1. PITFALLS IN THE MANAGEMENT
OF ANAL FISSURE
Dukes’ Club 2013
Mr Graham Williams
Consultant Colorectal Surgeon
Royal Wolverhampton Hospitals

2. What I’ve Learned the Hard Way

3. Anal Fissure- Pitfalls
Dear Mr Williams,
I would be grateful if you would see this 43 year
old man who has a very painful bottom and
some bleeding. This has gone on for a few
weeks and has not responded to laxatives and
soothing ointments. He is otherwise fit and
well. He is too sore to examine.

4. Anal Fissure- Pitfall 1
A fissure is not visible – too sore to examine

5. Anal Fissure- Pitfall 1
A fissure is not visible – too sore to examine
• Length of history
• Age
• Associated features
Low Threshold for EUA
-Consent issues

6. Anal Fissure- Pitfall 1
A fissure is not visible – too sore to examine
• Anal / low rectal tumour
• Intersphincteric abscess
• Anal fissure
• Crohn’s ulcer
If you don’t think of these things, you will miss them

7. Anal Fissure- Pitfall 1
Intersphincteric abscess

8. Anal Fissure- Pitfall 1
Common Garden Variety
• Midline (posterior)
• Sentinel tag
• Internal sphincter fibres visible

9. Anal Fissure- Pitfall 2
What else could it be?
• Crohn’s ulcer • Hepetic ulcer
• Severe pruritis ani • Chancre
• TB • Drugs
• Anal cancer –Nicorandil
• HIV

10. Anal Fissure- Pitfall 3
Looking for the Best Treatment

11. Anal Fissure- Pitfall 3
What are the treatment goals?
• Resolve the pain
• Heal the fissure
• Maintain continence
• Keep the fissure healed

12. Treatment Algorithm
Male Chronic Anal Fissure Female
Healed GTN Healed
Surgery Unhealed
Healed Diltiazem Healed
Surgery Unhealed
Botox
ARP studies Surgery

14. Anal Fissue - GTN vs Placebo
Healing
47% 33% RL Nelson: Cochrane review 2008

16. GTN vs Topical Diltiazem
Healing
64%
53% 53% RL Nelson: Cochrane review 2008

17. Anal Fissure
Botulinum toxin vs GTN
Healing
67% 53% RL Nelson: Cochrane review 2008

19. Lateral Sphincterotomy
• Anal retractor to put IAS on stretch
• Closed technique – small blade
• Open technique – direct vision
• Divide IAS to upper margin of
fissure

26. Anal Fissure
Surgery vs Medical treatment
Healing
90% 51% RL Nelson: Cochrane review 2008

27. Anal Sphincterotomy
Post Operative Anal Incontinence

29. Sphincterotomy for Anal Fissure
Wolverhampton Data
Follow up after 6 weeks [86/101] attended -85%
..
Fissure Healed 83 3
97%
Altered Control 4 82
5%
Bleeding 1 85
1%
Anal Pain 8 78
10%
Yes No

30. Sphincterotomy for Anal Fissure
Wolverhampton Data
Patient Satisfaction 86%
31
Visual Analog Point Scale
0-10
11 11
4 9
0 1 1 1 1 2
0 1 2 3 4 5 6 7 8 9 10
Not Happy Very Happy

31. Surgery for Anal Fissure
Pitfalls - 4
• Be sure of the diagnosis
• Be aware of potential for previous
sphincter damage
– Anal surgery, Vaginal deliveries
• Be aware of the “low pressure” fissure
• Consider investigation with anal ultrasound
(AUS) and anorectal physiology (ARP)

32. Open vs closed sphincterotomy
Questionnaire follow-up (1-6 years)
Open Closed
Number 324 225
Persistent symptoms 3.4% 5.3%
Further surgery 3.4% 4.0%
Poor flatus control 30.3% 23.6%
Soiling 26.7% 16.1%
Garcia-Aguilar et al DCR 1996

33. Manual Dilatation of the Anus
• Four fingers
• Significant incontinence and
recurrence in some series
• Fragmentation of IAS seen
on anal ultrasound

34. Anal Dilatation
Uncontrolled sphincter disruption

35. Manual Dilatation of the Anus
• 302 patients
• Neuromuscular blockade
• 89% healed
• 3.8% impaired continence
• No sphincter defect
Strugnell et al BJS 1999

36. Anal Fissure- Pitfall 5
Dear Mr Williams,
I would be grateful if you would see this
unfortunate 26 year old man. He had an anal
fissure and had an operation under you
colleague Miss Soulsby, which has been a
complete disaster and he is still in a lot of pain.
Understandably he does not want to see her
ever again ......... (goes on for 2 more pages)

37. Anal Fissure- Pitfall 5
The fissure does not heal

38. Anal Fissure- Pitfall 5
The fissure does not heal
• Have you got the diagnosis
right?

39. Anal Fissure- Pitfall 5
The fissure does not heal
• Have you got the diagnosis
right?
• Has the operation been done
effectively?

40. Anal Fissure- Pitfall 5
The fissure does not heal
• Have you got the diagnosis
right?
• Has the operation been done
effectively?
• Is the anal pressure reduced?

41. The Unhealed Fissure

42. The Unhealed Fissure
Ano-rectal Manometery
10 cms water
100 cms Water
10 secs
SQUEEZE
PRESSURE
50 cms Water
RESTING PRESSURE
EMG

43. The Unhealed Fissure
Options for treatment
• Tincture of time
• Pastes or Botox
• Further sphincterotomy (open)
• Anal advancement flap

44. Anal advancement flaps
Whipps Cross Hospital
• 51 patients
• Cutaneous advancement flap
• 3 (6%) early flap dehiscence
• All eventually healed
• 3 (6%) late fissure recurrence
• No change in control
Giordano et al World J Surg 2009

45. Anal advancement flaps
Frenchay, Bristol
• 54 patients, V-Y advancement
flap
• 3 (6%) wound dehiscence
• 1 (2%) failed to heal
• No change in anal control
Chambers et al, Int J Colorectal Dis, 2010

46. PITFALLS IN THE MANAGEMENT
OF ANAL FISSURES
The “low pressure” fissure
• High index of suspicion
• Post partum
• Predominantly anterior
• Aetiology uncertain
• Avoid sphincter weakening surgery

47. PITFALLS IN THE MANAGEMENT
OF ANAL FISSURES
Conclusions
• Not as easy as you would like to think
• Non surgical treatments of some help, at
most
• Surgery still the “gold standard”
• Case selection and technique paramount
• Informed consent needs time

48. Picture millstone

49. A Big Scouse Welcome
ACPGBI – Liverpool July 1st -3rd 2013