Management of anal fissures: Latest guideline by American Society of Colon and Rectal Surgeons

An anal fissure is a linear tear within the anal canal that extends from the dentate line toward the anal verge. The most common location of anal fissures is in the posterior midline (73%). Still, they can be found in the anterior midline in 8% of men and 13% of women, with 2.6% occurring both anteriorly and posteriorly simultaneously.

The updated recommendation for the management of anal fissures is given below:

· Nonoperative treatment of acute anal fissures is safe, and authors recommend that it should typically be a first-line treatment.

· The authors recommend that anal fissures be treated with topical nitrates, although headache symptoms may limit their efficacy.

· The authors recommend using calcium channel blockers for chronic anal fissures as they have similar efficacy and a superior side-effect profile compared with topical nitrates and can be used as first-line treatment.

· Botulinum toxin showed similar results compared with topical therapies as first-line therapy for chronic anal fissures and modest improvement in healing rates as second-line therapy after failed treatment with topical therapies.

· The authors recommend lateral internal sphincterotomy in selected pharmacologically naive patients with chronic anal fissures.

· Lateral internal sphincterotomy (LIS) is the chronic anal fissures treatment in selected patients without baseline faecal incontinence (FI).

· Open and closed techniques of LIS yielded comparable results, and either technique may be used.

· LIS tailored to the fissure length yields comparable healing rates but decreased FI rates compared with traditional LIS extending to the dentate line.

· Short-term outcomes of repeat LIS or botulinum injection for recurrent anal fissures have shown reasonable healing rates with a low risk of FI. Still, the data are limited and require further study.

Jennifer S. Davids, University of Massachusetts, Worcester, Massachusetts, and colleagues wrote, "These guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed toward obtaining the same results."

"The physician should make the ultimate judgment regarding the propriety of any specific procedure considering all the circumstances presented by the individual patient."

Reference:

Davids, Jennifer S. M.D.1; Hawkins, Alexander T. M.D., M.P.H.2; Bhama, Anuradha R. M.D.3; Feinberg, Adina E. M.D.C.M.4; Grieco, Michael J. M.D.5; Lightner, Amy L. M.D.3; Feingold, Daniel L. M.D.6; Paquette, Ian M. M.D.7;  On behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anal Fissures. Diseases of the Colon & Rectum 66(2):p 190-199, February 2023. | DOI: 10.1097/DCR.0000000000002664