A total of 1355 patients underwent internal sphincterotomy for chronic fissure in ano between 1980 and 1985. Surgical data were obtained for 1102 patients, and 829 patients responded to a questionnaire. Of the 1057 for whom the time of healing was recorded, 1033 (97.7 per cent) healed by a mean time of 5.6 weeks. No significant differences in satisfaction with the outcome or in deficits in continence were noted between groups undergoing lateral, bilateral or posterior midline sphincterotomy. Excision of the fissure was found to be unnecessary. According to responses on the questionnaires, deficits in continence ranging from 'sometimes' to 'frequently' included lack of control of flatus (35.1 per cent), soiling of underclothing (22.0 per cent) and accidental bowel movements (5.3 per cent). A significantly higher proportion of patients who had accidental bowel movements were aged over 40 years.

Sequelae of internal sphincterotomy for chronic fissure in ano.

The authors believed that it might be possible to explain the local frequency of the anal fissure at the posterior commissure by an anatomic relationship, and examined the blood supply of the anus. The inferior rectal artery is demonstrated by postmortem angiography and by manual preparations (N=4) and histologic study after angiography of the vessels (N=10). The blood supply at the different sites of the anal canal are demonstrated by a morphometric study (N=20). The inferior rectal artery presents two variants in the postmortem angiographies, type 1 (85. 4 percent) and type 2 (14.6 percent). In type 1, the posterior commissure is less perfused than the other sections of the anal canal. In addition, the blood supply may be more compromised by contusion of the vessels passing vertically through the muscle fibers of the sphincter ani internus muscle during increased sphincter tone. The role of topography in the pathogenesis of the primary anal fissure is illustrated in a model

Topography of the inferior rectal artery: a possible cause of chronic, primary anal fissure

Background
Reports of direct comparisons between operative techniques for anal fissure are variable in their results. These reports are either subject to selection bias (in non-randomized studies) or observer bias (in all studies) or have inadequate numbers of patients enrolled to answer the question of efficacy.

Objectives
To determine the best technique for fissure surgery.

Search methods
The Cochrane Central Register of Controlled Trials and MEDLINE (1965-2011), Medline (Pubmed) and Embase were searched March to 2011. The list of cited references in all included reports and several study authors also were helpful in finding additional comparative studies.

A total of four new trials were included in this update of the review.

Selection criteria
All reports in which there was a direct comparison between at least two operative techniques were reviewed and when more than one report existed for any given pair, that report was included. All studies must also be randomised. If crude data were not presented in the report, the authors were contacted and crude data obtained.

Data collection and analysis
The two most commonly used end points in all reported studies were treatment failure and post-operative incontinence both to flatus and faeces. These are the only two endpoints included in the meta-analysis.

Main results
Four trials, encompassing 406 patients were included in this update, with now a total of 2056 patients in the review from 27 studies that describe and analyze 13 different operative procedures. These operative techniques used by these studies include closed lateral sphincterotomy, open lateral internal sphincterotomy, anal stretch, balloon dilation, wound closure, perineoplasty, length of sphincterotomy and fissurectomy. Two new procedures in the update, similar to anal stretch were described- sphincterolysis and controlled intermittent anal dilatation. A new comparison was described, comparing the effects of unilateral internal sphincterotomy and bilateral internal sphincterotomy.

Manual Anal stretch has a higher risk of fissure persistence than internal sphincterotomy and also a significantly higher risk of minor incontinence than sphincterotomy. The combined analyses of open versus closed partial lateral internal sphincterotomy show little difference between the two procedures both in fissure persistence and risk of incontinence

Unilateral internal sphincterotomy was shown to be more likely to result in treatment failure compared to bilateral internal sphincterotomy, but there is no significant difference in the risk of incontinence.

Sphincterotomy was less likely to result in treatment failure when compared to fissurectomy, but there was no significant difference when considering post-operative incontinence.

When comparing sphincterotomy to sphincterolysis, there was no significant difference between the two procedures both in treatment failure and risk of incontinence; the same is the case when comparing sphincterotomy with controlled anal dilation.

Authors' conclusions
Manual anal stretch should probably be abandoned in the treatment of chronic anal fissure in adults. For those patients requiring surgery for anal fissure, open and closed partial lateral internal sphincterotomy appear to be equally efficacious. More data are needed to assess the effectiveness of posterior internal sphincterotomy, anterior levatorplasty, wound suture or papilla excision. Bilateral internal sphincterotomy shows promise, but needs further research into its efficacy.

/pdf/operative-procedures-for-fissure-in-ano-1v99qpnkw0.pdf

Operative procedures for fissure in ano

BACKGROUND: In their practice nurses constantly make decisions in a dynamic context including complex situations. Besides affecting elements related to the decision-maker and the task itself, the setting where the decision-making process takes place are of decisive importance to the quality of the decision-making outcome. AIM: The aim of this study was to explore environmental elements related to the decision-making process in nursing practice. METHODS: Six expert nurses, from three Swedish nursing settings, participated voluntarily in the study, which were designed of participated observations in everyday nursing practice. Permission to carry out the study was given by the clinics and an ethical committee. A content analysis was used to analyse the field notes where themes emerged which were found to be environmental elements affecting decision-making process of nurses. CONCLUSIONS: The most striking theme, environmental elements, included the sub-themes interruptions and the work procedures are presented in this report. The implications of environmental elements, are discussed from a perspective of nurses' competence, where the elements could be seen as a facilitator or as a hindrance to developing nursing competence. It were concluded that environmental elements have to be well considered before knowledge can be reached about decision-making in practice. RELEVANCE TO CLINICAL PRACTICE: Interpersonal and technological interruptions were features highlighted in the study, features which could jeopardize the decision-making outcome. Therefore, it is of greatest importance that nurses learn to use decision-making strategies to guarantee patient care security and patient care quality.

Environmental elements affecting the decision-making process in nursing practice.

The Principles and Practice of Rectal Surgery.

One hundred and three patients with anal fissures have been treated by lateral internal sphincterotomy performed by a subcutaneous myotomy technique, and 99 have been successfully followed up for from 3 to 24 months (mean 11 months). The operation was free from significant complications, apart from slight reactionary bleeding in one case and a perianal abscess in another. The fissure persisted or recurred in three cases, in one of which a further lateral sphincterotomy was performed, with cure. Various minor defects of anal continence were noted in 12 cases. These results have been found to be superior to those obtained previously in the same surgical unit with open posterior internal sphincterotomy and simple sphincter-stretching respectively in the treatment of anal fissure. The most reliable and satisfactory operation at present available for this condition seems, therefore, to be lateral subcutaneous internal sphincterotomy.

Lateral subcutaneous internal sphincterotomy in treatment of anal fissure.

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Lateral subcutaneous internal sphincterotomy in treatment of anal fissure.