This protocol covers patients with chronic anal fissure at elevated risk for fecal incontinence — including those with baseline fecal incontinence, women with prior obstetrical injuries, patients with inflammatory bowel disease, patients who have had previous anorectal operations, or patients with a documented anal sphincter injury — in whom first-line treatment has not resulted in adequate healing.
Those in whom lateral internal sphincterotomy may be excluded as first-line therapy include women with prior obstetrical injuries, patients with inflammatory bowel disease, patients who have undergone previous anorectal operations, and patients with a documented anal sphincter injury. Baseline fecal incontinence further elevates the risk of sphincter-dividing procedures in this population.
For patients at higher risk for fecal incontinence after conventional sphincterotomy, a sphincter-preserving surgical alternative has been described using a variety of techniques and is associated with good fissure healing rates and low rates of minor fecal incontinence.
This protocol is the next step when first-line therapy did not meet its goals at 3 months.
Botulinum toxin injection into the internal anal sphincter, alone or combined with topical nitroglycerin
Goals not reached: healing of the anal fissure and at least a 50% reduction in pain score at 3 months.
For patients in this high-risk group, the approach centres on a sphincter-preserving anocutaneous flap procedure — designed to achieve fissure healing while avoiding further compromise to continence.
Treatment goal: Healing of the chronic anal fissure at 2 months.
DOI: 10.1097/DCR.0000000000002664
Those in whom LIS may be excluded as first-line therapy include women with prior obstetrical injuries, patients with IBD, patients who have undergone previous anorectal operations, and patients with a documented anal sphincter injury.
For patients with chronic anal fissure who are at higher risk for FI after LIS, an alternative sphincter-preserving surgical approach is an anocutaneous (dermal V-Y or house) flap, which has been described using a variety of techniques.
Anocutaneous flap is a safe surgical alternative for managing chronic anal fissure with a decreased risk of FI compared with LIS and comparable healing rates.
For patients with chronic anal fissure who are at higher risk for FI after LIS, an alternative sphincter-preserving surgical approach is an anocutaneous (dermal V-Y or house) flap, which has been described using a variety of techniques and which has been associated with good fissure healing rates (81%–100%) and low rates of minor FI (0%–6%).
A prospective study reported a 98% healing rate at 2 months after the construction of a flap in 51 consecutive patients, with no recurrences or changes in continence at a median follow-up of 6 months.
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