Document 63133

The Royal
Ann R Coll Surg Engl 2000; 82: 254-257
College of Surgeons of England
Original article
Fissurectomy as a treatment for anal
in chld ren
GF Lambe, CP Driver, S Morton, RR Tumock
Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK
Introduction: Anal fissures, characterised by painful defecation and rectal bleeding, are
common in both children and infants. A significant proportion are resistant to simple
laxative therapy, and no simple surgical treatment has been described which does not
risk compromising sphincteric function. This study reports the initial experience of
fissurectomy as a treatment of this condition.
Patients and Methods: Over a 36 month period, 37 children with an anal fissure were
treated by fissurectomy. There were 14 boys and 23 girls, with an age range of 17 weeks to
12 years. Fissurectomy was performed under general anaesthetic, with additional caudal
anaesthesia. Stay sutures were used to avoid the need for an anal retractor, thereby
preventing stretching of the internal anal sphincter. Of the 37 operations, 36 (97%) were
performed as day cases and all children were discharged on laxative therapy.
Results: At review, 6 weeks postoperatively, 30 (81%) were asymptomatic. Six (16%)
patients were symptomatic; however, 4 of these had failed to comply with the
postoperative laxative regimen. One patient failed follow-up.
Conclusions: Fissurectomy is a successful treatment for anal fissures, when combined
with postoperative laxative therapy. As dilatation of the internal anal sphincter is not
involved, the risk of iatrogenic faecal incontinence is obviated.
Key words: Paediatric surgery Anal fissure Constipation
Tnfants and children with an anal fissure, characterised
Iby painful defecation and rectal bleeding, commonly
present to the paediatric surgeon. The peak age at
presentation is 6-24 months, coincident with weaning.1
Conventional treatments in children have included
combination of an increase in dietary fibre, the
application of topical local anaesthetic preparations and
laxative therapy.1 In fissures resistant to medical management, surgical treatment has been offered. Anal
dilatation is traditionally recommended as the initial
Correspondence to: Mr RR Turnock, Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool L12 2AP, UK
Tel: +44 151 252 5750; Fax: +44 151 252 5362; E-mail: [email protected]
Ann R Coll Surg Engl 2000; 82
Figure 1 Stay sutures placed either side of the fissure
Figure 2 Excised fissure, with internal sphincter fibres visible in
base of wound
surgical procedure,2 with lateral internal sphincterotomy reserved for intractable cases.3 Both approaches,
although often effective, carry the risk of faecal incontinence in later life. Moreover, no surgical therapy for
the treatment of anal fissure in children has been
subjected to a randomised controlled trial. Fissurectomy
in the treatment of anal fissures in adults has been
previously described,4 but has usually been combined
with a posterior midline internal anal sphincterotomy.
We describe a new technique for simple anal fissurectomy without dilatation, for the management of anal
fissures in children.
All children underwent fissurectomy under general
anaesthesia together with, in 34/37 (92%) children, a
caudal anaesthetic using 2.5% bupivicaine hydrochloride (0.3-0.5 ml/kg). The child was placed in the
lithotomy position and the presence of a fissure
confirmed on visual inspection. A 3/0 silk stay suture
was then placed on each side of the fissure (Figure 1),
thus avoiding the need for an anal retractor. The
fissure was excised through the full thickness of the
anal mucosa using sharp dissection (Figure 2). The
fibres of the internal anal sphincter were identified and
preserved. The resulting mucosal defect was repaired
with interrupted 4/0 polyglactin 910 (Vicryle®, Ethicon
Ltd, Edinburgh, UK; Figure 3). All patients were
discharged on lactulose and senna at a weight-related
dose and reviewed at a surgical out-patient clinic 6
weeks later.
Patients and Methods
Over a 36 month period, 37 children (age range 17
weeks to 12 years; 14 boys and 23 girls) with an anal
fissure presented to a paediatric surgical out-patient
clinic. The fissure was diagnosed on a clinical history
and visual inspection of the anus. Digital rectal examination was not performed. The duration of symptoms
ranged from 6 weeks to 4 years. Symptoms at presentation were rectal bleeding in 8 (22%), pain in 5 (13%),
with 24 (65%) having both. Twenty-eight children had
been on laxatives prior to admission.
Ann R Coll Surg Engl 2000; 82
On examination under anaesthesia, the anal fissure was
identified as anterior in 19 (56%) children, posterior in
13 (38%) and both anterior and posterior in 5 (15%). No
sex difference in the distribution of the fissure was
identified. One child had an additional superficial fistula255
Figure 3 Final result following closure of defect with interrupted
in-ano, treated by fistulotomy under the same anaesthetic. At review 6 weeks postoperatively, 30 (81%) were
asymptomatic, with 1 other defaulting. Of the 6 (16%)
symptomatic patients, 4 had failed to comply with the
postoperative laxative regimen. A further fissurectomy
was performed in 2 of these children with a subsequent
resolution of symptoms.
The results of this study suggest that excision of the
open ulcer that is an anal fissure is a successful
treatment for anal fissure, with 81% children reporting
as asymptomatic at review. It does, however, require
combination with a stool softener to prevent recurrence
of the original pathology.
The pathogenesis of anal fissures in children is
traditionally associated with the passage of a constipated stool with resultant tearing of the anal mucosa.
The associated pain encourages stool retention, increasing constipation and establishment of a cycle of worsening pain. Adult studies have also demonstrated
ischaemia of the anal canal and anal sphincter spasm as
important aetiological factors.5 There is, however, no
current evidence for an ischaemic mechanism in childhood fissures. The mainstay of therapy in childhood
anal fissures must be directed, therefore, to reducing the
associated pain and allowing restoration of normal
patterns of defecation.
The treatment of anal fissures in children is
essentially empirical. The use of laxative therapy alone
will allow healing of a proportion of fissures, and many
of these patients will never attend a surgical out-patient
clinic. A significant number of children in our study,
28/37 (76%), were already on laxative therapy at
presentation. The traditional surgical treatments of anal
dilatation and lateral sphincterotomy are extrapolated
from adult practice, with no therapeutic regimen used in
children having been subjected to a randomised trial.
The potential hazards of each technique are also poorly
documented. In adult series, anal dilatation carries a
significant risk of internal sphincter injury, and
subsequent minor and major incontinence at prolonged
follow-up.6 Endo-anal ultrasound studies have also
demonstrated significant injury to the internal anal
sphincter following anal dilatation.7 While there is, to
date, no evidence for similar injury to the internal
sphincter in children, the potential risk must be of
concern. Lateral sphincterotomy deliberately disrupts
the internal anal sphincter in a more controlled fashion.
Again, little follow-up data is available in children, but
adult series have demonstrated faecal incontinence in
0-21% of patients.89
Recent studies in adult patients have demonstrated
the efficacy of topical glyceryl trinitrate in both reducing
anal sphincter pressure and healing anal fissures.'0 To
date, however, there are no available data in children;
but, if internal sphincteric spasm is important in
childhood fissures, this may be a useful therapeutic
The major advantage of this method of fissurectomy
is that the internal anal sphincter is not stretched or
disrupted at any stage, thus avoiding any risk of
subsequent incontinence. The stay sutures allow access
to the fissure without the need for an anal retractor,
which can produce a significant anal stretch in a young
child. The mechanism of action of fissurectomy remains
unclear, but excising an 'ulcer' and replacing it with a
surgical wound may aid healing and reduce pain. The
use of additional caudal anaesthetic also allows a
prolonged period of postoperative analgesia and may be
an important part of the technique. Its use is to be
recommended in all children.
This study has demonstrated that the technique of
fissurectomy, combined with adjuvant laxative therapy,
can be useful in the management of anal fissures in
children. There remains, however, a paucity of data on
the management of anal fissures in children and there is
a clear need for randomised controlled trials of all
Ann R Coll Surg Engl 2000; 82
available therapeutic options before an ideal treatment
regimen can be recommended. In particular, the role of
surgical therapy must be compared with appropriate
medical regimens, including the use in children of
topical glyceryl trinitrate.
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