Anal advancement flap versus conventional surgical technique in management of chronic anal fissure

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Abstract

Background and Study aims
Chronic anal fissures (CAF) are common and associated with reduced quality of life. Partial posterior internal sphincterotomy (PPIS) is frequently carried out and involves partial division of the internal anal sphincter. It carries a risk of anal incontinence, which can be as high as 14%. Anal advancement flap (AAF) combined with fissurectomy has emerged as an alternative, ‘sphincter-preserving’ procedure. Fissurectomy involves excision of the underlying fissure, effectively converting a chronic fissure to an acute one, whereas AAF involves the transfer of well-vascularized, healthy tissue onto the fissure base. The objective of this study was to compare the conventional PPIS and the AAF, using a V-Y advancement flap, regarding healing, anal continence, operative time, postoperative pain, and postoperative bleeding.
Patients and methods
Our study included 200 consecutive patients who presented at Kasr Al-Ainy colorectal outpatient clinic with CAF, who were randomized and divided into two groups. Group A underwent V-Y advancement flap, whereas group B underwent PPIS. Patients were followed up in the outpatient clinic at 1 week, 6 weeks, and 3 months postoperatively.
Results
The current study shows group A had lower healing rate (82%) compared with group B (96%). However, there were no recorded cases of anal incontinence postoperatively in group A compared with 14% in group B. Operative time was much less in group B. There were no significant differences regarding postoperative bleeding or pain.
Conclusion
We recommend the AAF for the surgical management of patients with CAF who are at high risk of developing anal incontinence. Further studies with bigger sample sizes are required to properly assess the rate of healing of the AAF compared with PIS.

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