318.2011.02840.x
Engel AF, Eijsbouts QA, Balk AG (2002) Fissurectomy and isosorbide dinitrate for chronic fissure in ano not responding to conservative treatment. Br J Surg 89(1):79–83. doi:10.1046/j.0007-1323.2001.01958.x
Scholz T, Hetzer FH, Dindo D, Demartines N, Clavien PA, Hahnloser D (2007) Long-term follow-up after combined fissurectomy and Botox injection for chronic anal fissures. Int J Colorectal Dis 22(9):1077–1081. doi:10.1007/s00384-006-0261-z
Pelta AE, Davis KG, Armstrong DN (2007) Subcutaneous fissurotomy: a novel procedure for chronic fissure-in-ano. a review of 109 cases. Dis Colon Rectum 50(10):1662–1667. doi:10.1007/s10350-007-9022-5
Christie A, Guest JF (2002) Modelling the economic impact of managing a chronic anal fissure with a proprietary formulation of nitroglycerin (Rectogesic) compared to lateral internal sphincterotomy in the United Kingdom. Int J Colorectal Dis 17(4):259–267. doi:10.1007/s00384-001-0371-6
DasGupta R, Franklin I, Pitt J, Dawson PM (2002) Successful treatment of chronic anal fissure with diltiazem gel. Colorectal Dis Off J Assoc Coloproctol Gr Br Irel 4(1):20–22
Conflict of interest
None.
Ethical standard
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent
For this type of study formal consent is not required.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Vershenya, S., Klotz, J., Joos, A. et al. Combined approach in the treatment of chronic anal fissures. Updates Surg 67, 83–89 (2015). https://doi.org/10.1007/s13304-015-0290-7
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s13304-015-0290-7