Review of Medical and Surgical Management of Chronic Anal Fissure

Abstract

To determine which treatment modality has the best outcome for chronic anal fissures in terms of pain relief, fissure healing, and recurrence. The main symptoms are pain while the passage of stools is acute in primary fissures but often persists in case of longstanding fissures causing significant discomfort to the patient. The management of anal fissure has progressed immensely in the last decade due to a better understanding of its pathophysiology. The main aim of the treatment is to reduce the spasm of the internal anal sphincter, thereby reducing the anal canal pressure. The Conservative approach consists of topical nitrates, calcium channel blockers, and calcium channel blockers. It is often preferred over surgical alternatives as it is not invasive. Surgeries for chronic anal fissures include anal dilatation, posterior mid-line sphincterotomy, lateral internal sphincterotomy, fistulectomy, sphincterolysis, and advancement flap repair. This narrative review article aims to review all the existing and newer complex modalities available for the management of chronic anal fissures. Currently the initial management of fissures is pharmacological therapy with topical nitroglycerin or diltiazem or botulinum toxin A injection. The following line of treatment is surgical, which is lateral internal sphincterotomy. Non-surgical therapy often proves ineffective in providing relief and healing, frequently culminating in the recurrence of fissures. On the other hand, surgical therapy has postoperative drawbacks like intestinal incontinence, commonly gas, loose stool or rarely hard stool. There is inadequate data on the latest treatment modalities like fistulotomy, sphincterolysis, flap procedures, etc. They may be considered only when conventional therapy fails to provide relief.