Operative procedures for fissure in ano

Nelson RL

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Summary

This review assesses the usefulness surgery for anal fissure, a painful ulcer at the anal opening, by comparing the efficacy of various surgical procedures and how likely they are to result in complications.

Anal stretch is not as efficacious as controlled sphincterotomy and there is no difference found between open and closed sphincterotomy. Excision of papillae and wound closure might augment wound healing and patient satisfaction.
The results of the meta-analysis demonstrate that anal stretch may be more likely to result in persistence and is more likely to result in incontinence, when compared to all forms of sphincter division. The means of performing lateral sphincterotomy (open versus closed) appeared roughly equivalent in this analysis.
More data are needed to determine if posterior internal sphincterotomy is as effective as lateral sphincterotomy as well as a number of newer procedures..

This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2009 Issue 4, Copyright © 2009 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
This record should be cited as: Nelson RL. Operative procedures for fissure in ano. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD002199. DOI: 10.1002/14651858.CD002199.pub2.

This version first published online: July 23. 2001
Last assessed as up-to-date: July 23. 2008

Abstract

Background

Operative techniques commonly used for fissure in ano include: anal stretch, open lateral sphincterotomy, closed lateral sphincterotomy, posterior midline sphincterotomy and to a lesser extent dermal flap coverage of the fissure. Reports of direct comparisons between operative techniques for anal fissure are variable in their results. These reports are either subject to selection bias (in non-randomized studies) or observer bias (in all studies) or have inadequate numbers of patients enrolled to answer the question of efficacy.

Objectives

To determine the best technique for fissure surgery.

Search strategy

The Cochrane Central Register of Controlled Trials and MEDLINE (1965-2008), Medline (Pubmed) and Embase were searched July 2008. The list of cited references in all included reports and several study authors also were helpful in finding additional comparative studies.

A total of five new trials were included in this version of the review.

Selection criteria

All reports in which there was a direct comparison between at least two operative techniques were reviewed and when more than one report existed for any given pair, that report was included. If crude data were not presented in the report, the authors were contacted and crude data obtained.

Data collection and analysis

The two most commonly used end points in all reported studies were persistence of the fissure and post operative incontinence of flatus. These are the only two endpoints included in the meta-analysis.

Main results

Twenty-four trials encompassing 3475 patients are included in this review .
Anal stretch has a higher risk of fissure persistence than internal sphincterotomy and also a significantly higher risk of minor incontinence than sphincterotomy. The combined results of open versus closed partial lateral internal sphincterotomy show little difference between the two procedures both in fissure persistence and risk of incontinence.

Authors' conclusions

Anal stretch and posterior midline internal sphincterotomy should probably be abandoned in the treatment of chronic anal fissure in adults. For those patients requiring surgery for anal fissure, open and closed partial lateral internal sphincterotomy appear to be equally efficacious. More data are needed to assess the effectiveness of posterior internal sphincterotomy, anterior levatorplasty, wound suture or papilla excision.

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