A comparison between the results of fissurectomy and lateral internal sphincterotomy in the surgical management of chronic anal fissure. Comparative study of lateral internal sphincterotomy versus local 0.2% glyceryl trinitrate ointment for the treatment of chronic anal fissure. Evaluation of healing and complications after lateral internal sphincterotomy for chronic anal fissure: marginal suture of incision vs. open left incision: prospective, randomized, controlled study. Open versus closed lateral sphincterotomy performed as an outpatient procedure under local anesthesia for chronic anal fissure: prospective randomized study of clinical and manometric longterm results. Surgical treatment of chronic fissure-in-ano: a prospective randomised study. A prospective randomized trial betwen subcutaneous lateral internal sphincterotomy with radiofrequency bistoury and conventional parks' operation in the treatment of anal fissures. Adequate internal sphincterotomy for chronic anal fissure: subcutaneous or open technique? Topical nitroglycerin versus lateral internal sphincterotomy for chronic anal fissure: prospective, randomized trial. Lateral sphincterotomy compared with anal advancement flap for chronic anal fissure. 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. Clinical, manometric, and ultrasonographic results of pneumatic balloon dilatation vs. lateral internal sphincterotomy for chronic anal fissure: a prospective, randomized, controlled trial. 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. 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. Extent of lateral internal sphincterotomy: up to the dentate line or up to the fissure apex? Chronic fissure-in-ano: a randomized study comparing open and subcutaneous lateral internal sphincterotomy. [Surgical or biologic sphincterotomy in the treatment of chronic anal fissure]. Manual dilatation of the anus vs. lateral subcutaneous sphincterotomy in the treatment of chronic fissure-in-ano. Results of a prospective, randomized, clinical trial. Unilateral versus bilateral lateral internal sphincterotomy: a randomized controlled trial for chronic fissure in ano. Anal sphincter function after treatment of fissure-in-ano by lateral subcutaneous sphincterotomy versus anal dilatation. A randomized study. Topical 0.5% nifedipine vs. lateral internal sphincterotomy for the treatment of chronic anal fissure: long-term follow-up. Comparison of controlled-intermittent anal dilatation and lateral internal sphincterotomy in the treatment of chronic anal fissures: a prospective, randomized study.
We compare lateral internal sphincterotomy as an effective treatment of chronic fissure in ano to fissurectomy, which is as an alternative surgical treatment.
                Sixty two consecutive patients were divided into two groups through sequential sampling. Thirty patients underwent fissurectomy and 32 underwent lateral internal sphincterotomy. After a median follow-up of 22 months, we compared the results of the two procedures. In addition to frequent visits on a predetermined basis, a telephone inquiry into fissure recurrence and continence status was made.
                All patients in both groups were pain-free and without bleeding within 1 week. In both groups, urinary retention was noted in one patient. Incontinence to flatus was noted in the fissurectomy (F) group in two (6.2%) patients, but no incontinence was noted in the lateral internal sphincterotomy (LIS) group. There was one patient (3.1%) with fissure recurrence in the F group but none in the LIS group. No patient in either group was afflicted with anal stenosis or perianal infections. All wounds healed within 8 weeks. Twenty nine patients (96.6%) in the LIS group and 28 (87.5%) in the F group reported satisfactory results with their procedure.
                In the surgical treatment of chronic anal fissure not responding to conservative management, LIS may be the better treatment and, perhaps, the preferable surgical technique with fewer total complications (P < 0.005). The gold standard surgical treatment of chronic anal fissure is lateral internal sphincterotomy which lowers the resting anal pressure and effectively heals the majority of fissures. Local application of 0.2% glyceryl trinitrate ointment has been used as an agent for chemical sphincterotomy, causing temporary alleviation of sphincter spasm and allowing the fissure to heal without compromising the anal continence. The aim of the present study was to compare the results of surgical sphincterotomy with that of local 0.2% glyceryl trinitrate ointment in the treatment of chronic anal fissure. Seventy adult patients between the age of 18 and 50 years with chronic anal fissure were randomized in a prospective trial to receive either surgical sphincterotomy or 0.2% glyceryl trinitrate ointment locally. Patients were followed up at 2 weeks' interval for 10 weeks. Symptom relief, fissure healing and continence scores were the outcomes assessed. Six patients were excluded for protocol violations. Surgical sphincterotomy was significantly more effective in providing pain relief and was associated with significantly better fissure healing rates at 6 weeks and 10 weeks (both p < 0.001). There were substantial problems with compliance in ointment group related to slow healing and longer time needed for symptomatic relief. Minor incontinence was 6% in sphincterotomy group and none in ointment group (p > 0.05). Considering early symptomatic relief, rapid fissure healing and better patient compliance surgical sphincterotomy is the treatment of choice for chronic anal fissure. Internal sphincterotomy remains the standard for treatment of anal fissure, but it is associated with risks of infection, bleeding, and incontinence. Recent studies have suggested that the complications after lateral internal sphincterotomy are related to surgical technique. This study was designed to assess the incidence of early and late complications after lateral internal sphincterotomy with marginal sutured incision. Fissure healing, pain, and complications were compared in patients undergoing a procedure involving three interrupted marginal sutures after open lateral internal sphincterotomy procedure.
                Ninety patients of chronic anal fissure were randomly assigned to two groups. Both groups received open lateral internal sphincterotomy via standardized method. The incisions of the patients in Group 1 (n=45) were sutured marginally with three interrupted sutures using 2-0 chromic catgut, whereas the incisions of the patients in Group 2 (n=45) were left open. The patients were assessed at 12 weeks postoperatively by an independent observer.
                The fissure-healing rate was not significantly different in both groups (95 and 93.1 percent, respectively). The pain score was slightly higher in Group 2, and it was statistically significant. Four cases of bleeding and two abscesses were observed in Group 2. These complications were not observed in Group 1. One case of incontinence was observed at the beginning in Group 1 and four in Group 2, but the incontinence was transient in both cases.
                Marginal sutures of incision after lateral internal sphincterotomy may be beneficial to reduce complications related to early wound healing. The aim of this prospective randomized trial was to compare the effectiveness and morbidity of open and closed sphincterotomy performed as an outpatient procedure under local anesthesia in the treatment of chronic anal fissure.
                Eighty patients with chronic anal fissure were treated by open (group 1) or closed lateral internal sphincterotomy (group 2). Clinical and manometric results were recorded at the time of admission and at 1-week, 2-month, 6-month, 1-year, and 2-year followup visits.
                Overall healing after 2 years was 92.5% in the open sphincterotomy group and 90% in the closed sphincterotomy group (p > 0.05). Fissures were notably less likely to heal in patients in whom the condition had been present for longer than 12 months and who had a sentinel pile before treatment. At the 2-year revision, incontinence was present in two patients (5%) in the open sphincterotomy group and one patient (2.5%) in the closed sphincterotomy group (p > 0.05). In all cases, the incontinence was mild (<4, Cleveland score). Increased mean resting pressure (113.9 mmHg) was found in patients with anal fissure before treatment compared with the healthy control group (mean resting pressure = 66 mmHg) (p < 0.001). The mean resting pressure in patients cured after 2 years was 75.65 mmHg, and in those with a recurrent fissure was 112.85 mmHg (p < 0.001).
                Morbidity and recurrence were similar in open and closed sphincterotomies when the procedures were performed under local anesthetic, and sphincterotomy under local anesthesia as an outpatient procedure has several socioeconomic advantages (high degree of satisfaction and comfort to the patient, rapid solution of the problem, and no admission to the hospital or an operating room and no preoperative studies). A prospective randomised study compared anal dilatation (n = 37), posterior internal sphincterotomy (n = 21) and lateral sphincterotomy (n = 20) in the surgical treatment of chronic anal fissures in 78 consecutive patients. All the operations were performed under general anaesthesia using standard techniques. Anal dilatation relieved anal pain early (immediate relief in 57% of patients; the mean pain-days +/- SD of 3.2 +/- 5.4 days). Anal fissures after this operation healed in a mean time +/- SD of 20.3 +/- 12.5 days, coming in second place to lateral sphincterotomy. Anal dilatation was followed by insignificant wound infection but its main disadvantage was a high rate of post operative anal incontinence (in 24.3% of patients). Fissurectomy and posterior internal sphincterotomy was followed by the longest period of post operative anal pain (mean +/- SD of 32.4 +/- 10 days) as compared to the other two operations. It was the least favourable operation. Lateral sphincterotomy was followed by early relief of pain (immediate relief in 95% of patients). It was not followed by wound infection. It had the quickest healing time for the fissures (a mean +/- SD of 14.7 +/- 8.7 days). It was followed by anal incontinence in only one patient. In conclusion lateral sphincterotomy was the most favourable operation and it is perhaps the operation of choice to perform in patients with chronic anal fissures needing surgical treatment. Anal fissure is a frequent proctologic disease. There are many and various treatments adopted to cure this disease. In this study we applied radiofrequencies to the subcutaneous lateral internal sphincterotomy and we compared the techniques in a randomised trial.
                Patients have been randomized in two groups: in group A 18 patients underwent subcutaneous lateral internal sphincterotomy using radiofrequency bistoury while in group B 17 patients underwent the conventional lateral internal sphincterotomy described by Parks.
                The mean values for operative time were 6.6 min for group A and 9.1 min for group B. According to pain score, patients' mean values were 1.8 for group A and 1.9 for group B. Healing of the wound was faster in group A than group B, while healing of the anal fissure was approximately the same.
                Lateral subcutaneous sphincterotomy is the most advantageous operation for the treatment of the idiopathic anal fissure. The radiofrequency bistoury easies the procedure, lessens operating times and healing process of the surgical wounds. The extent of sphincter division by the subcutaneous or the open technique is examined by comparing the change in anal canal pressure after either method of sphincterotomy in twenty-eight patients with chronic anal fissure randomly allocated. In all patients the fissures healed at one month with significant reduction (P less than 0.01) of anal canal pressures to 52 (17-75) cmH2O after subcutaneous and 47.5 (35-100) cmH2O after open sphincterotomy, a 51 (22-77) and 50 (11-68) per cent reduction of their respective pre-operative measurements. Adequate sphincterotomy can be achieved by both techniques. Topical nitroglycerin (GTN) is one of the medical treatments of choice in chronic anal fissure. The present prospective, randomized, clinical trial was conducted to study the symptomatic relief, healing, and changes in the maximum anal resting pressure (MARP) in patients with chronic anal fissure comparing topical GTN and lateral sphincterotomy.
                Forty consecutive patients with chronic anal fissure were randomized for treatment with either topical GTN or internal sphincterotomy (20 patients in each group). Anal manometry was done before treatment in all patients, and 1 h after application of GTN or sphincterotomy. Patients were followed at 2-weekly intervals for 6 weeks for symptomatic relief and healing.
                Both GTN and sphincterotomy brought about a highly significant, but comparable drop in the MARP after treatment (P < 0.0001 in both groups). Sphincterotomy relieved pain much earlier compared to GTN (70% vs 40% at 2 weeks, P = 0.0032); but after 4 weeks of treatment, pain relief in both groups was comparable. Healing in the sphincterotomy group was also earlier than with GTN (55% vs 0% at 2 weeks, P < 0.0001; and 85% vs 30% at 4 weeks, P < 0.0001); but after 6 weeks, healing in both groups was comparable. Sphincterotomy had a significant incidence of minor, short-term complications; it also required surgical expertise, theatre time, and day-care beds. Nitroglycerin is safe, with mild and tolerable side-effects of headache and local burning sensation.
                Topical GTN should be the initial treatment in chronic anal fissure. Lateral sphincterotomy should be reserved for patients with severe disabling pain (because pain relief is much faster), and for patients not responding to at least 4 weeks of GTN therapy. This study was designed to assess differences between lateral internal anal sphincterotomy and anal advancement flap for chronic anal fissure.
                Forty patients with chronic anal fissure were prospectively studied. Patients randomized to the sphincterotomy group (n = 20; median age, 34 (range, 16-61) years) underwent lateral internal anal sphincterotomy. Patients randomized to the flap group (n = 20; median age, 32 (range, 20-44) years) had an anal advancement flap.
                All fissures in the sphincterotomy group healed following surgery compared with three patients that failed to heal in the flap group (P = 0.12). No patient in either group was incontinent to any degree following surgery. Patient satisfaction with surgery was similar in both groups.
                Anal advancement flap is an alternative to lateral sphincterotomy for chronic anal fissure. This was a multicenter, randomized, controlled trial to compare the effectiveness of topical nitroglycerin with internal sphincterotomy in the treatment of chronic anal fissure.
                Patients with symptomatic chronic anal fissures were randomly assigned to 0.25 percent nitroglycerin tid or internal sphincterotomy. Both groups received stool softeners and fiber supplements and were assessed at six weeks and six months.
                Ninety patients were accrued, but 8 were excluded from the analysis because they refused internal sphincterotomy after randomization (6), the fissure healed before surgery (1), or a fissure was not observed at surgery (1). There were 38 patients in the internal sphincterotomy group (22 males; mean age, 40.3 years) and 44 patients in the nitroglycerin group (15 males; mean age, 38.7 years). At six weeks 34 patients (89.5 percent) in the internal sphincterotomy group compared with 13 patients (29.5 percent) in the nitroglycerin group had complete healing of the fissure (P = 5x10(-8)). Five of the 13 patients in the nitroglycerin group relapsed, whereas none in the internal sphincterotomy group did. At six months fissures in 35 (92.1 percent) patients in the internal sphincterotomy group compared with 12 (27.2 percent) patients in the nitroglycerin group had healed (P = 3x10(-9)). One (2.6 percent) patient in the internal sphincterotomy group required further surgery for a superficial fistula compared with 20 (45.4 percent) patients in the nitroglycerin group who required an internal sphincterotomy (P = 9x10(-6)). Eleven (28.9 percent) patients in the internal sphincterotomy group developed side effects compared with 37 (84 percent) patients in the nitroglycerin group (P<0.0001). Nine (20.5 percent) patients discontinued the nitroglycerin because of headaches (8) or a severe syncopal attack (1).
                Internal sphincterotomy is superior to topical nitroglycerin 0.25 percent in the treatment of chronic anal fissure, with a high rate of healing, few side effects, and low risk of early incontinence. Thus, internal sphincterotomy remains the treatment of choice for chronic anal fissure. This prospective, randomized, controlled trial was designed to compare the clinical, functional, and morphologic results of pneumatic balloon dilatation with lateral internal sphincterotomy for the treatment of chronic anal fissure.
                All patients with symptomatic chronic anal fissure were randomly assigned to pneumatic balloon dilatation or lateral internal sphincterotomy and invited to complete a standardized questionnaire inquiring about their symptoms. Anal ultrasonography and anal manometry were performed before and six months after surgery. A proctologic examination was performed between the fifth and sixth postoperative weeks. Anal continence, scored by using a validated continence grading scale, was evaluated preoperatively at 1 and 6 weeks and at 12 and 24 months.
                Fifty-three patients, who satisfied selection criteria, were enrolled in the trial. Four patients (7.5 percent) were lost to follow-up. Twenty-four patients (11 males; mean age, 42 +/- 8.2 years) underwent pneumatic balloon dilatation and 25 patients (10 males; mean age, 44 +/- 7.3 years) underwent lateral internal sphincterotomy. Fissure-healing rates were 83.3 percent in the pneumatic balloon dilatation and 92 percent in the lateral internal sphincterotomy group. Recurrent anal fissure was observed in one patient (4 percent) after lateral internal sphincterotomy. At anal manometry, mean resting pressure decrements obtained after pneumatic balloon dilatation and lateral internal sphincterotomy were 30.5 and 34.3 percent, respectively. After pneumatic balloon dilatation, anal ultrasonography did not show any significant sphincter damage. At 24-month follow-up, the incidence of incontinence, irrespective of severity, was 0 percent in the pneumatic balloon dilatation group and 16 percent in the lateral internal sphincterotomy group (P < 0.0001).
                As lateral internal sphincterotomy, pneumatic balloon dilatation grants a high anal fissure-healing rate but with a statistically significant reduction in postoperative anal incontinence. Troublesome fecal incontinence following a lateral internal sphincterotomy is often attributed to faulty surgical technique. However, it may be associated with coexisting occult sphincter defects. Whether continence is related to the extent of sphincterotomy remains debatable. The aim of the study is to identify fecal incontinence related to chronic anal fissure before and after lateral internal sphincterotomy and its relationship to the extent of internal anal sphincter division.
                One hundred eight patients with chronic anal fissure were prospectively studied before and after lateral internal sphincterotomy. A questionnaire was completed for each patient before and after surgery with regard to any degree of fecal incontinence. Fecal incontinence severity index was assessed using the Cleveland Clinic Incontinence Score. The patients with preoperative perfect continence were randomized into two groups (46 patients in each group): Group 1 underwent traditional lateral internal sphincterotomy (up to the dentate line) and Group 2 were underwent a conservative internal anal sphincterotomy (up to the height of the fissure apex or just below it).
                Minor degrees of incontinence were present before surgery in 16 patients (14.8%). Results of the randomized trial revealed that temporary postoperative incontinence was newly developed in 6/92 of patients (6.52 %) who did not have it before surgery. Five of the six (10.86%) were in Group 1 one (2.17%) was in Group 2 (p = 0.039). Persistent incontinence occurred in two in Group 1 (4.35%). All of them were females. All have had a history of one or more vaginal deliveries.
                A mild degree of fecal incontinence may be associated with chronic anal fissure at presentation rather than as a result of internal sphincterotomy. Troublesome fecal incontinence after lateral internal sphincterotomy is uncommon. Sphincterotomy up to the dentate line provided faster pain relief and faster anal fissure healing, but it was associated with a significant postoperative alteration in fecal incontinence than was sphincterotomy up to the fissure apex. Care should be exercised in female patients with a history of previous obstetric trauma, as internal anal sphincter division may further compromise sphincter function. To compare outcomes 24 months after treatment of chronic anal fissure with 0.2% glyceryl trinitrate ointment (GTN) or lateral internal sphincterotomy.
                Prospective, randomised trial.
                One teaching, one private, and 3 district hospitals, U.K.
                Seventy patients were randomised into two groups of 35 each to use 0.2% GTN ointment or have a lateral internal sphincterotomy.
                Resolution of symptoms and healing of fissures assessed after 24 months.
                All those operated on were initially cured but one fissure recurred after 8 months. Nineteen of 35 fissures treated with GTN healed. The remaining 16 patients randomised to use GTN ointment whose fissures did not heal were then treated by sphincterotomy. Three patients whose fissures healed successfully with GTN developed recurrences within 6 months of completing treatment. The remaining 16 of 19 patients treated with GTN whose fissures healed were free of symptoms with no clinical evidence of recurrence after 24 months follow-up.
                Many anal fissures heal with topical treatment with GTN. Lateral internal sphincterotomy remains effective but should be reserved for patients who fail to respond to initial chemical sphincterotomy. The aim of this randomized, prospective study was to compare the results of lateral internal sphincterotomy up to the dentate line or up to the fissure apex in the treatment of chronic anal fissure.
                Adult patients with chronic anal fissure were randomly assigned to undergo lateral internal sphincterotomy to the level of the dentate line or to the level of the fissure apex. The patients were reexamined on postoperative Days 1, 7, 14, 28, and then at 2 and 12 months.
                The time required for relief of pain postoperatively was 2.08 +/- 1.44 days in the dentate line group, which was significantly shorter than that for the fissure apex group (4.72 +/- 4.86 days; P = 0.002). Objective healing was achieved in 23.7 percent and 17.6 percent at 14 days, 97.4 percent and 88.2 percent at 28 days, and 100 percent and 97.7 percent at 2 months in the dentate line and fissure apex groups, respectively (P > 0.05 for all comparisons). Only sphincterotomy up to the dentate line caused a significant change in anal incontinence (P = 0.016). Both groups had significantly lower anal resting pressures at 4 months postoperatively, compared with their corresponding preoperative levels (P = 0.005 and P = 0.007). The postoperative resting pressures did not differ significantly between the two groups (P = 0.273). By 12 months postoperatively, no treatment failures or recurrences were noted in the dentate line group (100 percent healing rate). In the fissure apex group, there was one nonhealing case and four recurrences, resulting in a 13.2 percent rate of treatment failure (P = 0.058).
                Sphincterotomy up to the dentate line provided a faster and definitive healing within the time limits of this study, but it was associated with a significant alteration in anal continence. In turn, sphincterotomy up to the fissure apex was free of significant disturbance of continence, but its healing effect was slower and it was prone to an insignificantly higher rate of treatment failure. A prospective study comparing open and subcutaneous lateral internal sphincterotomy for chronic anal fissure was conducted. One hundred twelve patients were randomized to open (n = 54) or subcutaneous (n = 58) sphincterotomy. There was no significant difference in acute complications between the subcutaneous (8.6 percent) and open (7.4 percent) groups. Postoperative length of stay was significantly shorter for the subcutaneous group (1.7 +/- 0.2 days) than for the open group (2.3 +/- 0.1 days; P less than 0.001). Although the response rate to a pain questionnaire was less than 50 percent, the data suggest a lower level of postoperative pain in the subcutaneous group. Fissure healing was similar between the subcutaneous (96.6 percent) and open (94.4 percent) groups. We conclude that subcutaneous lateral internal sphincterotomy for chronic fissure-in-ano is effective and may result in significantly less postoperative discomfort, shorter postoperative lengths of stay, and a comparable rate of complications compared with the open technique. Chronic anal fissure is a lineal ulcer of the lower part of the anal canal. It is a painful condition characterized by postdefecational pain and bleeding. It is associated with internal anal sphincter spasm. The relief of internal anal sphincter spasm is the key for providing fissure healing. Gold standard in the treatment of chronic anal fissure is partial lateral internal anal sphincterotomy.
                Sixty patients with chronic anal fissure were randomly assigned into two groups treated either by surgical sphincterotomy or injections of botulinum toxin into internal anal sphincter. Manometric measurements were performed before and three months after treatment. Follow up period was six months. The aim of the study was to compare results between these two groups.
                Both methods efficiently reduced resting anal pressure and successfully healed chronic anal fissure.
                Surgical and biologic sphincterotomy are almost equally effective in the treatment of chronic anal fissure. Injecting botulinum toxin into internal anal sphincter is a safe, easy to apply and effective method in the management of anal fissure. The results of a prospective randomized trial in 111 patients were recorded to compare manual dilatation of the anus with lateral subcutaneous sphincterotomy performed under general anesthesia. There was no significant difference in the clinical results nor in the incidence of complications. Persistent or recurrent fissure occurred in three of 59 patients after manual dilatation of the anus and two of 39 patients after lateral subcutaneous sphincterotomy, an incidence of 5.1 percent in each group. Only one patient developed serious impairment of continence, and this occurred following lateral subcutaneous sphincterotomy (5.1 percent). Standard treatment for Chronic Anal Fissure (CAF) is unilateral Internal Sphincterotomy (UIS). Still there is recurrence and the risk of of incontinence. Bilateral Internal Sphincterotomy (BIS) as a treatment for CAF has not been adequately evaluated.
                A prospective randomized controlled trial of UIS at 3 o'clock compared with BIS at 3 and 9 'O' clocks. The outcome variables were: post operative pain, recurrence and incontinence.
                There was 104 and 107 cases in UIS and BIS group respectively with similar age and sex. There were 12 recurrences in UIS and only one in the BIS group (p < 0.001) with no change in the continence. BIS group had less pain (p < 0.001).
                BIS for CAF resulted in less postoperative pain, lower recurrence with no increase in the incontinence. However, further study is required with pre and post operative anal manometry. Twenty patients with chronic anal fissure were randomized into two groups. Ten patients were treated with lateral subcutaneous sphincterotomy and 10 with anal dilatation. Anal dilatation was carried out preoperatively, and at 1 and 3 months after the operation in all patients. Preoperatively there was a significantly increased maximal resting pressure in the 20 fissure patients (80 mmHg median) compared with 20 control subjects (50 mmHg median). Postoperatively a significant decrease in pressure occurred in the dilated group (49 mmHg median p less than 0.05), whereas the pressure was not significantly reduced in the group that underwent sphincterotomy (65 mmHg median p less than 0.05). At 1 year three patients complained of recurrent symptoms of anal fissure in the dilated group compared with one in the sphincterotomy group. Minor continence disturbance was noted in two patients in both groups. The aim of this study was to compare the efficacy of the local application of 0.5% nifedipine ointment vs. lateral internal sphincterotomy in the healing of chronic anal fissure.
                Sixty-four patients with symptomatic chronic anal fissures were randomly assigned to 0.5% nifedipine ointment (n=32) every 8 h for 8 weeks or lateral internal sphincterotomy (n=32). Both groups received stool softeners and fiber supplements and were assessed at 2, 4, 6, and 8 weeks. Long-term outcomes were determined after a median follow-up of 19 months (nifedipine group) and 20.5 months (lateral internal sphincterotomy group).
                Complete healing at 8 weeks was achieved in 30 out of 31 patients (96.7%) in the nifedipine group and 32 out of 32 patients (100%) in the lateral internal sphincterotomy group (p=0.49). The overall healing rates at the end of follow-up were 28 out of 30 (93%) vs. 32 out of 32 (100%) in the nifedipine and sphincterotomy groups respectively (p=0.48). Two of the 30 patients in the nifedipine group relapsed whereas none in the sphincterotomy group did. Sixteen patients (50%) developed side effects in the nifedipine group, compared with six patients (18.7%) in the sphincterotomy group.
                Topical application of 0.5% nifedipine ointment represents a new, promising, easily handled, effective alternative to lateral internal sphincterotomy. The results of controlled-intermittent anal dilatation (CIAD) or lateral internal sphincterotomy (LIS) in the treatment of chronic anal fissures are presented.
                Forty patients who were randomized to two groups underwent CIAD or a LIS. The pre- and post-operative mean anal canal resting pressures (MACRPs) and symptoms were recorded and the results were compared.
                Two months post-operatively, 18 patients in the CIAD group and 17 patients in the LIS group had healed completely, and had no anal incontinence or other complications. The post-operative improvement in pain, bleeding, and constipation did not differ significantly between the two groups. In the CIAD and LIS groups, the pre-operative MACRPs were 89.7+/-16.5 and 87.6+/-12.3 mmHg, respectively; 2 months post-operatively, the MACRPs had significantly decreased to 76.9+/-13.7 and 78.1+/-11.3 mmHg in the CIAD and LIS groups, respectively. No statistical difference existed in the pre- or post-treatment MACRPs between the groups.
                CIAD applied with a standardized technique reduced anal canal resting pressure and provided symptomatic healing that was equivalent to a LIS. Since there were no findings of incontinence, or situations which resulted in sphincter damage, we conclude that CIAD is suitable for patients with chronic anal fissures because it is less invasive than LIS, with equivalent efficacy and safety. In addition, the CIAD method may be an alternative procedure in older and multiparous women who has a higher risk of incontinence.
Manual anal stretch 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. Bilateral internal sphincterotomy shows promise, but needs further research into its efficacy.