CHANGING PATTERNS OF TREATMENT FOR CHRONIC ANAL-FISSURE

To assess changing patterns of treatment for chronic anal fissure, a r etrospective analysis of treatment for chronic anal fissure within one hospital between January 1990 and December 1996 was undertaken. A tot al of 221 patients received treatment for a chronic anal fissure in th is period, of whom 209 had a surgical procedure. Manual dilatation of the anus was performed in 21 patients (10%) and has not been performed since 1995. Lateral internal sphincterotomy was performed in 183 pati ents (88%) and continues to be the mainstay of treatment. Five female patients (2%) were identified as having a sphincter defect by anal man ometry combined with endoanal ultrasound and were treated by an anal a dvancement flap. From 1996 onwards, 15 patients (7%) were treated by t opical glyceryl trinitrate (GTN) paste as the first line of treatment. Of these patients, nine have experienced healing of their fissure, an d three have had relief of pain without healing of the fissure. Three have gone on to have a lateral internal sphincterotomy. Lateral intern al sphincterotomy remains the primary form of treatment for chronic an al fissure. GTN cream has increasingly been offered as preliminary tre atment over the last 12 months. Perioperative use of endoanal ultrasou nd allowed identification of patients who may be at high risk of posto perative incontinence from a sphincterotomy. An anal advancement flap has been used as an alternative surgical approach for these patients.