Fissurectomy and anoplasty in posterior normotensive chronic anal fissure
Keywords:
proctology; anal fissure; anoplasty; sphincterectomy; fissurectomy.Abstract
Purpose: Anal Fissure (AF) is the second most frequent proctological disease in Italy. Chronic AF (CAF) most common located at the posterior anal commissure (CAPF). CAPF are thought to be associated with hypertonic internal anal sphincter (IAS) but manometric findings showed that a normotonic IAS is present in the 20-40%. Sphincterotomy is often recommended as treatment of choice for CAF independently from IAS tone; nevertheless, this approach appears less logical for CAF with normotonic IAS, as in those cases there’s a higher risk of post-operative anal incontinence. The aim of this study is to evaluate the results of fissurectomy and anoplasty with V-Y cutaneous advancement flap, as treatment for patients suffering from CAPF without hypertonic IAS.
Methods: We enrolled 30 patients affected by CAPF without IAS hypertonia. All patients were followed up for 2 years after the surgical procedure, with evaluation of anal continence, recurrence rate and maximum resting pressure, maximum squeeze pressure, ultraslow wave activity.
Results: All patients healed within 40 days after surgery. We didn’t observe any “de novo” post-operative anal incontinence cases. We reported 2 cases of recurrences, within 18 months from surgery, all healed after conservative therapy. We didn’t record statistically significant differences in pre- and post-operative manometry findings.
Conclusion: At 2 years after the surgical procedure we achieved good results, these evidences shows that sphincter preserving procedures are more suitable for CAPF without hypertonic IAS.
References
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2. Ortiz H, Marzo J, Armendariz P, De Miguel M. Quality of life assessment in patients with chronic anal fissure after lateral internal sphincterotomy.Br J Surg. 2005;92:881-5.
3. Mapel DW, Schum M, Von Worley A The epidemiology and treatment of anal fissures in a population-based cohort.BMC Gastroenterol. 2014;14:129
4. Patti R, Famà F, Barrera T, Migliore G, Di Vita G. Fissurectomy and anal advancement flap for anterior chronic anal fissure without hypertonia of the internal anal sphincter in females. Colorectal Dis.2010; 12:1127-30.
5. Bove A, Balzano A, Perrotti P, Antropoli C, Lombardi G, Pucciani F. Different anal pressure profiles in patients with anal fissure. Tech Coloproctol.2004; 8:151-6.
6. Pascual M, Pera M, Courtier R, et al.Endosonographic and manometric evaluation of internal anal sphincter in patients with chronic anal fissure and its correlation with clinical outcome after topical glyceryl trinitrate therapy. Int J Colorectal Dis.2007; 22:963-7.
7. Anaraki F, Foroughifar T, Laleh Hossein S, Etemad O. Evaluation of outcomes in fissurectomy and V-Y advancement flap for the treatment of chronic anal fissure.J Coloproctol (RIO J) 2018; 38:132-6
8. Patti R, Caruso AM, Aiello P, Angelo GL, Buscemi S, Di Vita G. Acute inflammatory response in the subcutaneous versus periprosthethic space after incisional hernia repair: an original article.BMC Surg. 2014;14:91.
9. Jones OM, Ramalingam T, Lindsey I, Cunningham C, George BD, Mortensen NJ. Digital rectal examination of sphincter pressures in chronic anal fissure is unreliable. Dis Colon Rectum.2005; 48:349-52.
10. Jenkins JT, Urie A, Molloy RG. Anterior anal fissures are associated with occult sphincter injury and abnormal sphincter function. Colorectal Dis.2008;10:280-5
11. Patti R, Famà F, Tornambè A, Restivo M, Di Vita G. Early results of fissurectomy and advancement flap for resistant chronic anal fissure without hypertonia of the internal anal sphincter. Am Surg.2010; 76:206-10.
12. Patti R, Territo V, Aiello P, Angelo GL, Di Vita G. Manometric evaluation of internal anal sphincter after fissurectomy and anoplasty for chronic anal fissure: a prospective study. Am Surg. 2012; 78:523-7.
13. Patti R, Almasio PL, Arcara M,et al. Long-term manometric study of anal sphincter function after hemorrhoidectomy.Int J Colorectal Dis.2007; 22:253-7.
14. Gupta PJ, Kalaskar S. Removal of hypertrophied anal papillae and fibrous anal polyps increases patient satisfaction after anal fissure surgery.Tech Coloproctol. 2003; 7:155-8.
15. Patti R, Famà F, Tornambè A, Asaro G, Di Vita G. Fissurectomy combined with anoplasty and injection of botulinum toxin in treatment of anterior chronic anal fissure with hypertonia of internal anal sphincter: a pilot study. Tech Coloproctol.2010; 14:31-6.
16. Pescatori M, Anastasio G, Bottini C, Mentasti A. New grading and scoring for anal incontinence. Evaluation of 335 patients. Dis Colon Rectum.1992; 35:482-7.
17. Collins EE, Lund JN. A review of chronic anal fissure management.Tech Coloproctol.2007; 11:209-23.
18. 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.Int J Surg. 2018;49:16-21.
19. Griffin N, Acheson AG, Tung P, Sheard C, Glazebrook C, Scholefield JH. Quality of life in patients with chronic anal fissure.Colorectal Dis.2004; 6:39-44.
20. Di Vita G, Patti R, Barrera T, Arcoleo F, Ferlazzo V, Cillari E. Impact of heavy polypropylene mesh and composite light polypropylene and polyglactin 910 on the inflammatory response. Surg Innov. 2010;17:229-35.
21. Sobrado Júnior CW, Hora JAB, Sobrado LF, Guzela VR, Nahas SC, Cecconello I. Anoplasty with skin tag flap for the treatment of chronic anal fissure. Rev Col Bras Cir.2019; 46:e20192181.
22. 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; 33:1058-63.
23. Chowcat NL, Araujo JG, Boulos PB. Internal sphincterotomy for chronic anal fissure: long term effects on anal pressure. Br J Surg.1986; 73:915-16.
24. Nelson RL, Manuel D, Gumienny C, et al. A systematic review and meta-analysis of the treatment of anal fissure.Tech Coloproctol. 2017; 21:605-25.
25. Pescatori M, Maria G, Anastasio G. ‘Spasm related’ internal sphincterotomy in the treatment of anal fissure. A randomized prospective study. Coloproctology 1991;1:20-22
26. Prohm P, Bönner C. Is manometry essential for surgery of chronic fissure-in-ano?Dis Colon Rectum. 1995 ; 38:735-8.
27. Marti L., Post S., Herold A., et al. S3-Leitlinie:Analfissur. AWMF-Registriernummer:081-010. Coloproctology 2020 ; 42:90-6
28. Higuero T. Update on the management of anal fissure.J Visc Surg.2005; 152:S37-43.
29. Altomare DF, Binda GA, Canuti S, Landolfi V, Trompetto M, Villani R. The management of patients with primary chronic anal fissure: a position paper.Tech Coloproctol. 2011; 15:135-41.
30. Alonso-Coello P, Marzo-Castillejo M, Mascort JJ,et al. [Clinical practice guideline on the treatment of hemorrhoids and anal fissure (update 2007)].Gastroenterol Hepatol. 2008; 31:668-81
31. Holzgang M., Jayne D. Lateral Internal sphincterotomy (LIS)- still top gun in chronic anal fissure treatment? Coloproctology 2020; 42:478-84
32. Cross KL, Massey EJ, Fowler AL, Monson JR; ACPGBI. The management of anal fissure: ACPGBI position statement.Colorectal Dis.2008; 3:1-7
33. Emile SH. Indications and Technical Aspects of Internal Anal Sphincterotomy: Highlighting the Controversies.Dis Colon Rectum. 2017; 60:128-32.
34. Topal U, Eray İC, Rencüzoğulları A, Dalcı K, Yalav O, Alabaz Ö. The effect of anorectal manometric examination on the surgical treatment plan in chronic anal fissure. Ann Ital Chir. 2020; 31;9:S0003469X20030997.
35. Aigner F, Conrad F. Fissurectomy for treatment of chronic anal fissures.Dis Colon Rectum. 2008;51:1163; author reply 1164.
36. Aivaz O, Rayhanabad J, Nguyen V, Haigh PI, Abbas M. Botulinum toxin A with fissurectomy is a viable alternative to lateral internal sphincterotomy for chronic anal fissure.Am Surg. 2009;75:925-8.
37. Hancke E. Sphinkterschonende operative Therapie der chronischen Analfissur durch primäre plastische Deckung. Coloproctology 2020; 42:270-6.
38. Hancke E, Rikas E, Suchan K, Völke K. Dermal flap coverage for chronic anal fissure: lower incidence of anal incontinence compared to lateral internal sphincterotomy after long-term follow-up.Dis Colon Rectum. 2010;53:1563-8.
39. Alver O, Ersoy YE, Aydemir I,et al. Use of "house" advancement flap in anorectal diseases.World J Surg. 2008 ;32:2281-6.
40. Halahakoon VC , Pitt JP. Anal advancement flap and botulinum toxin A (BT) for chronic anal fissure (CAF). Int J Colorectal Dis. 2014;29:1175-7.
41. Singh M, Sharma A, Duthie G, Balasingh D, Kandasamy P. Early results of a rotation flap to treat chronic anal fissures.Asian J Surg. 2005;28:189-91.
42. Patti R, Guercio G, Territo V, Aiello P, Angelo GL, Di Vita G. Advancement flap in the management of chronic anal fissure: a prospective study. Updates Surg. 2012; 64:101-6.
43. D’Orazio B, Geraci G, Famà F, et al.Long term outcomes of fissurectomy and anoplasty for chronic anterior anal fissure without hypertonia: low recurrences and continence conservation. Ann Ital Chir 2020. Ahead of print.
44. D’Orazio B.,Sciumé C , Famà F,et al. Surgical Sphincter Saving Approach and Topical Nifedipine for Chronic Anal Fissure with Hypertonic Internal Anal Sphincter. Chirurgia, 2020; 115:585-94
45. D’Orazio B, Geraci G, Sciumé C, Cudia B, , Di Vita G. Surgical sphincter saving approach for chronic anal fissure without internal anal sphincter hypertonia: is it effective? Policlinico Sez. Med. 2020; 127: 1-00 doi.10.7353/polmed.2020.127.001
46. D’Orazio B., Bonventre S , Sciumé C ,et al. Lateral INternal Sphincterotomy is still crucial to heal hypertonic chronic anal fissure and normalize the internal anal sphincter tone? Is fissurectomy and V en Y plastic a valuable alternative?Ann. Ital. Chir 2020. Accepted for publication
47. D’Orazio B.,Geraci G.,Martorana G., Sciumé C., Corbo G., Di Vita G. Fisurectomy and anoplasty with botulinum toxin injection in patients with chronic anal posterior fissure with hypertonia: a long-term evaluation. Updates Surg. 2020. Ahead of print. DOI: 10.1007/s13304-020-00846-y
48. Iesalnieks I. Kombinations therapie Fissurektomie und Botulinum toxin in der Behandlung der chronischen Analfissur. Coloproctology 2020; 42: 464-8
2. Ortiz H, Marzo J, Armendariz P, De Miguel M. Quality of life assessment in patients with chronic anal fissure after lateral internal sphincterotomy.Br J Surg. 2005;92:881-5.
3. Mapel DW, Schum M, Von Worley A The epidemiology and treatment of anal fissures in a population-based cohort.BMC Gastroenterol. 2014;14:129
4. Patti R, Famà F, Barrera T, Migliore G, Di Vita G. Fissurectomy and anal advancement flap for anterior chronic anal fissure without hypertonia of the internal anal sphincter in females. Colorectal Dis.2010; 12:1127-30.
5. Bove A, Balzano A, Perrotti P, Antropoli C, Lombardi G, Pucciani F. Different anal pressure profiles in patients with anal fissure. Tech Coloproctol.2004; 8:151-6.
6. Pascual M, Pera M, Courtier R, et al.Endosonographic and manometric evaluation of internal anal sphincter in patients with chronic anal fissure and its correlation with clinical outcome after topical glyceryl trinitrate therapy. Int J Colorectal Dis.2007; 22:963-7.
7. Anaraki F, Foroughifar T, Laleh Hossein S, Etemad O. Evaluation of outcomes in fissurectomy and V-Y advancement flap for the treatment of chronic anal fissure.J Coloproctol (RIO J) 2018; 38:132-6
8. Patti R, Caruso AM, Aiello P, Angelo GL, Buscemi S, Di Vita G. Acute inflammatory response in the subcutaneous versus periprosthethic space after incisional hernia repair: an original article.BMC Surg. 2014;14:91.
9. Jones OM, Ramalingam T, Lindsey I, Cunningham C, George BD, Mortensen NJ. Digital rectal examination of sphincter pressures in chronic anal fissure is unreliable. Dis Colon Rectum.2005; 48:349-52.
10. Jenkins JT, Urie A, Molloy RG. Anterior anal fissures are associated with occult sphincter injury and abnormal sphincter function. Colorectal Dis.2008;10:280-5
11. Patti R, Famà F, Tornambè A, Restivo M, Di Vita G. Early results of fissurectomy and advancement flap for resistant chronic anal fissure without hypertonia of the internal anal sphincter. Am Surg.2010; 76:206-10.
12. Patti R, Territo V, Aiello P, Angelo GL, Di Vita G. Manometric evaluation of internal anal sphincter after fissurectomy and anoplasty for chronic anal fissure: a prospective study. Am Surg. 2012; 78:523-7.
13. Patti R, Almasio PL, Arcara M,et al. Long-term manometric study of anal sphincter function after hemorrhoidectomy.Int J Colorectal Dis.2007; 22:253-7.
14. Gupta PJ, Kalaskar S. Removal of hypertrophied anal papillae and fibrous anal polyps increases patient satisfaction after anal fissure surgery.Tech Coloproctol. 2003; 7:155-8.
15. Patti R, Famà F, Tornambè A, Asaro G, Di Vita G. Fissurectomy combined with anoplasty and injection of botulinum toxin in treatment of anterior chronic anal fissure with hypertonia of internal anal sphincter: a pilot study. Tech Coloproctol.2010; 14:31-6.
16. Pescatori M, Anastasio G, Bottini C, Mentasti A. New grading and scoring for anal incontinence. Evaluation of 335 patients. Dis Colon Rectum.1992; 35:482-7.
17. Collins EE, Lund JN. A review of chronic anal fissure management.Tech Coloproctol.2007; 11:209-23.
18. 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.Int J Surg. 2018;49:16-21.
19. Griffin N, Acheson AG, Tung P, Sheard C, Glazebrook C, Scholefield JH. Quality of life in patients with chronic anal fissure.Colorectal Dis.2004; 6:39-44.
20. Di Vita G, Patti R, Barrera T, Arcoleo F, Ferlazzo V, Cillari E. Impact of heavy polypropylene mesh and composite light polypropylene and polyglactin 910 on the inflammatory response. Surg Innov. 2010;17:229-35.
21. Sobrado Júnior CW, Hora JAB, Sobrado LF, Guzela VR, Nahas SC, Cecconello I. Anoplasty with skin tag flap for the treatment of chronic anal fissure. Rev Col Bras Cir.2019; 46:e20192181.
22. 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; 33:1058-63.
23. Chowcat NL, Araujo JG, Boulos PB. Internal sphincterotomy for chronic anal fissure: long term effects on anal pressure. Br J Surg.1986; 73:915-16.
24. Nelson RL, Manuel D, Gumienny C, et al. A systematic review and meta-analysis of the treatment of anal fissure.Tech Coloproctol. 2017; 21:605-25.
25. Pescatori M, Maria G, Anastasio G. ‘Spasm related’ internal sphincterotomy in the treatment of anal fissure. A randomized prospective study. Coloproctology 1991;1:20-22
26. Prohm P, Bönner C. Is manometry essential for surgery of chronic fissure-in-ano?Dis Colon Rectum. 1995 ; 38:735-8.
27. Marti L., Post S., Herold A., et al. S3-Leitlinie:Analfissur. AWMF-Registriernummer:081-010. Coloproctology 2020 ; 42:90-6
28. Higuero T. Update on the management of anal fissure.J Visc Surg.2005; 152:S37-43.
29. Altomare DF, Binda GA, Canuti S, Landolfi V, Trompetto M, Villani R. The management of patients with primary chronic anal fissure: a position paper.Tech Coloproctol. 2011; 15:135-41.
30. Alonso-Coello P, Marzo-Castillejo M, Mascort JJ,et al. [Clinical practice guideline on the treatment of hemorrhoids and anal fissure (update 2007)].Gastroenterol Hepatol. 2008; 31:668-81
31. Holzgang M., Jayne D. Lateral Internal sphincterotomy (LIS)- still top gun in chronic anal fissure treatment? Coloproctology 2020; 42:478-84
32. Cross KL, Massey EJ, Fowler AL, Monson JR; ACPGBI. The management of anal fissure: ACPGBI position statement.Colorectal Dis.2008; 3:1-7
33. Emile SH. Indications and Technical Aspects of Internal Anal Sphincterotomy: Highlighting the Controversies.Dis Colon Rectum. 2017; 60:128-32.
34. Topal U, Eray İC, Rencüzoğulları A, Dalcı K, Yalav O, Alabaz Ö. The effect of anorectal manometric examination on the surgical treatment plan in chronic anal fissure. Ann Ital Chir. 2020; 31;9:S0003469X20030997.
35. Aigner F, Conrad F. Fissurectomy for treatment of chronic anal fissures.Dis Colon Rectum. 2008;51:1163; author reply 1164.
36. Aivaz O, Rayhanabad J, Nguyen V, Haigh PI, Abbas M. Botulinum toxin A with fissurectomy is a viable alternative to lateral internal sphincterotomy for chronic anal fissure.Am Surg. 2009;75:925-8.
37. Hancke E. Sphinkterschonende operative Therapie der chronischen Analfissur durch primäre plastische Deckung. Coloproctology 2020; 42:270-6.
38. Hancke E, Rikas E, Suchan K, Völke K. Dermal flap coverage for chronic anal fissure: lower incidence of anal incontinence compared to lateral internal sphincterotomy after long-term follow-up.Dis Colon Rectum. 2010;53:1563-8.
39. Alver O, Ersoy YE, Aydemir I,et al. Use of "house" advancement flap in anorectal diseases.World J Surg. 2008 ;32:2281-6.
40. Halahakoon VC , Pitt JP. Anal advancement flap and botulinum toxin A (BT) for chronic anal fissure (CAF). Int J Colorectal Dis. 2014;29:1175-7.
41. Singh M, Sharma A, Duthie G, Balasingh D, Kandasamy P. Early results of a rotation flap to treat chronic anal fissures.Asian J Surg. 2005;28:189-91.
42. Patti R, Guercio G, Territo V, Aiello P, Angelo GL, Di Vita G. Advancement flap in the management of chronic anal fissure: a prospective study. Updates Surg. 2012; 64:101-6.
43. D’Orazio B, Geraci G, Famà F, et al.Long term outcomes of fissurectomy and anoplasty for chronic anterior anal fissure without hypertonia: low recurrences and continence conservation. Ann Ital Chir 2020. Ahead of print.
44. D’Orazio B.,Sciumé C , Famà F,et al. Surgical Sphincter Saving Approach and Topical Nifedipine for Chronic Anal Fissure with Hypertonic Internal Anal Sphincter. Chirurgia, 2020; 115:585-94
45. D’Orazio B, Geraci G, Sciumé C, Cudia B, , Di Vita G. Surgical sphincter saving approach for chronic anal fissure without internal anal sphincter hypertonia: is it effective? Policlinico Sez. Med. 2020; 127: 1-00 doi.10.7353/polmed.2020.127.001
46. D’Orazio B., Bonventre S , Sciumé C ,et al. Lateral INternal Sphincterotomy is still crucial to heal hypertonic chronic anal fissure and normalize the internal anal sphincter tone? Is fissurectomy and V en Y plastic a valuable alternative?Ann. Ital. Chir 2020. Accepted for publication
47. D’Orazio B.,Geraci G.,Martorana G., Sciumé C., Corbo G., Di Vita G. Fisurectomy and anoplasty with botulinum toxin injection in patients with chronic anal posterior fissure with hypertonia: a long-term evaluation. Updates Surg. 2020. Ahead of print. DOI: 10.1007/s13304-020-00846-y
48. Iesalnieks I. Kombinations therapie Fissurektomie und Botulinum toxin in der Behandlung der chronischen Analfissur. Coloproctology 2020; 42: 464-8
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D'Orazio B, Cudia B, Bonventre S, Famà F, Sciumé C, Cudia B, et al. Fissurectomy and anoplasty in posterior normotensive chronic anal fissure. Acta Biomed [Internet]. 2021 Nov. 3 [cited 2024 Jul. 17];92(5):e2021176. Available from: https://mattioli1885journals.com/index.php/actabiomedica/article/view/11200
