The Evolution of the Treatment of Anal Fissure in the United States

Alexander Marcia, Herand Abcarian, Ariane Abcarian


Chronic Anal Fissure (CAF) is arguably the most painful anal disease with the severity of pain disproportionate to the size of the fissure (8-10mm). Its location in the posterior midline of the anus allows for easy diagnosis without need for rectal examination or instrumentation.

The treatment of CAF was excision based on the theory of crypititis causing ulceration, healing and breakdown resulting in anal stenosis. Lockhart Mummery at St. Mark’s Hospital attributed the stenosis to “pecten band” in the external sphincter. So, the treatment of choice became fissurectomy and division of the pecten band. In 1951 Eisenhammer from South Africa demonstrated the role of the internal anal sphincter (IAS) in CAF. Thereafter midline internal sphincterotomy became the customary operation of CAF.

The advent of manometry in the late 60s allowed for accurate measurement of anal sphincter pressures. Nothman and Schuster demonstrated the high resting tone of the IAS in fissure patients and attributed the severe postcibal pain to “overshoot phenomenon”. Notaras in1969 proposed lateral internal sphincterotomy to reduce the anal resting tone and healing of CAF without excising the fissure itself. This procedure has become the procedure of choice of CAF in the last 40 years.

In 1989 Khubchandani and Read reported a significant rate of anal seepage and incontinence after LIS and the stage was set for attempting “chemical sphincterotomy” with pharmaceuticals used to reduce the IAS pressure in CAF. Nitroglycerine was soon followed by Nifedipine and Diltiazem gel and later Botulinum toxin injection to cause relaxation of IAS. All these measures may help the healing of CAF initially but in most cases the result was temporary, and fissures recur after stoppage of chemicals. To this date there is no chemical agent that can compare with the result of LIS in CAF patients, irrespective of the fear of incontinence in the litigious population in the United States.


Chronic Anal Fissure, Lateral Internal Sphincterotomy, Chemical Sphincterotomy, Fecal Incontinence

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