Almost half of all patients in whom an acute anal fissure has been diagnosed will heal with nonoperative measures, ie, sitz baths, psyllium fiber and bulking agents, with or without the addition of topical anesthetics or anti-inflammatory ointments. 1– 6 In addition to fissure healing, symptomatic relief of pain and bleeding can be achieved with virtually no side effects.
2. Anal fissures may be treated with topical nitrates, although nitrates are marginally superior to placebo with regard to healing. Grade of Recommendation: Strong recommendation based on high-quality evidence 1A
Topical nitric oxide donors have been associated with healing in at least 50% of treated chronic fissures, 7–13,18 –21 and use of topical nitroglycerin significantly decreases pain during the therapy period. 7,9,16 An updated Cochrane review of medical treatment of anal fissures has concluded, however, that topical nitroglycerin remains only marginally better than placebo in healing anal fissures. 22 Dose escalation does not improve healing rates. 7,14,16 The principal side effect is headache, occurring in at least 20% to 30% of treated patients. 7,17,22 This adverse effect is dose-related and causes cessation of therapy in up to 20% of patients. 15 The incidence of fissure recurrence after treatment with topical nitric oxide donors is dramatically higher 7,8 compared with outcomes after surgery, although morbidity is lower. 8,10,12 Patients who do not respond to topical nitrates should be referred for botulinum toxin injections or surgery. 7,8,10
3. Anal fissures may be treated with topical calcium channel blockers, with a lower incidence of adverse effects than topical nitrates. There are insufficient data to conclude whether they are superior to placebo in healing anal fissures. Grade of Recommendation: Strong recommendation based on moderate-quality evidence 1B
Topical calcium channel blockers have been associated with healing of chronic anal fissures in 65% to 95% of patients. 24 –31 Side effects include headache, in up to 25% of patients, 29 and occur less frequently than with topical nitrates. 27–29 There are still fewer randomized controlled trials of topical calcium channel blockers than of topical nitric oxide donors. Anal fissures may also be treated with oral calcium channel blockers. 32–35 This is associated with a lower rate of fissure healing than topical application and has a higher incidence of side effects. 32 Few direct comparisons of topical and oral calcium channel blockers exist.
4. Botulinum toxin injection has been associated with healing rates superior to placebo. There is inadequate consensus on dosage, precise site of administration, number of injections or efficacy. Grade of Recommendation: Strong recommendation based on low-quality evidence 1C
Injection of botulinum toxin into the internal anal sphincter allows healing in 60% to 80% of fissures, 36,39,41,43,45,46 and at a higher rate than placebo. 42 The most common side effects are temporary incontinence to flatus in up to 18% of patients 38,39,42,45 and stool in 5%. 49 Recurrences may occur in up to 42% of cases, 38,39,46,47 but patients may be re-treated with a good rate of healing. 39,44 Higher doses are associated with improved rates of healing and are as safe as lower doses. 39,44 Topical nitrates appear to potentiate the effects of botulinum toxin in patients with refractory anal fissure. 37,48 There is no consensus on dose, site, or number of injections. 40,47 Patients in whom botu linum toxin injection therapy fails should be recommended for surgery. 40
There are few reports regarding the use of gonyautoxins for treatment of anal fissure. We have intentionally not included this treatment modality because of the paucity of data and the widespread unavailability of these agents.
5. Lateral internal sphincterotomy is the surgical treatment of choice for refractory anal fissures. Grade of Recommendation: Strong recommendation based on high-quality evidence 1A
Lateral internal sphincterotomy (LIS) remains the surgical treatment of choice for refractory anal fissures. 22,49 Multiple studies 50 –53 and a recent Cochrane re view 54 show that LIS is superior to uncontrolled manual anal dilation, yielding superior healing rates with less incontinence. Controlled pneumatic balloon dilation has shown promise in one small series. 55 LIS offers superior healing and lower incontinence rates compared with posterior sphincterotomy-fissurectomy alone. 56 The addition of topical nitric oxide donors 57 or botulinum toxin 58–60 improves results of fissurectomy in nonrandomized series.
6. Open and closed techniques of lateral internal sphincterotomy (LIS) yield similar results. Grade of Recommendation: Strong recommendation based on highquality evidence 1A
Further well-done studies confirm the prior assertion that there is no difference in outcomes between properly performed open or closed sphincterotomy. 54,61– 64
7. LIS tailored to fissure characteristics yields equivalent or worse healing rates, and less incontinence, than traditional LIS to the dentate line. Grade of Recommendation: Weak recommendation based on moderate equality evidence 2B
A “tailored sphincterotomy” has been proposed in an effort to reduce the rate of minor incontinence following LIS. Two methods are typically employed—sphincterotomy only to the apex of the fissure or anal calibration. Three randomized trials of traditional vs fissure apex sphincterotomy show statistically superior healing rates in the traditional arm; 2 reported worse continence in the traditional arm, 65,66 whereas one did not. 67 To improve these results, a calibrated sphincterotomy has been reported. In these studies, fissure apex sphincterotomy was compared with a sphincterotomy that was extended based on the amount of residual anal stenosis remaining by use of a calibrated sound. In 3 small series, this method showed equivalent healing and lower incontinence rates than traditional sphincterotomy. 68 –70
8. Anal advancement flap and subcutaneous fissurotomy are surgical alternatives to LIS. Grade of Recommendation: Weak recommendation based on low-quality evidence 2C
Techniques that do not divide the internal anal sphincter yet allow good healing rates are theoretically attractive, especially in patients with preexisting continence problems or in those without internal anal sphincter hypertonia. Small series of various anal advancement flaps show promise. 71,72 One series of unroofing subcutaneous sinuses associated with typical anal fissures reported excellent healing without changes in continence. 73 Larger trials in this area are still needed.
9. Surgery is consistently superior to medical therapy and may be offered without a pharmacological treatment failure. Grade of Recommendation: Strong recommendation based on high-quality evidence 1A
Multiple trials continue to confirm the superiority of LIS to any topical or injected agent with low rates of incontinence. 10,46,74 –78 Most investigations show that compliance with long-term medical therapy remains an issue. The Cochrane Collaboration analyses of both surgical and nonsurgical therapies for anal fissure confirm these conclusions. 22,54 Quality of life (QOL) is poor in patients with persistent fissure, whereas patients undergoing LIS report significantly improved QOL. Fecal continence QOL is preserved in the vast majority of patients following LIS. 79–81
The practice parameters set forth in this document have been developed from sources believed to be reliable. The American Society of Colon and Rectal Surgeons makes no warranty, guarantee, or representation whatsoever as to the absolute validity or sufficiency of any parameter included in this document, and the Society assumes no responsibility for the use of the material contained.
Appendix A: Contributing Members Of The ASCRS Standards Committee
Farshid Araghizadeh, M.D., Robin Boushey, M.D., Sridhar Chalasani, M.D., George Chang, M.D., Robert Cima, M.D., Gary Dunn, M.D., Daniel Feingold, M.D., Philip Fleshner, M.D., Daniel Geisler, M.D., Jill Genua, M.D., Sharon Gregorcyk, M.D., Daniel Herzig, M.D., Andreas Kaiser, M.D., Ravin Kumar, M.D., David Larson, M.D., Steven Mills, M.D., John Monson, M.D., P. Terry Phang, M.D., Feza Remzi, M.D., David Rivadeneira, M.D., Howard Ross, M.D., Peter Senatore, M.D., Elin Sigurdson, M.D., Thomas Stahl, M.D., Scott Steele, M.D., Scott Strong, M.D., Charles Ternent, M.D., Judith Trudel, M.D., Madhulika Varma, M.D., Martin Weiser, M.D.
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