Surgical treatment of chronic fissure-in-ano: a prospective randomised study. Open versus closed lateral internal anal sphincterotomy in the management of chronic anal fissures: a prospective randomized study. Adequate internal sphincterotomy for chronic anal fissure: Subcutaneous or open technique? Randomized clinical trial of transcutaneous electrical posterior tibial nerve stimulation versus lateral internal sphincterotomy for treatment of chronic anal fissure. 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 Comparative Study of Conventional Lateral Internal Sphincterotomy, V-Y Anoplasty, and Tailored Lateral Internal Sphincterotomy with V-Y Anoplasty in the Treatment of Chronic Anal Fissure Lateral subcutaneous sphincterotomy versus anal dilatation in the treatment of fissure in ano in outpatients: a prospective randomised study. 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 Lateral sphincterotomy compared with anal advancement flap for chronic anal fissure Chronic fissure-in-ano: A randomized study comparing open and subcutaneous lateral internal sphincterotomy A prospective randomized trial betwen subcutaneous lateral internal sphincterotomy with radiofrequency bistoury and conventional parks' operation in the treatment of anal fissures. Glyceryl trinitrate vs. lateral sphincterotomy for chronic anal fissure: Prospective, randomized trial Randomized prospective controlled trial of lateral internal sphincterotomy versus injection of botulinum toxin for the treatment of idiopathic fissure in ano Clinical, Manometric, and Ultrasonographic Results of Pneumatic Balloon Dilatation vs. Lateral Internal Sphincterotomy for Chronic Anal Fissure: A Prospective, Randomized, Controlled Trial A Comparative Study of Lateral Sphincterotomy and 2% Diltiazem Gel Local Application in the Treatment of Chronic Fissure in ANO. Glyceryl trinitratevs. sphincterotomy for treatment of chronic fissure-in-ano 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. 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. 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 Comparative Study of Glyceryl Trinitrate Ointment Versus Surgical Management of Chronic Anal Fissure Lateral internal sphincterotomy is not redundant in the era of glyceryl trinitrate therapy for chronic anal fissure Botulinum Toxin Injection Versus Lateral Internal Sphincterotomy in the Treatment of Chronic Anal Fissure: A Randomized Controlled Trial
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 OBJECTIVE Chronic anal fissure is a benign disorder that is associated with considerable discomfort . Surgical treatment in the form of lateral sphincterotomy has long been regarded as the gold st and ard of treatment . This study compared the open and closed techniques of lateral sphincterotomy in terms of their postoperative outcomes . METHODS A prospect i ve , r and omized comparative study was conducted between October 2010 and August 2012 . A total of 136 patients were r and omly assigned to each of two groups . Patients were followed up postoperatively for more than 1 year to assess any complications . The outcomes were compared among the two groups using the Chi-square test and Student t test . RESULTS The mean age at presentation was 40.13 years . The male to female ratio was 1.47:1 . The typical presentation was  painful defecation . Fissures were most often located in the posterior midline and associated with a sentinel pile . Delayed postoperative healing was found in 4.4 % of the group of patients undergoing open lateral sphincterotomy . The mean pain score and duration of hospital stay were lower with the closed technique . CONCLUSION Closed lateral internal sphincterotomy is the treatment of choice for chronic fissures as it is effective , safe , less expensive , and associated with a lower rate of complications than the open sphincterotomy technique 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 OBJECTIVES The objective of this study was to evaluate the efficacy of transcutaneous electrical posterior tibial nerve stimulation in treatment of patients with chronic anal fissure and to compare it with the conventional lateral internal sphincterotomy . PATIENTS AND METHODS Consecutive patients with chronic anal fissure were r and omly allocated into two treatment groups : transcutaneous electrical posterior tibial nerve stimulation group and lateral internal sphincterotomy group . The primary outcome measures were number of patients with clinical improvement and healed fissure . Secondary outcome measures were complications , VAS pain scores , Wexner 's constipation and Peascatori anal incontinence scores , anorectal manometry , and quality of life index . RESULTS Seventy-three patients were r and omized into two groups of 36 patients who were subjected to transcutaneous electrical nerve stimulation and 37 patients who underwent lateral internal sphincterotomy . All ( 100 % ) patients in lateral internal sphincterotomy group had clinical improvement at one month following the procedure in contrast to 27 ( 75 % ) patients in transcutaneous electrical nerve stimulation group . Recurrence of anal fissure after one year was reported in one ( 2.7 % ) and 11 ( 40.7 % ) patients in lateral internal sphincterotomy and transcutaneous electrical nerve stimulation groups respectively . Resting anal pressure and functional anal canal length were significantly reduced after lateral internal sphincterotomy . CONCLUSION Transcutaneous electrical posterior tibial nerve stimulation for treatment of chronic anal fissure is a novel , non-invasive procedure and has no complications . However , given the higher rate of clinical improvement and fissure healing and the lower rate of fissure recurrence , lateral internal sphincterotomy remains the gold st and ard for treating chronic anal fissure 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 Background Lateral internal sphincterotomy has been proven highly effective in curing anal fissure but with a high incidence of postoperative incontinence . Objective We compared conventional lateral internal sphincterotomy , V-Y advancement flap , and combined tailored lateral internal sphincterotomy with V-Y advancement flap in treating anal fissure . Patients Consecutive patients treated for anal fissure at our colorectal unit were evaluated for inclusion . Participants were r and omly allocated to receive conventional sphincterotomy ( GI ) , V-Y advancement flap ( GII ) , or combined tailored lateral sphincterotomy with V-Y advancement l flap (GIII).Main Outcome Measures The primary outcome measure was the incontinence rate ; secondary outcomes included healing rate , operative time , anal manometery , and recurrence rate . Results One hundred fifty patients with chronic anal fissure were r and omized . Healing rate after 1 year was 84 % in GI , 48 % in GII , and 94 % in GIII , respectively ( P = 0.001 ) . The recurrence rate was 4 % in G1 , 22 % in GII , and 2 % in GIII ( P = 0.01 ) . Incontinence rate was 14 % in GI , 0 % in GII , and 2 % in GIII ( P = 0.03 ) . Conclusion Although all three procedures are simple and easy to perform , tailored lateral internal sphincterotomy with V-YF appears to produce the greatest healing rate , with the fewest complications and less rate of recurrence 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 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 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 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 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 INTRODUCTION : Glyceryl trinitrate has been shown to be an effective treatment for  chronic anal fissure .  It decreases anal tone and ultimately heals anal fissures . The aim of this trial was to compare glyceryl trinitrate with lateral sphincterotomy ( current st and ard treatment ) as definitive management for  chronic anal fissure . METHODS : All patients with symptoms of chronic anal fissure were r and omly assigned to one of two treatment arms . The glyceryl trinitrate group applied 0.2 percent paste to the perianal area three times a day for eight weeks . Patients in the lateral sphincterotomy group underwent surgery on the next available operating list . Patients were review ed at two weekly intervals until the fissure healed . RESULTS : Sixty‐five patients were enrolled in the trial , with 31 in the lateral sphincterotomy group and 34 in the glyceryl trinitrate group . Five patients were excluded after r and omization . Twenty of 33 ( 60.6 percent ) glyceryl trinitrate patients had healed fissures in eight weeks compared with 26 of 27 ( 97 percent ) in the sphincterotomy group ( P = 0.001 ) . Twelve patients in the glyceryl trinitrate group had little improvement in their symptoms and underwent lateral sphincterotomy .  Poor tolerance and poor compliance with treatment were important factors in patients whose fissures did not heal with glyceryl trinitrate .  Fissures healed significantly faster after sphincterotomy compared with glyceryl trinitrate treatment ( P = 0.0001 ) . Nine of the 20 patients whose fissures healed with glyceryl trinitrate paste subsequently had a recurrence of their fissures . There were no long‐term complications from lateral sphincterotomy . CONCLUSION : Glyceryl trinitrate paste heals the majority of chronic anal fissures . However , a significant minority have little improvement or develop side effects and require conventional surgical treatment . Poor compliance with prescribed treatment often contributes to nonhealing . In addition , some fissures which initially heal with glyceryl trinitrate paste recur and require further treatment . Glyceryl trinitrate treatment is labor intensive for patients and physicians and has not been shown to be superior to lateral sphincterotomy Background : Chronic anal fissure is a significant cause of morbidity . Internal sphincterotomy has long been the operative treatment of choice . Concerns remain , however , on its effects on continence .  Botulinum toxin has been used as an agent for chemical sphincterotomy , causing temporary alleviation of sphincter spasm and allowing the fissure to heal . The aim of the present study was to compare the results of sphincterotomy to botulinum toxin Purpose This prospect i ve , r and omized , controlled trial was design ed to compare the clinical , functional , and morphologic results of pneumatic balloon dilatation with lateral internal sphincterotomy for the treatment of chronic anal fissure . Methods All patients with symptomatic chronic anal fissure were r and omly assigned to  pneumatic balloon dilatation or lateral internal sphincterotomy  and invited to complete a st and ardized question naire 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 vali date d continence grading scale , was evaluated preoperatively at 1 and 6 weeks and at 12 and 24 months . Results 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 ) . Conclusions As lateral internal sphincterotomy , pneumatic balloon dilatation grants a high anal fissure-healing rate but with a statistically significant reduction in postoperative anal incontinence INTRODUCTION Anal fissures are commonly encountered in routine clinical practice . Anal fissure has traditionally been treated surgically . Developments in the pharmacological underst and ing of the internal anal sphincter have result ed in more conservative approaches towards treatment . In this study we compare symptomatic relief , healing and side effects of topical 2 % Diltiazem gel and lateral internal sphincterotomy in the treatment of chronic fissure in ano . MATERIAL S AND METHODS In this prospect i ve trial , 60 surgical out patients and /or admitted patients with chronic fissure in ano were r and omly divided into Group 1 ( Diltiazem gel ) and Group 2 ( internal sphincterotomy ) with 30 patients in each Group . Patients were followed up at weekly intervals for six consecutive weeks and biweekly for subsequent 3 months . RESULTS Fissure was completely healed in 88.46 % of patients in Group 1 and in 100 % in Group 2 . The mean duration required for healing of fissure was 5.04 weeks in Group 1 and 3.6 weeks in Group 2 . 78.26 % patients were free from pain in Group 1 whereas 85.18 % patients were free from pain in Group 2 . No patient had any side effects in either group . CONCLUSION Topical Diltiazem should be considered as first line treatment in chronic fissure in ano . Internal sphincterotomy should be reserved for patients with relapse and therapeutic failure to prior pharmacological treatment PURPOSE : This study was undertaken to compare local application of a glyceryl trinitrate ointment with lateral internal sphincterotomy for the treatment of chronic fissure-in-ano . PATIENTS AND METHODS : A sample of 24 consecutive patients with chronic anal fissure was r and omly allocated to treatment with sphincterotomy or local glyceryl trinitrate . Patients were followed-up for a median of 22 months . RESULTS : All 12 patients healed following sphincterotomy ; 10 of 12 healed with local glyceryl trinitrate ( P=0.239 ) . There were no recurrences or side-effects in either group . CONCLUSIONS : Local application of glyceryl trinitrate can avoid surgery in more than 80 percent of patients with chronic anal fissure 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 compare outcomes 24 months after treatment of chronic anal fissure with 0.2 % glyceryl trinitrate ointment ( GTN ) or lateral internal sphincterotomy .  DESIGN Prospect i ve , r and omised trial . SETTING One teaching , one private , and 3 district hospitals , U.K. SUBJECTS Seventy patients were r and omised into two groups of 35 each to use  0.2 % GTN ointment or have a lateral internal sphincterotomy .  MAIN OUTCOME MEASURES Resolution of symptoms and healing of fissures assessed after 24 months . RESULTS 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 r and omised 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 . CONCLUSIONS 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 Purpose Internal sphincterotomy remains the st and ard 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 design ed 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 . Methods Ninety patients of chronic anal fissure were r and omly assigned to two groups . Both groups received open lateral internal sphincterotomy via st and ardized 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 . Results 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 . Conclusions Marginal sutures of incision after lateral internal sphincterotomy may be beneficial to reduce complications related to early wound healing Chronic Anal Fissure ( CAF ) is common perineal condition and well-known painful entity . St and ard surgical treatment even though available , may require long hospital stay and sometimes have worrying complications like anal incontinence . So non-surgical treatment , Glyceryl Trinitrate has been shown to be an effective for chronic anal fissure . It decreases anal tone and ultimately heals the anal fissure . The present study is the attempt to know the efficacy of 0.2 % Glyceryl Trinitrate ointment in the treatment of chronic anal fissure and to compare the effectiveness of 0.2 % Glyceryl Trinitrate ointment ( GTN ) versus fissurectomy with lateral internal sphincterotomy ( LIS ) and fissurectomy with posterior internal sphincterotomy ( PIS ) in the management of chronic anal fissure . This is a prospect i ve comparative study of management of chronic anal fissure done in our hospital during the period of one and half year from October 2005 to March 2007 . Thirty patients treated with 0.2 % Glyceryl Trinitrate ointment and 30 patients treated with fissurectomy and lateral internal sphincterotomy and 30 patients treated with posterior internal sphincterotomy , for chronic anal fissure were selected for study . A single br and of 0.2 % Glyceryl Trinitrate ointment ( Nitrogesic ) used for trial arm . Dose of administration was 1.5 cm to 2 cm in the anal canal with device provided by manufacturers of the proprietary preparation and applied twice a daily for 12 weeks . Patients were followed up for 12 weeks and thereafter evaluated for relief of symptoms in all three groups . Observations were recorded at 2 weeks ; 6 weeks and 12 weeks of follow up period , regarding symptoms like pain and bleeding during defecation , healing of CAF and also for side effects like headache in GTN group and flatus , fecal incontinence in surgical groups . Data collected in proforma and analyzed . Study revealed CAF was more in male 59 patients ( 66 % ) than the female 31 patients ( 34 % ) , the ratio being 1 : 0.52 . The maximum number of patients was encountered in the age group of 20 to 40 years with mean duration of age 34.14 years . In all three groups symptoms like pain , bleeding , constipation and sphincter spasm were present . Sentinel pile was present in 56 % of the patients . Common site of fissure was found to be posterior in 94 % of patients . Observations with respect to relief of pain , no bleeding and healing were recorded at 2 , 6 and 12 weeks of duration . Lateral sphincterotomy remains effective but should be reserved for the patients who fail to respond to initial chemical sphincterotomy or GTN therapy . GTN is good alternative mode of therapy for patients who refuse surgery and prefer medical line of treatment Lateral internal sphincterotomy has been the st and ard treatment for chronic anal fissure , but fissure healing rates of up to 80 % with topical glyceryl trinitrate ( GTN ) treatment have suggested that this operation may become redundant . We evaluated the results of topical treatment of chronic anal fissures with 0.2 % GTN for 6 weeks in the outpatient clinical setting , outside the confines of a r and omized clinical trial . The role of lateral internal sphincterotomy in the GTN era was also assessed . GTN induced fissure healing in 21 of 49 consecutive patients .  Fissures healed spontaneously in 2 patients who discontinued GTN because of headache . Lateral internal sphincterotomy was performed in 26 patients who had persistent symptoms after 6 weeks of GTN therapy . At the 6-week post-sphincterotomy review , all fissures had healed and there were no complications . In this study topical GTN for treatment of chronic anal fissure in the outpatient setting was not as effective as demonstrated in controlled clinical trials . Lateral internal sphincterotomy is still a good therapeutic option , especially in patients not responding to GTN Background Although lateral internal sphincterotomy has been the gold st and ard of treatment for chronic anal fissure , the main concern remains its effects on anal continence . Intrasphincteric injection of botulinum toxin seems to be a reliable option providing temporary alleviation of sphincter spasm and allowing the fissure to heal . The aim of the present prospect i ve controlled r and omized study was to compare the outcome of lateral internal sphincterotomy and botulinum toxin injection treatments in patients with uncomplicated chronic anal fissure . Methods Eighty consecutive patients with uncomplicated chronic anal fissure who had failed conservative treatment were r and omized to receive either intrasphincteric injection of botulinum toxin ( BT ) or lateral internal sphincterotomy ( LIS ) .  Postoperative pain relief , healing of fissure , continence scores , and fissure relapse during 18 weeks of follow-up were the outcomes assessed . Results There was a statistically significantly higher healing in the LIS group than the BT group ( p = 0.0086 and 95 % CI = 7.38–45.69 % ) . In addition , LIS was associated with a high rate of anal incontinence as compared to BT ( p = 0.0338 and 95 % CI = −1.64–27.53 % ) . The recurrence rate in the BT group was significantly higher statistically than that in the LIS group ( p = 0.0111 and 95 % CI = 6.68–46.13 % ) . Conclusions Surgical internal sphincterotomy has a higher healing rate and a lower recurrence rate than intrasphincteric injection of botulinum toxin in the treatment of uncomplicated chronic anal fissure . Injection of botulinum toxin , however , is a simple noninvasive technique that avoids the greater risk of incontinence . It could be used as the first therapeutic approach in patients without clinical risk factors of recurrence
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 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 .