Combined mucosal advancement and lateral internal sphincterotomy in treatment of chronic anal fissure: could be an effective alternative procedure?

Mohammed A. Elbalshy, Mahmoud S. Eldesouky


Background: Chronic Anal Fissure (CAF) is a common anal problem. Lateral Internal Sphincterotomy (LIS) is the recommended treatment when conservative treatment fails, however it has its drawbacks. On the other hand, Anal Advancement Flap (AAF) may help in some cases. In this study, we tried to combine both techniques to evaluate the outcome of this dual procedure.

Methods: This prospective study was conducted on one hundred patients with chronic anal fissure who were divided randomly into two groups group (A) LIS, group (B) the combined technique. Both groups were compared regarding, pain and constipation prior to treatment and at 1, 2, 4, 6 weeks post-operative using Visual Analogue Scale (VAS) and Wexner constipation score at 6weeks in addition to timing of complete fissure healing.

Results: Both groups were comparable preoperatively regarding demographic data, pain score, constipation score but post-operative group B has achieved an earlier significant decrease in pain score, (1.7±0.65 vs 4.4±1.1) at 1st week (P<0.001) and (1.5±0.55 vs 3.3±1.04) at 2nd week also (P<0.001). In addition to a superior healing rate (96% vs 76%) at 4th week (P=0.009) with non-significantly longer operative time or complication rate.

Conclusions: The combined technique of mucosal advancement and LIS can achieve a superior outcome compared to the traditional LIS in the treatment of CAF regarding faster healing rates with marked decrease in early post- operative pain and by far earlier return to normal life habits.


CAF, Combined technique, LIS, Mucosal advancement

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Nelson RL. Treatment of anal fissure. BMJ. 2003;327(7411):354-5.

Anal fissure. BMJ Best Practice, best-practice/monograph/563/basics/classification.html. Accessed on February 4, 2017.

Aslam MI, Pervaiz A, Figueiredo R. Internal sphincterotomy versus topical nitroglycerin ointment for chronic anal fissure. Asian J Surg. 2014;37(1):15-9.

Mapel DW, Schum M, Worley VA. The epidemiology and treatment of anal fissures in a population-based cohort. BMC Gastroenterol. 2014;14(1):129.

Beaty JS, Shashidharan M. Anal fissure. Clin Colon Rectal Surg. 2016;29(01):030-7.

Stewart Sr DB, Gaertner W, Glasgow S, Migaly J, Feingold D, Steele SR. Clinical practice guideline for the management of anal fissures. Dis Colon Rectum. 2017;60(1):7-14.

Jensen SL, Lund F, Nielsen OV, Tange G. Lateral subcutaneous sphincterotomy versus anal dilatation in the treatment of fissure in ano in outpatients: a prospective randomised study. Brit Med J. 1984;289(6444):528-30.

Abcarian H. Surgical correction of chronic anal fissure: results of lateral internal sphincterotomy vs. fissurectomy-midline sphincterotomy. Dis Colon Rectum. 1980;23(1):31-6.

Singh M, Sharma A, Gardiner A, Duthie GS. Early results of a rotational flap to treat chronic anal fissures. Inter J Colorectal Dis. 2005;20(4):339-42.

Giordano P, Gravante G, Grondona P, Ruggiero B, Porrett T, Lunniss PJ. Simple cutaneous advancement flap anoplasty for resistant chronic anal fissure: a prospective study. World J Surg. 2009;33(5):1058-63.

Agachan F, Chen T, Pfeifer J, Reissman P, Wexner SD. A constipation scoring system to simplify evaluation and management of constipated patients. Dis Colon Rectum. 1996;39(6):681-5.

García‐Granero E, Sanahuja A, García‐Botello SA, Faiz O, Esclápez P, Espí A, et al. The ideal lateral internal sphincterotomy: clinical and endosonographic evaluation following open and closed internal anal sphincterotomy. Colorectal Dis. 2009;11(5):502-7.

Hasse C, Brune M, Bachmann S, Lorenz W, Rothmund M, Sitter H. Lateral, partial sphincter myotomy as therapy of chronic anal fissue. Long-term outcome of an epidemiological cohort study. Surgeon J All Areas Operative Med. 2004 Feb;75(2):160-7.

Schouten WR, Briel JW, Auwerda JJ, Graaf EJ. Ischaemic nature of anal fissure. Brit J Surg. 1996;83(1):63-5.

Hananel N, Gordon PH. Lateral internal sphincterotomy for fissure-in-ano-revisited. Dis Colon Rectum. 1997;40(5):597-602.

Herzig DO, Lu KC. Anal fissure. Surg Clin North Am. 2010;90(1):33-44.

Gupta PJ. Closed anal sphincter manipulation technique for chronic anal fissure. Rev Gastroenterol Mex. 2008;73(1):29-32.

Sahebally SM, Walsh SR, Mahmood W, Aherne TM, Joyce MR. Anal advancement flap versus lateral internal sphincterotomy for chronic anal fissure-a systematic review and meta-analysis. Inter J Surg. 2018;49:16-21.

Magdy A, El Nakeeb A, Youssef M, Farid M. Comparative study of conventional lateral internal sphincterotomy, VY anoplasty, and tailored lateral internal sphincterotomy with VY anoplasty in the treatment of chronic anal fissure. J Gastrointestinal Surg. 2012;16(10):1955-62.

Singh M, Sharma A, Gardiner A, Duthie GS. Early results of a rotational flap to treat chronic anal fissures. Inter J Colorectal Dis. 2005;20(4):339-42.

Nyam DC, Wilson RG, Stewart KJ, Farouk R, Bartolo DC. Island advancement flaps in the management of anal fissures. Brit J Surg. 1995;82(3):326-8.

Theodoropoulos GE, Spiropoulos V, Bramis K, Plastiras A, Zografos G. Dermal flap advancement combined with conservative sphincterotomy in the treatment of chronic anal fissure. Am Surg. 2015;81(2):133-42.