**12.2 Fissurectomy**

Fissurectomy as a treatment for anal fissures in children was found successful only when combined with postoperative laxative therapy (Lambe et al., 2000a). An important part of their technique was the use of stay sutures to avoid the need for an anal retractor, thereby preventing stretching of the internal anal sphincter. A triangular part of the anoderm is excised along with the fissure itself. A good and reliable operation, but leaves behind a large and uncomfortable external wound, which takes a long time to heal. Application of a split thickness graft to the wound has been advocated, in order to improve healing.

#### **12.3 Internal anal sphincterotomy**

Internal anal sphincterotomy (IAS) was popularized for the treatment of anal fissure during the 1950s by Eisenhammer (1951). Lateral internal sphincterotomy (LIS) has been found to be the preferred operation. LIS can be performed using either the open or closed technique , the method of Notaras, dividing the IAS via a small stab wound (Notaras, 1971). Equal success has been reported with open or closed lateral sphincterotomy for acute and chronic anal fissures in children. A systematic review on the treatment of anal fissure was published by Steele & Madoff in 2006. Current concepts in anal fissures were reported by Ayantude et al. (2006) in the same year, involving a literature search from 1970 to 2004.

Chronic anal fissures tend to be refractory and are usually reluctant to heal with conservative treatment. Chronicity is defined by chronology (6-8 weeks) and morphologic features (visible transverse internal anal sphincter fibers, chronic granulation tissue, indurated edge, a sentinel pile, and a hypertrophic anal papilla). A very large series of adult patients was published by Lysy et al. in 2006. Prolonged periods of treatment were necessary and 384 patients were healed (84.4%) by the end of four months. Older age and longer time interval between symptom appearance and treatment negatively affected fissure healing. The explanation for the latter was that longer time exposure of the fissure area to

Nifedipine Gel with Lidocaine in the Treatment

Fig. 4. Clinical presentation (percentage)

bases and overlapping skin edges.

**14. Special situations** 

results (12 improved).

**15. Conclusions** 

require hospitalization.

of Anal Fissure in Children: A Pilot Study and Review of the Literature 65

1. Crohn's disease: Platell et al. (1996) noted symptomatic anal pathology in 42.4% of Crohn's disease patients, 27.6% of them presenting anal fissures. Frequently, they are multiple or off the midline, and often coexist with other pathology (Sangwan et al., 1996). They can be locally aggressive, progressing to form deep ulcers with granulating

2. HIV/AIDS: Anal fissures maintain their typical appearance, but have poor wound healing (Lord, 1997). Barrett et al. (1998) reported their experience with perianal disease in 260 HIV-positive patients, 32% of them with anal fissures (Barrett et al., 1998). Eighteen patients underwent sphincterotomies. Viamonte et al. (1993) reviewed the treatment of 33 HIV-positive fissure patients. Thirteen underwent LIS, with excellent

Topical 0.2% nifedipine with lidocaine appears today as the most efficient mode of treatment for anal fissures in children, with a significant healing rate and no side effects. It is safe and effective, prevents the evolution of acute anal fissures in children to chronicity, avoids surgical procedures in the great majority of cases, avoids complications and does not

inflammation and ischemia and subsequent fibrosis may compromise the healing process. After recurrence, patient education for self and prompt retreatment was found to improve outcome. Chronic anal fissures are caused by internal sphincter hypertonia, which leads to reduced blood flow and tissue hypoxia, with consequent healing failure. A cautious surgical approach is required to treat those who do not respond to medical treatment, and should include excision of the fissure along with its sentinel tag and internal sphincterotomy at the base of the ulcer (Cohen & Dehn, 1995; Lambe et al., 2000b). The wound is left open and should heal in 7-14 days without scarring. Local reconstruction with advancement flaps is a relatively new and effective adjunct to chronic fissure excision. Practice parameters for the management of anal fissures from the American Society of Colon and Rectal Surgeons were reported by Orsay et al. (2004) and a very extensive review on the diagnosis and care of patients with anal fissure was reported by the American Gastroenterological Association (Madoff & Fleshman, 2003).
