title: Operative procedures for fissure in ano.
abstract: BACKGROUND
  Operative techniques commonly used for fissure in ano include: anal stretch, open lateral sphincterotomy, closed lateral sphincterotomy, posterior midline sphincterotomy and to a lesser extent dermal flap coverage of the fissure. Reports of direct comparisons between operative techniques for anal fissure are variable in their results. These reports are either subject to selection bias (in non-randomized studies) or observer bias (in all studies) or have inadequate numbers of patients enrolled to answer the question of efficacy.
  
  
  OBJECTIVE
  To determine the best technique for fissure surgery.
  
  
  METHODS
  The Cochrane Controlled Trials Register [Cochrane2000] and MEDLINE (1965-2000) were searched. The list of cited references in all included reports and several study authors also were helpful in finding additional comparative studies.
  
  
  METHODS
  All reports in which there was a direct comparison between at least two operative techniques were reviewed and when more than one report existed for any given pair, that report was included. If crude data were not presented in the report, the authors were contacted and crude data obtained.
  
  
  METHODS
  The two most commonly used end points in all reported studies were persistence of the fissure and post operative incontinence of flatus. These are the only two endpoints included in the meta-analysis.
  
  
  RESULTS
  Anal stretch has a higher risk of fissure persistence than internal sphincterotomy and also a significantly higher risk of minor incontinence than sphincterotomy. The combined results of open versus closed partial lateral internal sphincterotomy show little difference between the two procedures both in fissure persistence and risk of incontinence.
  
  
  CONCLUSIONS
  Anal stretch and posterior midline internal sphincterotomy should probably be abandoned in the treatment of chronic anal fissure in adults. For those patients requiring surgery for anal fissure, open and closed partial lateral internal sphincterotomy appear to be equally efficacious. More data are needed to assess the effectiveness of posterior internal sphincterotomy.
authors.affiliation: Surgery, University of Illinois, 1740 West Taylor, Room 2204 m/c 957, Chicago, Illinois 60612, USA. altohorn@uic.edu
authors.forename: R
authors.initials: R
authors.lastname: Nelson
mesh_terms: D001003:Anal Canal / Q000601:surgery*; D005401:Fissure in Ano / Q000601:surgery*; D005414:Flatulence / Q000209:etiology; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome