ZAGS

Morning Presentation
MSMC

Management Options For

Anal Fissures
Presenter: Dr Virginia Njungu
Supervisor: Dr Michael Mbambiko
Date: 18th Sept 2024
Introduction

• An anal fissure is a superficial tear in the

skin distal to the dentate line
• As a result of hard stools or
constipation, or injury.
• Can be acute (lasting less than 6 weeks)
or chronic (more than 6 weeks).
• The majority are primary and typically
occur at the posterior midline.
• Other locations (atypical/secondary
fissures) can be caused by other
underlying conditions that require
further workup.
• The diagnosis is primarily clinical.
• Several treatment options exist,
including medical management and
surgical options
Etiology

• Constipation
• Childbearing
• Chronic diarrhea
• Inflammatory bowel disease
• Anal cancer
• HIV
• Tuberculosis
• Sexually transmitted
diseases
• Prior anal surgery and
• Anal sexual intercourse.
 Pathophysiolog
y

• The anoderm is a very sensitive area to

microtrauma
• It can tear with repetitive trauma or increased
pressure.
• The high pressures in this area can result in
delayed healing secondary to ischemia.
• The tear can sometimes be deep enough to expose
the sphincter muscle.
• Together with spasms of the sphincter, this creates
severe pain with bowel movements, as well as
some rectal bleeding.
• The pathogenesis of chronic fissures
arises from underlying hypertonicity of
the internal anal sphincter, leading to
local ischemia and impaired wound
healing.
• There is considerable evidence that the
failure to heal is, at least in part, due to
localized tissue ischaemia from a high
anal pressure. A permanent surgical, or
temporary pharmacological, reduction in
resting anal pressure is the mainstay of
treatment.
Clinical presentation

Acute anal fissure Chronic anal fissure

• painful defecation
with or without
• Anal pain that is rectal bleeding that
worse during has been ongoing for
defecation usually several months to
persisting for hours possibly years
after defecation and
sometimes
associated with
bleeding
Physical exam

• The best position is the prone jackknife

position
• An anal fissure appears as a superficial
laceration
• usually longitudinal,
• extending proximally.
• Bleeding may or may not be present
• The fissure/entire anal sphincter may be
extremely tender to palpation.
Evaluation

• Examination under anesthesia is

recommended
• Primary or secondary anal fissure
• a primary or typical anal fissure occurs in
the posterior or anterior midline, and
• an atypical or secondary anal fissure
occurs in any location other than a
primary anal fissure.
Management

• Medical interventions
• Frequent sitz baths,
• analgesics,
• stool softeners, and a
• high-fiber diet
• fluid intake
• Other options
• topical analgesics such as
• 2% lidocaine jelly,
• topical nifedipine,
• topical nitroglycerin, or
• a combination of topical nifedipine and
lidocaine compounded by another
medication.
Nonoperative treatment
• first-line treatment
• sitz baths
• psyllium fiber or other bulking agents,
• with or without the addition of topical anesthetics or topical steroids
• Healing rates decrease as duration of symptoms increases
• stool softeners
• local anaesthetic
• steroid ointments,
Topical nitrates
• Topical nitroglycerin is associated with healing in approximately 50%
of CAF
• Reduce smooth muscle tone
• Headache occurs in at least 30% of treated patients
• Higher doses not associated with increased rates of healing
• Eg: 0.2% to 1% Topical glyceryl trinitrate (GTN)
Calcium channel blockers
• Similar efficacy to nitrates
• Superior side-effect profile
• Eg 2% Diltiazem (DTZ)
• 0.2% topical nifedipine,
Botulinum toxin
• Similar results compared with topical therapies as first-line therapy
• Modest improvement in healing rates as second-line therapy
following failed treatment with topical therapies.
• Combined therapy indicate higher healing rate
Lateral internal sphincterotomy (LIS)

• Contraindicated in
• The gold standard for CAF • women with prior obstetrical
injuries,
• can safely be offered as first-line
• patients with IBD,
therapy
• patients who have undergone
• preventing hypertonia of the
previous anorectal operations,
internal sphincter.
• patients with a documented anal
• healing rates of 88% to 100%
sphincter injury
• FI rates ranging from 8% to 30%
• A partial internal anal sphincter
release is very effective in
reducing resting tone, relieving
the symptoms and healing the
fissure
• Conservative treatment has
therefore become more popular,
and internal sphincterotomy is
now used selectively and only
when conservative measures
have failed
• A lateral release of the internal
sphincter, separate from the
fissure
LIS
 Open LIS

• Patient anaesthetized and positioned

• Palpate Intersphincteric groove at the

anal verge
Open LIS

• A 1- to 2-cm circumferential incision is

made across the intersphincteric groove

• Blunt scissor dissection opens the plane

inside and outside to separate the
internal sphincter from the anal mucosa .

• The free lower edge of the internal

sphincter is then grasped, drawn into the
wound and its distal portion divided.

• Tailored sphincterotomy vs conventional

Closed LIS
• A pointed no. 11 blade is introduced into the inter-sphincteric plane

• Blade advanced cephalad up to the level of the dentate line

• Blade is then moved medially incising the internal sphincter from without.

• The scalpel is withdrawn

• On digital palpation the tight band of the distal internal sphincter can be felt
to have released.
LIS
• Gentle digital pressure on the anoderm over residue band.

• This is safer than reintroducing the scalpel.

• Sentinel skin tag and hypertrophic papilla should be excised.

• The wounds are left open

• Open and closed LIS yield similar results and either technique may be used
COMPLICATIONS of LIS

• Fecal incontinence • Excessive bleeding,

• is the major complication; • encountered more commonly during the
• 45% of patients in the immediate postoperative open technique,
period
• may require suture ligation.
• it is transient and usually resolves.

• Recurrence of CAF
• post-LIS patients is approximately 5%, • keyhole deformity.
• conservative methods with pharmacological • long-term complication
treatment cure approximately 75 • encountered more frequently in the repair
of posterior CAFs
• A keyhole deformity is usually
• Perianal abscess asymptomatic and is well tolerated by
• 1% of closed technique patients.
Recurrent CAF
• Repeat contralateral tailored LIS
• showed a 98% healing rate and a
• 4% minor FI rate at a 12.5-year mean follow-up

• Inject botulinum toxin into the internal anal sphincter

• healing rate of 74% with a
• 10% rate of temporary flatus incontinence
MDA
• LIS superior to uncontrolled manual anal dilation
• 7 studies found that anal dilation, compared to LIS, was associated
with
• a nonsignificant increased rate of persistent fissure and
• greater incidence of incontinence
• An anal stretch is also effective but is a less-controlled method of
disrupting the internal sphincter; there is also a greater danger of
additional damage to the external sphinc
Fissurectomy

• LIS has been compared to fissurectomy in

one randomized trial of 62 patients,
• Demonstrating no incontinence or
recurrence in the LIS group,
• Compared to a 6.2% rate of incontinence
and 3.1% recurrence rate with
fissurectomy
Historically, the practice of incising the base
of a fissure, or of excising the whole fissure,
was effective as these operations divided the
internal sphincter, the fibres of which are
visible in the floor of a chronic fissure.
However, these operations create a keyhole
deformity of the anal canal which is less
effectively sealed by the haemorrhoidal
cushions and may be detrimental to passive
continence
Anal flaps

• Anocutaneous flap is a safe surgical

alternative for managing CAF
• Decreased risk of FI compared with LIS
and comparable healing rates.
• Used For patients with baseline
preoperative FI and
• Inadequate response to previous
treatment
• V-Y cutaneous advancement flap
Flaps

• Excision of the fissure and sentinel pile

with preservation of the integrity of the
internal sphincter
• Followed by a diamond-shaped anal
advancement flap to bring healthy, well-
vascularized tissue into the fissure bed
• The flap has been marked.
• It will be left attached to the underlying
tissue from which it obtains its blood
supply.
• The resultant donor defect can be closed
or left to granulate.
Laser surgery
Thank you