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139
removed. The surgeon deliberately avoids sphincterotomy. He also excises hyper-
trophied anal papillae and skin tags, and splits involved crypts and fistulas.
A sufficiently large triangle is created up to the perianal region to allow wound
drainage. The wound is then left to secondary healing. The application of this tech-
nique leads to a very low recurrence rate (Figs. 11.5, 11.6, 11.7, 11.8, 11.9, 11.10,
11.11 and 11.12).
After the first postoperative year, Wittmer et al. (2003) achieved in 97.1% of 216
patients healing without recurrence. Only 2.4% had a permanent anal continence defi-
ciency. Meier zu Eissen (2001) arrives at similar results: 3.1% of his 470 patients
operated had an anal continence deficiency. In a randomized controlled trial with a
total of 60 patients, Hancke and Schwaner (2003) compared the results in Group 1
(fissurectomy using Parks’ anal retractor for anal dilatation) with the results of Group
2, which additionally had received open lateral internal sphincterotomy. Three months
after surgery, no significant differences in the healing process were found. Group 1
patients showed incontinence to flatus in 4% of cases and soiling in 7%. Group 2
patients showed 20 and 13%, respectively. The authors demand from their colleagues
to abandon sphincterotomy because of the risk of postoperative anal incontinence.
Mousavi et al. (2009) performed fissurectomy in 30 patients and lateral sphinc-
terotomy in 32 patients. After 20 months on average, they conducted telephone
Fig. 11.5 Chronic anal fis-
sure: site of inserted Parks’
anal retractor
Line of incision
Fissure base
Subcutaneous
adipose tissue
Anoderm
Internal anal
sphincter muscle
Fig. 11.6 Extent of fissurectomy (schematic)
11.3 Surgical Treatment
140
Fig. 11.7 Chronic anal
fissure: onset of excision
outside. Wide excision of the
external skin to avoid a
transversal bridge of scar
tissue on the anal edge
Fig. 11.8 Chronic anal
fissure: excision of the lateral
portions
Fig. 11.9 Chronic anal
fissure: dissection in cranial
direction with regard to
sparing the internal anal
sphincter muscle
11 Therapy for Chronic Anal Fissure
141
Fig. 11.10 Chronic anal
fissure: resected fissure
complete with sentinel tag
and hypertrophied anal
papilla
Fig. 11.11 Chronic anal
fissure: postoperative status
with Parks’ anal retractor
Fig. 11.12 Chronic anal
fissure: postoperative status,
exterior view
11.3 Surgical Treatment
142
interviews with their patients. Eighty-seven percent of the anal fissure patients and
96% of the sphincterotomy patients were content with the results. In the first group,
6.2% of patients suffered from flatus incontinence, but 0% in the second group.
Moreover, there was one recurrency in the first group.
Rikas (2008), however, arrives at different results with 16 fissurectomy patients.
Five years after treatment, 43.75% of patients complained of incontinence problems
(Table 11.31).
In a survey on appropriate surgical therapy procedures, 88% of surgeons in
Germany said that it was fissurectomy (Kraemer et al. 1998). Fissurectomy accord-
ing to Gabriel is not even mentioned in the American guideline (Perry et al. 2010).
But in Germany, the Gabriel procedure is regarded as the therapy of choice for
patients suffering from chronic anal fissure.
Table 11.31 Details of 11 anal fissurectomy studies with 944 patients
Author
(year)
Patients
(n)
Additional
therapy
Time of
healing
(Weeks)
Healing
rate (%)
Follow-up
(Years)
Complications
(%)
Recurrence
rate (%)
Meier zu
Eissen
(2001)
381 4–5 100.0 2–6 3.0
Engel et al.
(2002)
17 ISDN oint. 10 100.0 2.5
Wittmer
et al.
(2003)
216 97.1 6.3
Hancke and
Schwaner
(2003)
15 12 73.0 11.0
Lindsey
et al.
(2004)
30 BTX ≤16 93.0 7.0
Scholz
et al.
(2007)
40 BTX 6 95.0 1 10.0
Pelta et al.
(2007)
109 Fistula 12 98.2
Baraza
et al.
(2008)
47
a
BTX 44 85.0 1–8 50.0
b
Rikas
(2008)
16 5 62.5
c
0.0
Mousavi
et al.
(2009)
30 8 2 6.0 3.1
Schornagel
et al.
(2012)
43 100.0 5 11.6
a
Women
b
Skin tags were left in situ
c
Not free of symptoms
11 Therapy for Chronic Anal Fissure
143
Conclusion
Fissurectomy according to Gabriel is the surgical method of choice because of its
high healing rates and low complication rates. Secondary healing, however, implies
a longer healing process. For the authors, this technique has been the standard pro-
cedure in the treatment of chronic anal fissure for more than 30 years.
Our experience is that the results of a consequently controlled secondary healing
process are low recurrence rates and extremely rare continence difficulties. The
surgical excision with secondary wound healing is a worldwide accepted procedure
for hemorrhoidectomy according to Milligan-Morgan. It is incomprehensible that
this principle should not apply to fissurectomy as well.
11.3.4 Anoplasty
Preliminary Notes
Only a few teams of surgeons report on this technique of surgical treatment for anal
fissure, and also the collectives presented are relatively small. This procedure uses
the advancement flap technique to cover the surgical wound to enable primary
wound healing.
In the past, the decision to apply the closed procedure for anal fissurectomy was
common, because delayed surgical intervention often led to an anal stenosis which
was induced by the anal fissure. It is also possible that the anal stenosis is a sequela
after circumferential hemorrhoid surgery, the Whitehead hemorrhoidectomy, for
example. The procedure of covering the defect reduced the danger of a recurring
anal stenosis. Owen et al. (2006) see the indication for this kind of surgery, the
“house” advancement flap anoplasty, in the presence of an anal stenosis and a defor-
mity of the anal canal after a previous surgery for anal fistula.
For De Marta and Nogueras (1997) and also Kenefick et al. (2002), the indication
for anoplasty includes both recurring and nonhealing anal fissures. Nyam et al.
(1995) and Singh et al. (2005) use anoplasty as an alternative to lateral internal
sphincterotomy or, in the case of recurrence, after lateral sphincterotomy.
Cross et al. (2008) recommend anoplasty for patients with reduced sphincter
muscle tone as an alternative to lateral sphincterotomy. The American guideline
also sees the advancement flap as an acceptable alternative to lateral internal sphinc-
terotomy with patients without sphincter hypertonicity. It is pointed out, however,
that the surgical measures for anal fissure are described only in clinical trials with a
small number of cases. Yet, the results are promising (Perry et al. 2010).
The collectives described include rarely more than 20 patients. Only Samson and
Stuart (1970) report on 2720 patients who they have operated within a period of 4
years using pedicle skin graft. This is also the earliest publication (1970) on this
technique. For the authors, the ventral position of anal fissure, an accompanying
fistula, and inflammatorily altered perianal skin are the contraindications, because
healing problems are to be expected.
Leong and Seow-Cheon (1995) recommend anoplasty for older patients to safe-
guard their anal continence, and for patients with an already evident continence defi-
ciency due to previous sphincterotomy or damage to the pudendal nerve (Table 11.32).
11.3 Surgical Treatment
144
Techniques
The majority of authors perform pedicle flap grafts either as simple sliding skin grafts
(Samson and Stewart 1970; Owen et al. 2006) or as rotational flaps (Singh et al. 2005),
while the blood vessels are supplied perianally via the nondissected base of the graft.
Singh et al. (2005) assume that the blood vessel supply is compromised in the
area of anal fissure. Well-perfused tissue is shifted intra-anally by the pedicle graft
into the fissure defect, which should lead to complete healing.
In recent years, V-Y advancement flap is performed more frequently (Kenefick
et al. 2002; Nyam et al. 1995; Leong and Seow-Choen 1995; De Marta and Nogueras
1997). This is an island pedicle graft which receives its blood supply from the sub-
cutaneous vessels. Yet, Singh et al. assume that the use of island flaps causes prob-
lems at the donor site in 60–70% of cases. Therefore, they favor the pedicle flap
graft procedure.
A particular technique is described by Case (1991), which has already been pre-
sented by Czerny in 1903, though (cf. Chap. 9.5 Historical Aspects). He uses
narrow- margin excision while sparing the sentinel tag and the enlarged papilla. In
this way, he creates a longitudinal rhombic defect which is then transversely sutured.
By doing so, he can avoid the formation of an anal stenosis. To us, however, this
procedure makes little sense because of the remaining secondary changes.
Cross et al. (2008) recommend anoplasty for patients with reduced sphincter
tonicity. Basically, this procedure is possible either as sliding skin graft, as rotation
flap or as V-Y advancement flap. They, however, advocate sliding skin graft. A vari-
ant has been recently described by Rikas (2008).
De Marta and Nogueras (1997) prefer the V-Y advancement flap technique.
Kenefick et al. (2002) recommend advancement anoplasty for persistent anal fissure
and have arrived at this medical decision after treating eight patients within 5 years.
In summary, it can be stated that the majority of authors recommend anoplasty
for particular therapeutic situations. In recent years, clinical trials were presented, in
which fissurectomy with anoplasty and additional BTX injection is compared with
lateral internal sphincterotomy. A narrow-margin excision is carried out each time,
but the authors do not tell whether all the secondary changes were removed (Aivaz
et al. 2009; Arthur et al. 2008; Chambers et al. 2010; Patel et al. 2011; Patti et al.
2010; Witte et al. 2010).
Chambers et al. (2010) seem to have changed their therapy, insofar they recom-
mend exclusively V-Y advancement flap anoplasty as first-line therapy for chronic
anal fissure.
By analogy, the same objections as expressed in the “Conclusion” of Chap. 11.3.3
apply to the evaluation of these procedures. So far, no clinical trial has compared
fissurectomy alone following the abovementioned principles or the original
Table 11.32 Number of probands for anoplasty in eight study collectives
Case
(1991)
De Marta
et al.
(1997)
Kenefick
et al.
(2002)
Leong and
Seow-Choen
(1995)
Nyam
et al.
(1995)
Samson and
Stewart
(1970)
Singh
et al.
(2005)
Owen
et al.
(2006)
n = 13
n/a
n = 8 n = 20 n = 21 n = 2072 n = 21 n = 13
11 Therapy for Chronic Anal Fissure
145
procedure according to Gabriel with the rest of the therapy modalities. To us, the
comparison with additional BTX injection or postoperative “chemical sphincterot-
omy” seems to be unnecessary.
Results
In all these publications, the authors withhold information about the kind of other
procedures they have performed alternatively and on which medical decisions they
were founded. This is especially true for the clinical trial by Samson and Stewart
(1970) with 2072 patients. Here, anoplasty for the anal fissure was obviously the
standard procedure. In 2.4% of cases, there was partial necrosis of the skin graft.
The reasons were hematomata or the fact that the pedicle chosen was too narrow.
Recurring anal fissures were observed in 10 patients, and mild anal stenosis – not in
need of surgical revision – in seven patients. All in all, the authors believe that ano-
plasty has advantages over the open excision insofar that pain is reduced, wound
healing is shortened, and healing disorders are rarer.
Case (1991) reports on complete healing in all cases, although – as pointed out
above – secondary changes were regularly left in situ. Nyam et al. (1995) also
reported primary healing in all cases.
Owen et al. (2006) saw four therapy failures in 13 patients operated in this man-
ner, Singh et al. (2005) one failure in 20 patients, and Kenefick et al. (2002) had also
one among eight patients. Singh et al. (2005) had two relapses in 21 patients.
Anoplasty Versus Lateral Internal Sphincterotomy
Leong and Seow-Choen (1995) present the only prospectively randomized clinical
trial, which compares 20 anoplasty patients with 20 patients who underwent lateral
internal sphincterotomy. In both groups, no case of wound infection and anal incon-
tinence was found. Three patients of the anoplasty group did not show complete
healing. Therefore, two patients received lateral internal sphincterotomy. The third
patient showed delayed healing after a period of about 3 months.
Conclusion
Obviously, anoplasty for the treatment of chronic anal fissure cannot be proposed as
standard procedure, because the collectives are mostly small, and the technique was
not further evaluated by any working group in larger collectives afterwards. The
open excision technique with subsequent secondary healing does not seem to be
inferior to anoplasty in view of the results concerning healing rates, recurrence
rates, and the problems in the area of the donor site.
11.3.5 Manual Anal Dilatation
Under the premise that the sphincter muscle tone is increased, Récamier introduced
already in 1838 manual anal dilatation (MAD) to terminate the muscle “cramp”
(French: contracture). Since then, many publications with totally different results in
terms of complications and healing rates have appeared.
11.3 Surgical Treatment
146
Technique
The anal canal is dilated with several fingers for some minutes under either general
or local anesthesia. Since not only the internal anal sphincter muscle, but also the
external sphincter muscle is stretched during this procedure, ruptures can occur in
both muscles. The procedure is not uniform. Depending on the author, three to ten
(sic!) fingers are inserted, and dilatation is exercised in a period between 10 s and
5 min (Table 11.33). No information is given about the magnitude and lateral or
medial location of the pressure exerted.
The procedure is neither controllable nor reproducible and therefore not compa-
rable. This explains the differing rates of complications and healing found in com-
parative MAD versus sphincterotomy trials.
Two to six years after manual anal dilatation, Nielsen et al. (1993) examined 32
patients using endosonography. In 65% of cases, they found defects inside the mus-
cles; 12.5% of patients had developed a mild incontinence.
Speakman et al. (1991) found similar sonographic results in 12 patients after anal
dilatation.
Apart from possible anal incontinence of various grades, no further complica-
tions seem to occur after MAD. Goldman et al. (1986), however, found evidence of
bacteremia immediately after interventions. Chazan et al. (2001) described osteo-
myelitis in a 17-year-old boy as a result of such an intervention. Kasik et al. (1984)
reported a case of meningitis in a newborn infant (Tables 11.33, 11.34 and 11.35).
Conclusion
We believe that manual anal dilatation as therapy for anal fissure should not be
applied any longer because of the high incontinence rates. The iatrogenic sphincter
damages are irreparable.
11.3.6 Instrumental Anal Dilatation
Manual anal dilatation (MAD) has especially fallen into disrepute because of fre-
quent consecutive continence disorders. The missing standardization was rightly
Table 11.33 Technique
and duration of manual
anal dilatation in 12 trials
Author (year)
Number of
fingers (n)
Duration of
dilatation (min)
Reinhard und Kirsch (1993) 3–4 1
Graham-Stewart et al. (1961) 4 1/6
Watts et al. (1964) 4 4
Riedler (1979) 4 2
Weaver et al. (1987) 4 4
Olsen et al. (1987) 4 n/a
Babor et al. (2003) 4 4
Ram et al. (2007) 4 4
Collopy and Ryan (1979) 5 3–5
Marby et al. (1979) 6 n/a
Hiltunen and Matikainen (1986) 6 2
Strugnell et al. (1999) 10 n/a
11 Therapy for Chronic Anal Fissure
147
Table 11.34 Details of seven studies on MAD versus lateral internal sphincterotomy (LIS) therapy
Author (year)
Patients treated with
Follow-up
(Months)
Healing rate Recurrence Bowel control problems
MAD
(n) LIS (n)
MAD
(%) LIS (%)
MAD
(%) LIS (%)
MAD
(%) LIS (%)
Fischer et al. (1978a) 34 32 24–36 n/a n/a 20 3 18 25
Marby et al. (1979) 78 78 12 32 22 10 29 0 0
Collopy and Ryan (1979) 74 86 60 40 51 29 15 56 79
Jensen et al. (1984) 28 30 18 n/a n/a 29 3 75 3
Weaver et al. (1987) 36 48 12–57 72 74 8 4 0 2
Olsen et al. (1987) 10 10 12 n/a n/a 30 10 20 20
Ram et al. (2007) 55 53 11.2 n/a n/a 11 2 15 4
11.3 Surgical Treatment
148
Table 11.35 Fecal incontinence after manual anal dilatation in six trials with 270 patients (in %)
Author (year) Patients (n)
Incontinence to
Flatus Feces Soiling
(n) (%) (n) (%) (n) (%)
Watts et al. (1964) 90 12 13.3 2 2.2 20 22.0
Collopy and Ryan (1979) 74 18 24.3 7 9.5 10 13.5
Jensen et al. (1984) 28 8 28.6 9 7.1 11 39.5
Olsen et al. (1987) 10 9 30.0 n/a n/a n/a n/a
Mac Donald et al. (1992) 46 2 19.6 2 4.3 n/a n/a
Nielsen et al. (1993) 32 2 6.3 2 6.3 n/a n/a
Total 270 51 22 22
criticized. No two MAD procedures are alike, even though they have been performed
by the same surgeon. Apart from the number of dilating fingers, other incalculable
factors are the diameter of the fingers, the power exerted, the pull direction, the dura-
tion of dilatation, and the thickness of the internal anal sphincter muscle.
In contrast, the parameters of instrumental anal dilatation (IAD) are constants:
the diameter of the dilator, the circular force effect, and the duration of dilatation.
This method can therefore be reproduced, but above all, the results can be compared
with those of other therapeutic measures.
Already in 1914, Hirschman reported on IAD in his textbook on proctology. He
performed IAD with the help of a pneumatic balloon.
In 1992, Sohn et al. found a healing rate of 94% in 66 anal fissure patients (acute
and chronic) after 3 months. They saw no recurrences or cases of anal incontinence
after therapy. They used a balloon of 40 mm in diameter, which they left in the anal
canal with a pressure of 1.54 atm for 5 min. The measure was carried out under local
anesthesia and under antibiotic protection. Subsequently, skin tags and hypertro-
phied anal papillae were removed.
Walfish and Silberstein (1998) found healing rates of 92% and recurrences in
4.5% of 175 anal fissure patients (acute and chronic) during a follow-up of 3–60
months. There were no complications or cases of anal incontinence.
In 2005, Renzi et al. (2005) published their findings in 33 patients with chronic
anal fissure, who had been treated with the balloon method. Anal manometry and
anal endosonography had been performed on these patients before and after the
intervention. After 3–5 weeks, 94% of patients were healed. After 12 months, they
found 3% recurrences, but no defects of the musculature after anal sonography. The
postoperative anal resting pressure was significantly reduced.
In 2008, Renzi et al. again presented a RCT, in which they compared this method
with lateral internal sphincterotomy. After therapy with IAD, the anal fissures
healed in 83.3% of 24 patients, in 92% after sphincterotomy. The recurrence rate
was 0% in contrast to 4% after sphincterotomy. The incontinence rate was 0% with
IAD patients and 16% with sphincterotomy patients after a follow-up of 24 months.
Tranqui et al. (2006) prescribed pneumatic pressure of 40 psi over a period of
45–120 s for 21 patients with chronic anal fissure and subsequently treated them with
GTN ointment. Anal fissure healed in 15 patients, but 4 of them developed a relapse.
11 Therapy for Chronic Anal Fissure