Study supports sphincter-saving surgery

Fissurectomy results in high levels of healing and low rates of anal incontinence, show the results of the largest ever prospective study of the technique.

In the French study, all patients achieved healing at a median time of 7.5 weeks, and the rate of de novo anal incontinence following surgery was 7%.

The authors say the technique could be an alternative to the standard technique of internal sphincterectomy, which can lead to levels of incontinence of up to 45%.

"Fissurectomy with anoplasty is a valuable sphincter-sparing surgical treatment for chronic anal fissure," say Laurent Abramowitz (Hôpital Universitaire Bichat-Claude Bernard, Paris, France) and colleagues.

The study included 257 patients, most of whom had not responded to previous medical treatment for anal fissure. In all, 86% had anoplasty at the same time as fissure removal. They, or their physicians, completed a questionnaire about their condition before their surgery, once healing was achieved, and at 1 year.

Pain was the most common reason for undergoing surgery, and was reported by 98% of patients before treatment. Following surgery, visual analog scale (VAS) scores for pain significantly decreased, and approached zero. For example, before surgery, patients reported an average VAS score of 5.4 for anal pain during the past 2 days on a scale where 0 meant none and 10 meant maximum. This had decreased to 0.2 at healing and to 0.0 at 1 year after surgery.

Patients also reported significant improvements in anal bleeding, pruritis, anal soiling, and constipation following surgery. Furthermore, quality of life improved, and was similar to that of the general population.

Anal incontinence is viewed as a major drawback of the otherwise highly effective technique of sphincterectomy. Fissurectomy does not normally affect the internal anal sphincter, leading researchers to believe it could offer a decreased risk for incontinence, compared with the traditional technique.

Reporting in Colorectal Disease, the authors found that, following fissurectomy, scores for anal incontinence were slightly but significantly increased at healing and at 1 year, compared with before surgery.

However, the rate of clinically significant incontinence, defined as a score of 5 or more on the Wexner scale, was 16% before surgery compared with 14% at 1 year. The authors also note that in patients in whom incontinence worsened, symptoms in 62 out of 80 were not considered clinically significant.

This study is one of only a few to investigate outcomes of fissurectomy, and is unusual in its large sample size.

While fissurectomy is common in France and some other countries, the authors say their results suggest its use should be expanded: "This technique is easy to learn and could be exported worldwide to cure chronic anal fissure without significant morbidity."

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