This protocol addresses the clinical scenario of a chronic anal fissure — one exhibiting stigmata of chronicity — that has recurred following initial surgical management with lateral internal sphincterotomy, in a patient without baseline fecal incontinence.
Chronic anal fissures are distinguished from acute presentations by structural stigmata that develop over time: a hypertrophied anal papilla at the proximal aspect of the fissure, a sentinel tag at the distal aspect, and/or exposed internal anal sphincter muscle within the fissure base. Lateral internal sphincterotomy (LIS) is the established treatment of choice for chronic anal fissures in selected patients without baseline fecal incontinence.
Prior intervention: Lateral internal sphincterotomy (LIS) tailored to the length of the fissure (open or closed technique).
Target not reached: Healing of the chronic anal fissure did not occur, necessitating a further structured intervention.
Following recurrence after LIS, the evidence-based approach involves a targeted procedure directed at the internal anal sphincter — with the specific technique determined by clinical reassessment of the individual patient.
Goal: Healing of the recurrent anal fissureDOI: 10.1097/DCR.0000000000002664
Fissures of a longer duration will often manifest 1 or more stigmata of chronicity, including a hypertrophied anal papilla at the proximal aspect of the fissure, a sentinel tag at the distal aspect of the fissure, and/or exposed internal anal sphincter muscle within the base of the fissure.
LIS is the treatment of choice for chronic anal fissures in selected patients without baseline FI.
Short-term outcomes of repeat LIS or botulinum injection for recurrent anal fissure have shown good healing rates with a low risk of FI, but the data are limited and require further study.
Fifty-seven patients underwent repeat contralateral tailored LIS and showed a 98% healing rate and a 4% minor FI rate at a 12.5-year mean follow-up.
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