title: Adequate internal sphincterotomy for chronic anal fissure: Subcutaneous or open technique? A prospective randomized trial betwen subcutaneous lateral internal sphincterotomy with radiofrequency bistoury and conventional parks' operation in the treatment of anal fissures. Open vs. Closed Lateral Internal Sphincterotomy for Idiopathic Fissure-in-Ano: A Prospective, Randomized, Controlled Trial Anal sphincter function after treatment of fissure-in-ano by lateral subcutaneous sphincterotomy versus anal dilatation Preoperative Intensive, Community-Based vs. Traditional Stoma Education: A 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 Anal dilatation versus left lateral sphincterotomy for chronic anal fissure: a prospective randomized study Surgical treatment of chronic fissure-in-ano: a prospective randomised study. Removal of hypertrophied anal
  papillae and fibrous anal polyps increases patient satisfaction
  after anal fissure surgery Chronic fissure-in-ano: A randomized study comparing open and subcutaneous lateral internal sphincterotomy Effects of Warm Water Sitz Bath on Symptoms in Post-anal Sphincterotomy in Chronic Anal Fissure—A Randomized and Controlled Study Incontinence After Lateral Internal Sphincterotomy: A Prospective Study and Quality of Life Assessment A prospective, randomized, controlled trial of primary wound closure after lateral internal sphincterotomy. 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 anal fissures under local anesthesia. Lateral subcutaneous sphincterotomy versus anal dilatation in the treatment of fissure in ano in outpatients: a prospective randomised study. Lateral sphincterotomy compared with anal advancement flap for chronic anal fissure Anterior Levatorplasty for the Treatment of Chronic Anal Fissures in Females With a Rectocele: A Randomized, Controlled Trial A randomized controlled trial to compare anal dilatation with lateral subcutaneous sphincterotomy for 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. Extent of Lateral Internal Sphincterotomy: Up to the Dentate Line or Up to the Fissure Apex? Pneumatic Balloon Dilatation for Chronic Anal Fissure: A Prospective, Clinical, Endosonographic, and Manometric Study Faecal incontinence in patients with anal fissure: a consequence of internal sphincterotomy or a feature of the condition?
abstract: 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 r and omly allocated . In all patients the fissures healed at one month with significant reduction ( P < 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 BACKGROUND 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 r and omised trial . METHODS Patients have been r and omized 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 .  RESULTS 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 . CONCLUSION 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 PURPOSE : Internal sphincterotomy remains the “ gold st and ard ” for treatment of anal fissure but is associated with a risk of imperfect continence . Recent studies have suggested that surgical technique ( open vs. closed ) may influence incontinence rates after sphincterotomy . This study was design ed to assess the short-term and long-term incidence of incontinence after open and closed internal sphincterotomy . METHODS : Seventy-nine patients were r and omly assigned to open or closed internal sphincterotomy  , performed in st and ardized fashion by trainee staff . St and ardized question naires assessing continence ( modified Wexner score ) were administered preoperatively and at 1 , 6 , and 52 weeks . Postoperative stay , pain scores , complications , and fissure healing were prospect ively assessed by an independent observer . RESULTS : Three patients were lost to follow-up , leaving 36 closed ( 16 males ; mean age , 45.1 years ) and 40 open ( 21 males ; mean age , 47.9 years ) internal sphincterotomy patients for assessment . All operations were performed as day case procedures with no readmissions . At six weeks postoperative , 96 percent of fissures had healed . There were no significant differences in pain scores between closed and open internal sphincterotomy at Day 1 or Day 3 postoperative . New incontinence of any grade was seen in 6.8 percent of patients at 52-week follow-up . Three patients ( 4.1 percent , 1 closed , 2 open ) suffered major incontinence at 52 weeks . There were no significant differences in continence at 1 , 6 , or 52 weeks , although more open patients experienced minor imperfections at 1 week . CONCLUSIONS : Incontinence after internal sphincterotomy is not insignificant . The technique ( closed vs. open ) does not seem to influence incontinence rates Twenty patients with chronic anal fissure were r and omized 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 medianp<0.05 ) , whereas the pressure was not significantly reduced in the group that underwent sphincterotomy ( 65 mmHg medianp<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 PURPOSE Conventional practice in colorectal surgery involves stoma education being imparted postoperatively . Proficiency in stoma management often delays patients ’ discharge following colorectal surgery . The aim of this r and omized , controlled trial was to compare preoperative intensive , community-based stoma education with conventional postoperative stoma education after elective colorectal surgery . METHODS Forty-two elective colorectal patients requiring a stoma were r and omized into an intensive preoperative teaching ( study ) or postoperative ( control ) group . Intervention for the study group included two preoperative visits in the community during which patients were taught with audiovisual aids to use and change the stoma pouching system . Goal -directed postoperative stoma education was st and ardized for both groups . Outcomes measured included time to stoma proficiency , postoperative hospital stay , unplanned stoma-related interventions in the community within six weeks of discharge , and preoperative and postoperative hospital anxiety and depression scores . Cost-effectiveness of the intervention was also evaluated . RESULTS All outcomes measured were improved in the study group , including time to stoma proficiency(5.5 vs. 9 days ; P = 0.0005 ) , hospital stay ( 8 vs. 10 days ; P = 0.029 ) , and unplanned stoma-related community interventions per patient ( median 0 vs. 0.5 ; P = 0.0309 ) . No adverse effects of the intervention were noted . The average cost saving per patient was £ 1,119 ( $ 2,104 ) for the study group compared with the control group . CONCLUSIONS Stoma education is more effective if undertaken in the preoperative setting . It results in shorter times to stoma proficiency and earlier discharge from the hospital . It also reduces stoma-related interventions in the community and has no adverse effects on patient well-being Background 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 . Methods One hundred eight patients with chronic anal fissure were prospect ively studied before and after lateral internal sphincterotomy . A question naire 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 Clevel and Clinic Incontinence Score .  The patients with preoperative perfect continence were r and omized 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 ) . Results Minor degrees of incontinence were present before surgery in 16 patients ( 14.8 % ) . Results of the r and omized 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 .  Conclusion 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 Background Several surgical methods are accepted for the treatment of chronic anal fissure . The most popular are anal dilatation ( AD ) and left lateral sphincterotomy ( LLS ) . The objective of the current study was to prospect ively evaluate the results of these two procedures in terms of recurrence rate , complications and patient satisfaction . Methods The study enrolled all patients who required operation for chronic anal fissure in the Division of General Surgery , Campus Golda , Rabin Medical Center , between the years 1997 and 2001 . Exclusion criteria were acute anal fissure or inflammatory bowel disease . Results A total of 108 patients participated in the study , at an average age of 42.4 years ( SD=12.5 ) . The patients were r and omly assigned to two groups ; one for LLS ( 53 patients , 49.1 % ) and one for AD ( 55 patients , 50.9 % ) . The study protocol included a question naire and a physical examination performed 1 , 2 , 3 , 6 and 12 months after operation . The question naire contained questions about pain , bloody stool , incontinence for gas , fluid or hard feces , during the day or night , and soiling . The patients were also asked about their satisfaction on an analog scale from 1 to 10 . The average follow-up was 11.2 months ( SD=4.1 ) . Minor incontinence occurred in 8 patients of AD group and in 2 patients of LLS group ( p<0.005 ) . Recurrence occurred in 6 cases of the AD group and in one case of the LLS group ( p<0.003 ) . Satisfaction score was insignificantly higher in the LLS group ( 9.1±0.8 in the LLS group and 7.4±2.0 in the AD group ) . Conclusions These results suggest that LLS is the preferred method for the treatment for chronic anal fissure A prospect i ve r and omised 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 st and ard 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 Abstract . Background : Hypertrophied anal papillae and fibrous anal polyps are frequently found in association with chronic fissure in ano . Usually , no specific attention is given to them and they are considered normal findings . The present prospect i ve study was aim ed at determining whether removal of hypertrophied anal papillae and fibrous anal polyps while dealing with chronic fissure in ano confers long-term benefit to patients . Methods : Between July 1999 and December 2000 , 140 patients undergoing anal sphincterotomy  were r and omized into two groups to have their fibrous polyps and hypertrophied anal papillae either removed by radiofrequency surgery or left intact . After two years , they underwent a detailed interview by an independent , masked investigator . Results : Overall 84 % of patients who had polyp and papilla removal rated the outcome of their surgery as excellent or good in comparison to 58 % of controls . The mean satisfaction grading was 9.2 on a visual analogue scale in the treatment group compared to 8.1 in controls ( p=0.004 ) . Conclusion : Removal of hypertrophied anal papillae and fibrous anal polyps should be an essential part of treatment of chronic fissure in ano . Persistence of these structures leaves behind a sense of incomplete treatment , reducing the overall satisfaction on the part of the patient . Radiofrequency procedure is useful in eradication of these concomitant pathologies A prospect i ve study comparing open and subcutaneous lateral internal sphincterotomy for chronic anal fissure was conducted . One hundred twelve patients were r and omized 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<0.001 ) . Although the response rate to a pain question naire was < 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 Background Sitz bath is frequently recommended by physicians for a variety of anal disorders including anal fissure . The aim of the present study was to determine whether sitz bath does have any therapeutic properties improving upon a patient ’s postoperative symptoms after a closed lateral sphincterotomy . Material s and Methods Forty-six patients were r and omly assigned to receive analgesics and fiber supplement alone ( control patients ) or a twice-daily sitz bath along with identical fiber and analgesics ( sitz bath group ) . A 24-h pain score — post-defecation anal burning and symptom improvement — was evaluated on a visual analog scale ( VAS ) . Results The groups were equally matched for age , gender distribution , and duration of disease . No significant difference in mean pain score between groups ( p = 0.284 ) was noticed after one week . However , the patients from the control group experienced significant anal burning compared with patients from sitz bath group ( p < 0.0001 ) . The improvement score was higher in the sitz bath group when compared with the control group ; however , it did not reached a statistically significant level . Conclusions Patients after sphincterotomy for anal fissure receiving sitz bath experienced similar levels of pain when compared with those not receiving sitz bath . However , they reported a significant relief in anal burning and a marginally better satisfaction score and no reported adverse side effects PURPOSE : Lateral internal sphincterotomy is an effective treatment for chronic anal fissures ; however , the risk of “ incontinence ” has generated interest in pharmacologic approaches that are far less effective and may be poorly tolerated . This study was design ed to objective ly define the risk of incontinence with sphincterotomy using the Fecal Incontinence Severity Index and assess the implication s for quality of life using the Fecal Incontinence Quality of Life Scale . METHODS : A prospect i ve study was undertaken on all patients undergoing lateral internal sphincterotomy for a chronic anal fissure by a single surgeon at a university teaching hospital from January 1 , 2000 to September 30 , 2002 . All patients had failed at least six weeks of nonoperative management . Patient demographics and use of nitroglycerin were noted . The Fecal Incontinence Severity Index was measured preoperatively and at a six-week postoperative visit when fissure healing and postoperative complications were assessed . The Fecal Incontinence Quality of Life Scale was administered to patients with an incontinence score > 0 . RESULTS : Thirty-five patients ( 15 males ) underwent sphincterotomy during the study period . Thirty-one of 35 had failed nitrates : 10 because of unacceptable side effects , and 21 because of lack of efficacy . Thirty-two patients returned for their six-week postoperative visits , and two completed their question naires by telephone . One patient was lost to follow-up . Mean age was 41.2 ( range , 21–67 ) years . Thirty of 32 ( 94 percent ) evaluable fissures had healed by six weeks , one healed by three months , and the other required V-Y anoplasty . There were two minor complications . Three patients had postoperative deterioration in their continence score . Quality of life deteriorated in only one patient . CONCLUSIONS : Lateral internal sphincterotomy is a safe and effective treatment for chronic anal fissures that only occasionally impairs continence and rarely diminishes quality of life BACKGROUND Much of the  lateral internal sphincterotomy ( LIS )  complications is related to LIS incision . In this study , incisions sutured primarily or left to secondary healing after open LIS procedure are compared regarding the wound healing and complications associated with wounds . METHODS Planning a prospect i ve , r and omized clinical study , 39 patients were separated into two groups .  Open LIS was performed on both of the groups . While the incisions of the patients in group 1 ( n = 22 ) were closed with two interrupted sutures using 3 - 0 chromic catgut , the incisions of the patients in group 2 ( n = 17 ) were left open . The patients were followed up for 90 days postoperatively . RESULTS Hematoma in 1 ( 4.5 % ) , ecchymosis in 7 ( 31.8 % ) , and wound infection in 1 ( 4.5 % ) developed in patients of group 1 . In this group no significant external bleeding was seen . Wound healing duration was 15.05 + /- 5.60 days . In group 2 no hematoma developed ( P = 0.98 ) , but 2 ( 11.7 % ) ecchymoses ( P = 0.25 ) , 4 ( 23.5 % ) , wound infections ( P = 0.14 ) , and 3 ( 17.6 % ) postoperative significant external bleedings ( P = 0.07 ) were seen . Wound healing duration was 33.94 + /- 6.67 days ( P < 0.001 ) . CONCLUSIONS To achieve early wound healing , primary closure of open LIS incision is useful , but this technique has no significant effect on wound-related complications in comparison with secondary healing BACKGROUND The aim of this prospect i ve r and omized 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 . STUDY DESIGN 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 . RESULTS 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 , Clevel and 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 ) . CONCLUSIONS 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 ) OBJECTIVE To evaluate lateral sphincterotomy under a mixture of local anesthesia versus general anesthesia in the treatment of anal fissures . METHODS A r and omized clinical trial of 62 consecutive patients requiring lateral sphincterotomy was carried out at Princess Haya Al-Hussein Hospital in Jordan . One group underwent  lateral sphincterotomy under general anesthesia , while the 2nd group had topical anesthetic cream ( xylocaine 2 % ) applied followed by local anesthesia . RESULTS There were no differences between the 2 groups in terms of operating time , postoperative pain , nausea or vomiting , pain-free interval after operation , analgesia requirements or patients satisfaction with the method of anesthesia . CONCLUSION Topical anesthetics and local anesthesia can be used effectively for lateral sphincterotomy and provides an alternative to general anesthesia Fifty eight patients with idiopathic chronic anal fissure were included in a r and omised prospect i ve trial of lateral subcutaneous sphincterotomy versus simple anal dilatation carried out as outpatient procedures . Operations were performed under local anaesthesia and the patients review ed 10 - 30 months later ( median follow up time 18 months ) . Altogether 30 patients were treated by lateral subcutaneous sphincterotomy and 28 by anal dilatation .  No serious complications were observed in either group . One recurrence was observed in the group treated by sphincterotomy , whereas eight occurred in the other group ( p less than 0.05 ) . Functional results with respect to impaired control of flatus and soiling of underwear were significantly better after sphincterotomy ( p less than 0.002 ) . It is concluded that lateral subcutaneous sphincterotomy is the treatment of choice for idiopathic chronic anal fissure resistant to conservative measures PURPOSE : This study was design ed to assess differences between lateral internal anal sphincterotomy and anal advancement flap for chronic anal fissure . METHODS : Forty patients with chronic anal fissure were prospect ively studied . Patients r and omized to the sphincterotomy group ( n=20 ; median age , 34 ( range , 16–61 ) years ) underwent lateral internal anal sphincterotomy . Patients r and omized to the  flap group ( n=20 ; median age , 32 ( range , 20–44 ) years ) had an anal advancement flap . RESULTS : 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 . CONCLUSION : Anal advancement flap is an alternative to lateral sphincterotomy for chronic anal fissure PURPOSE : It is postulated that an anterior anal fissure can result from mucosal trauma occurring during distention of a rectocele and that repair of the rectocele by anterior levatorplasty can lead to healing of these anal fissures . This study was design ed to compare anterior levatorplasty with internal sphincterotomy for the management of anterior anal fissures in females with a rectocele . METHODS : From June 2000 until May 2002 , 54 consecutive females with an anterior anal fissure and a rectocele were r and omized to be managed by internal sphincterotomy or anterior levatorplasty . Preoperatively , manometry was performed , continence was measured using the Clevel and Clinic scoring system , pain scores were obtained using a visual analog scale , and the symptoms of bleeding and straining to defecate were assessed . Postoperatively , pain scores were obtained at Days 2 , 7 , and 21 . Manometry , continence scores , and resolution of symptoms were measured between 8 and 12 weeks . Patient satisfaction and fissure healing also were assessed between 8 and 12 weeks . The average length of follow-up was 20 ( range , 6–30 ) months . RESULTS : Postoperatively , lateral sphincterotomy caused a decrease in the resting pressures and anterior levatorplasty result ed in an increased length of the anal canal . Anterior levatorplasty also caused increased postoperative pain scores . There were no differences in fissure healing and patient satisfaction . CONCLUSIONS : These data suggest that anterior levatorplasty is an option for the management of patients with a rectocele , which may avoid the risk of incontinence with lateral internal sphincterotomy and better address the etiology of anterior anal fissures Summary A prospect i ve r and omized trial has compared manual dilatation of the anus ( MDA ) during general anesthesia with lateral subcutaneous sphincterotomy ( LSS ) during local anesthesia for the management of anal fissure in 156 patients . The two groups were similar with respect to age , sex and symptoms . There was no difference in the duration of time off work or early complications of treatment but , four months after operation , 93 per cent cl aim ed to have been improved by MDA compared with 78 per cent after LSS ( P<0.05 ) . Recurrent fissure was recorded in 13 patients after LSS ( 29 per cent ) compared with four ( 10 per cent ) after MDA ( P<0.02 ) . There was a significant reduction in anal pressure at four months ( P<0.02 ) after MDA , ( 123±31 to 97±33 ) and LSS ( 127±36 to 104±32 ) , but the anal pressure remained unchanged by operation in all patients where pressures were measured with recurrent fissure . These data indicate that MDA gives better results than LSS for treatment of anal fissure and that successful treatment is associated with a reduction in anal pressure The results of a prospect i ve r and omized 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 ) PURPOSE The aim of this r and omized , prospect i ve 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 . METHODS Adult patients with chronic anal fissure were r and omly 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 . RESULTS 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 , result ing in a 13.2 percent rate of treatment failure ( P = 0.058 ) . CONCLUSIONS 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 PURPOSE Pneumatic balloon dilation has been shown to be effective in the management of  chronic anal fissure  , but its effect on the anal sphincter has not been fully investigated . The aim of this study was to evaluate prospect ively the clinical , anatomic , and functional pattern in a group of patients treated by pneumatic balloon dilation .  METHODS A series of 33 consecutive patients suffering from chronic anal fissure underwent pneumatic balloon dilation .  Anal manometry and ultrasonography were performed prior to and 6 to 12 months after the treatment . Manometry was accomplished by means of an endoanal 40-mm balloon inflated with a pressure of 1.4 atmospheres that was left in situ for six minutes under local anesthesia . All patients were interviewed daily for three days after surgery and then clinical ly evaluated between the third and fifth postoperative weeks . Most patients were interviewed after 25.7 ± 8.4 months ( mean ± st and ard deviation ) . Anal incontinence was evaluated by means of a vali date d score of 1 to 6 . RESULTS The chronic anal fissure healed between the third and fifth weeks in 31 patients ( 94 percent ) , who became asymptomatic 2.5 ± 1.4 days after pneumatic balloon dilation . None of them reported anal pain two years after the treatment ( n = 20 ) . The first post-pneumatic balloon  dilation defecation was painless in 27 cases ( 82 percent ) . Two multiparous females ( 6 percent of the patients ) complained of minor transient anal incontinence ( score , 3 ) . Chronic anal fissure recurred in one case ( 3 percent ) after treatment . At manometry , the preoperative anal resting pressure decreased from 91 ± 11.2 to 70.5 ± 5.6 and to 78 ± 5.7 mmHg , 6 and 12 months after pneumatic balloon dilation , respectively ( P < 0.0001 ) . Anal ultrasonography did not show any significant sphincter defect . CONCLUSIONS Pneumatic balloon dilation seems to be an effective , safe , easy procedure that decreases anal resting pressure without endosonographically detectable significant sphincter damage BACKGROUND AND OBJECTIVE The function of the internal sphincter is disturbed in patients with chronic anal fissure due to persistent hypertonia and it may lead to a certain degree of incontinence . Our aim is to assess the results of lateral internal sphincterotomy and to identify any degree of incontinence related to the disease . METHODS This prospect i ve study included a review of all patients operated upon by the authors who performed division of the internal sphincter at or below the upper limit of the fissure .  A question naire was completed by each patient before surgery and then after surgery with regard to any degree of incontinence such as soiling of underclothes , control of flatus and accidental bowel motion . RESULTS 126 patients with chronic anal fissure were studied . The male to female ratio was 0.8:1 . Minor degrees of incontinence were present prior to surgery in 35 patients ( 28 % ) and in 31 ( 25 % ) patients after surgery , the majority of them were incontinent before surgery . CONCLUSION Based on the results of this study , minor degrees of incontinence could be a symptom of chronic anal fissure and not the sequelae of lateral internal sphincterotomy
target: 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 ab and oned 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 .
background: 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-r and omized 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 .