Comparing closed versus open lateral internal sphincterotomy for management of chronic anal fissure: systematic review and meta-analysis of randomised control trials

Abstract

Chronic anal fissure is one of the most common benign anorectal health conditions, causing significant morbidity, quality of life, and economic loss. Eight randomized controlled trials with a total population size of 1035 were eligible for analysis. Seven studies included both males and female, while one only included females. The majority of randomized controlled trials involved female dominance [54.9% (43.5–66.3)] and posterior midline location [86.1% (95% CI 81.5–90.8%)]. This meta-analysis of randomised control trials found that overall postoperative healing was 90.2%, recurrent anal fissure was 3.7%, and postoperative incontinence was 8.9% after LIS. Even though there was no statistically significant difference, closed lateral internal sphincterotomy (LIS) had higher rates of recurrent anal fissure (RR = 1.73 (95% CI 0.86–3.47, p = 0.90, I2 = 0%) and lower rates of postoperative incontinence rate (RR = 0.60 (95% CI 0.37–0.96, p = 0.76, I2-0) as compared with open LIS. We recommended that closed lateral internal sphincterotomy (LIS) is a safe and effective surgical treatment option for chronic anal fissures.

Comparative Analysis of Open and Closed Sphincterotomy for the Treatment of Chronic Anal Fissure: Safety and Efficacy Evaluation

“…Therefore, greater caution should be exercised in analgesic treatment during the first month in female patients. While a previous meta-analysis [ 4 ] did not find a statistical difference in pain by patient sex and age, it is important to consider that young female patients can require more analgesics. Further research may be necessary to explore potential sex and age-related variations in pain perception and analgesic needs after LIS surgery [ 4 ].…”

“…The idea of decreasing or increasing the size of the internal sphincterotomy is complex, and the different results in the literature reflect this complexity [ 16 , 17 ]. The recent meta-analysis also found a higher recurrence rate with the closed LIS technique [ 4 ]. However, in our study, no statistically significant difference was found between the 2 techniques.…”

“…The meta-analysis reported that open LIS surgery led to more incontinence than did closed LIS surgery. However, there are some crucial points, including allocation concealment and blinding of participants or personnel, that need careful consideration in interpreting these findings [ 4 ]. Further research is needed.…”

“…Patients can sometimes present with a triad syndrome, which includes a hypertrophic anal papilla on the proximal part of the fissure, a sentinel pile on the distal part of the fissure, and a chronic anal fissure. Some studies describe the excision of a skin tag and hypertrophic papilla during LIS to be associated with reduced pain, irritation during defecation, decreased foreign body sensation, and reduced itching [ 4 ].…”

Can topical applicatıons be an alternative to surgery in the treatment of chronic anal fissures?

“…The aim in the treatment of chronic anal fissure is to reduce the pressure on the internal sphincter muscle and to weaken sphincter spasm and to increase local blood flow 6 . While the general tendency favours medical treatment in cases of acute anal fissure, surgical treatment is often preferred in the management of chronic anal fissures.…”