Fissurectomy versus Fissurectomy and Lateral Internal Sphincterotomy for Idiopathic Chronic Fissure in Ano. A Prospective, Randomized Trial 5 Years Postoperatively

Background and Purpose: Internal sphincterotomy remains the "gold standard" for treatment of anal fissure but is associated with a risk of anal continence. There are no long-term studies comparing results of treatment of chronic anal fissure with fissurectomy and fissurectomy and lateral sphincterotomy, respectively. This study was designed to assess the long-term healing rates and incidence of incontinence after fissurectomy versus fissurectomy and open lateral sphincterotomy in a prospective, randomized trial 5 years after operation. Patients and Methods: 60 patients (30 female, 30 male; age 17-77 years) were randomly assigned to fissurectomy (n = 30; group 1) or fissurectomy and lateral sphincterotomy (n = 30; group 2). Standardized questionnaires assessing complaints and continence were administered preoperatively, at 12 weeks, and after 5 years, and a proctologic examination was performed. Results: All operations were performed as short-stay hospital procedures in general anesthesia. Postoperative complications like bleeding, infection, or urinary retention did not occur. There were no significant differences in pain scores between groups at first defecation (median group 1: 2.5 versus group 2: 2.5), nor in pain medication. At 12 weeks postoperatively, 73% versus 80% of fissures had healed. 16 fissurectomy and 21 fissurectomy/sphincterotomy patients answered the questionnaire after 5 years (61.7%). At 5-year follow-up, new anal incontinence of minor grade was seen in 7/16 of patients in group 1 (43.75%) and 10/21 of patients in group 2 (47.62%). No patient suffered major incontinence. There were no significant differences in continence at 12 weeks or 5 years. 26/60 patients (43%) had reexamination (group 1: n = 13, group 2: n = 13) at 5 years. There was no recurrence of chronic anal fissure. Acute anal fissures were present in two patients (group 1: n = 1, group 2: n = 1), anal tags in four (group 1: n = 3, group 2: n = 1). Anal resting pressure was lower at 5-year follow-up than preoperatively but still in the normal range (median group 1: 85/75 mmHg, group 2: 92/80 mmHg; no significant difference). Conclusion: Healing rates are similar after fissurectomy or fissurectomy and lateral sphincterotomy. Incontinence after operative treatment of chronic fissure in ano is not insignificant. Fissurectomy is proposed as first-line operative procedure in the treatment of chronic anal fissure. Lateral internal sphincterotomy should remain an option for recurrence of fissure after fissurectomy.