Anal fissure treatment in 2022 - A global snapshot audit conducted by the International Society of University Colon and Rectal Surgeons (ISUCRS)

Anal fissure treatment in 2022 - A global snapshot audit conducted by the International Society of University Colon and Rectal Surgeons (ISUCRS) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Anal fissure treatment in 2022 - A global snapshot audit conducted by the International Society of University Colon and Rectal Surgeons (ISUCRS) Audrius Dulskas, Joseph Nunoo-Mensah, Richard Fortunato, Majid Huneidy, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4622979/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background An anal fissure is a longitudinal tear in the mucosa of the anal canal, distal to the dentate line. It is usually situated in the posterior midline but can occur in any quadrant. This condition affects both genders and is associated with pain, bleeding, anal discomfort, amongst other symptoms. Aim The aim of this study is to evaluate the global treatment and follow-up of patients with anal fissures in different countries and continents. Method A prospective cohort audit database was created with the cooperation of fifty-six doctors from twenty-one different countries. The patients were evaluated according to the type of anal fissure they had, treatment they underwent and results of 8-week post-treatment. Results Overall, 302 patients were included, with 106 (35%) diagnosed with an acute anal fissure and 196 (65%) a chronic anal fissure. Leading symptoms were painful defecation (n = 280, 92.7%) followed by anal bleeding (n = 194, 64.2%) and painful bleeding during defecation (n = 182, 60.2%). A total of 111 (36.8%) underwent surgical treatment. Out of the 264 (87%) who underwent follow-up at 8-weeks, 116 patients (44%) were cured, 86 (32.6%) showed marked improvements, 46 patients (17.4%) showed some improvement, 16 (5.0%) reported no change and one patient (0.3%) had worsened symptoms. Complications arising after treatment was recorded in 18 (6%) patients, with 15 (83%) complaining of headaches, 2 (5%) indicated hypotension, perineal sepsis, anal bleeding and/or allergies to medications used during treatment. Comparing pre-treatment and post-treatment Wexner Incontinence Scores, no patients had worsening fecal incontinence, 95.7% showed stable scores, while 13 (4.3%) showed improved scores. Conclusion The majority of surgeons chose a non-surgical approach as a first line treatment for anal fissures whether acute or chronic. Overall, 94% of all patients had resolution or improved symptoms, with none of the surgically treated patients developing fecal incontinence afterwards. anal fissure chronic anal fissure fissure treatment lateral sphincterotomy Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Anal fissure is one of the most common causes of anal pain and bleeding with 235,000 new cases occurring every year in the United States alone (1). It accounts for overall incidence of 1.1 per 1000 person-years and to an average life time risk of 7.8% (2). Anal fissure is described as a longitudinal tear in the mucosa of the anal canal, more specifically in the perineal skin, distal to the dentate line. It is believed that this pathology occurs due to an over distention or disease of the anal mucosa which leads to a laceration of the anoderm. (3). A spasm the exposed internal anal sphincter leads to pulling along the laceration, which impairs healing and worsens the extent of laceration with each bowel movement. It is believed that the posterior commissure has a poor blood supply, therefore predisposing it to ischemia (4, 5, 6). Anal fissures are usually managed conservatively (7), whether it is done with the use of calcium channel blockers (Nifedipine or Diltiazem), Nitrates, warm sitz bath, oral painkillers or Botulin Toxin. All of which have been deemed acceptable with few adverse effects and high cure rates. Guidelines set by the American Society of Colon and Rectal Surgeons supported the use of the previously mentioned conservative treatment methods and urged medical professionals to use non-surgical treatment modalities as a first line treatment since they are considered safe since they have few side effects (8). Surgically, however, lateral internal sphincterotomy (LIS) still remains the gold standard to treat anal fissures permanently, more often in chronic cases (9), with a low rate of complications and a reduced cost burden. Whether it is performed using an opened or closed approach, both can achieve similar recovery and complication rates (10). Although this pathology is very common, there is unfortunately few articles describing the real world data on treatment and management practice worldwide. Our aim from this study was to evaluate the treatment of anal fissures and to compare the success rate of treatment procedures in the follow-up in different countries. Patients and Methods After all approvals were issued according to each nation's laws and consent to participate in the study was obtained by signature from patients, a prospective cohort audit was performed. All the members of ISUCRS seeing at least 5 patients with anal fissures per month were invited to participate in the study. The inclusion period was any two weeks between June and July 2022. All the consecutive patients were included. Patient data from twenty-one countries were obtained with the cooperation of 56 doctors in a form of an electronic database. The Inclusion criteria were covered all the consecutive patients coming to the clinic for anal pain/bleeding, diagnosed with fissure using digital rectal examination and/or endoscopic evaluation (subjective classification). Moreover, the state of fissure (acute vs chronic) was decided by the treating physician upon examination (presence of sentinel piles or thick borders were signs of chronic fissure). Patients who had a psychiatric history, who were currently pregnant / breast feeding, immunosuppressed, with Crohn’s, concomitant anal fistulas, abscesses or anal tuberculosis were excluded from the research. The demographic information was collected from the medical records of the patients and the American Society of Anesthesiologist's classification system assessed the comorbidities associated with the anal fissure. All records of the past medical history, obstetrics history, vaginal delivery, number of vaginal deliveries, history of episiotomy, and history of perineal tear were taken into consideration. To assess the effect of the intervention of the anal fissures, the patient's current symptoms were recorded, and a pain visual analog scale was used to assess the severity of the pain. The greater the number in the pain visual analog scale, the greater the pain intensity is. Patients diagnosed at the time of the current intervention were considered the acute case, and those who had an anal fissure for more than six weeks (or the fissure had sentinel piles or harder boarders upon examination) were regarded as the chronic case. Wexner score was used to assess the continence (11). The number 0 referred to patients who had no incontinence, and the number 20 was given to patients who had the worst continence. The record of the treatment and surgical intervention done before the encounter was noted to assess the success of the current treatment as compared to the prior treatment. Later the intervention for the treatment of anal fissure was done and compared with the conditions above, and the data about the procedures, complications, and outcomes were recorded. Treatment success was recorded when resolution of symptoms was achieved (during follow up or a telephonic conversation with the patient in question) or the complete healing was noticed upon examination. All the details of the patient's demographic data, pre-and post-treatment details, and outcomes were noted. The success of the current treatment that was given to patients was assessed at an 8-week follow-up. Statistical analysis This report has been prepared in accordance to guidelines set by the STROBE (strengthening the reporting of observational studies in epidemiology) statement for observational studies Student's t-test was used for normal, continuous data, Mann-Whitney U test for non-normal continuous data or Chi-squared test for categorical data. Data analysis was undertaken using R Studio V3.1.1 (R Foundation, Boston, MA, USA). Results After excluding patients with psychiatric history, 302 patients were included in the study in which a higher prevalence was found in women with 155 patients (51.35%) than men with 147 individuals (48.65%). ASA I was assessed in 198 patients (65.6%), ASA II was found in 93 individuals (30.4%), while ASA III and ASA IV were recorded in nine and two (0.7%) subjects respectively Considering the medical history relevant to our study, a number of patients were grouped according to similar pathologies they encountered (Table 1 ). Table 1 Past medical history of patients included in the study. Past medical history Number of Patients Hemorrhoids 82 Vaginal childbirth 54 Anal Fistula 10 Anorectal trauma 5 HIV / AIDS 3 Psoriasis at genital area 1 Genital Herpes 1 Other 15 None 164 Focusing on the female cohort, 95 females were found to have had obstetrics history before this encounter with 78 patients having an account of vaginal deliveries, out of which 1 (1.2%) of patient having zero vaginal deliveries, 25 (32%) of individuals with one delivery, 35(46%) with two deliveries and 11 (14%) with three vaginal deliveries. Six females (7%)) had four or more vaginal deliveries. Moreover, 48 female patients were found to have had a history of episiotomy while two patients had perineal tears. Leading symptoms were painful defecation (n = 280, 92.7%) followed by anal bleeding (n = 194, 64.2%) and painful bleeding during defecation (n = 182, 60.2%) (Table 2 ). Table 2 Anesthetic technique used during surgical interventions Anesthetic technique Number of patients who underwent mentioned technique Intravenous anesthesia 23 (8.9%) Local anesthesia 33 (12.8%) Combination of Local and Intravenous anesthesia 36 (14%) Regional block 75 (29.3%) General anesthesia 89 (34.7%) The severity of the pain experienced by patients at the time of encounter was taken into account and categorized using the pain visual analog scale (Fig. 1 ). Of all, 106 patients (35%) had acute anal fissure while 196 (65%) patients were found to have chronic fissures. Before this encounter, a number of patients underwent various treatment methods, ranging from conservative (Fig. 2 ) to surgical approaches (Fig. 3 ). Moreover, 142 of them had some surgical treatment with 53 of them having already LIS undergone. Moreover, five patients had fissurectomy and later LIS. Thirty four patients had more than one surgical procedure. In the current encounter, conservative medical and surgical treatment was used as well for anal fissures. Conservative medical treatment ranged from the use of warm sitz baths to topical appliance of nifedipine/diltiazem (Fig. 4 ). In surgical intervention which totaled 256 interventions, 155 (60.5%) patients were given the ambulatory surgical procedure, whereas 101 (39.5%) patients were given inpatient admission with several anesthetic techniques used during interventions (Table 2 ). Sixty six patients underwent different surgical procedures, ranging from anal dilatation (22), to botulin toxin injection (24) and other. Treatment complications were seen in 18 patients, out of which 15 (83%) experienced headaches, one (5%) individual had reported allergy to anal fissure medication, one (5%) patient had hypotension, one presented perineal sepsis, two (10%) presented with anal bleeding, one (5%) with urinary retention while one (5%) experienced anesthetic complications and four (22%) declared to have had other forms of complications. Upon assessing the Wexner fecal incontinence score during the course of our study, we noticed a change in the pretreatment vs post-treatment score. In fact, the average Wexner score for individuals in between the range of 0 to 10 in the pretreatment was 1.07 compared to a post-treatment average of 1.31. However, in regards to a patients being scored in the range of 11 and above, only the pretreatment cohort indicated an average of 11.61 with no individual post-treatment possessing a score higher than 10. Of the total patients, 268 received follow-ups within eight weeks after the current treatment, of which 224 (84%) patients did the actual visit with the doctor and 44 (16%) had the virtual visit. After the treatment, 119 (44.4%) of patients were free of anal fissures. 86 (32.2%) showed marked improvements with no medications after intervention; 46 (17.1%) showed gradual improvement, needing medications every now and then. Sixteen (6.0%) of patients reported no change in the condition. One had worse (0.3%) symptoms. Discussion Our survey is the first to include colorectal surgical specialist physicians from across the globe encompassing (56 surgeons, from 21 countries including all continents). Over 300 patients are included with an 8 week follow up results. In our prospective cohort study, we found that surgeons started treatment in almost every patient (85%) with a conservative approach. The most common initial treatment was dietary modification due to the ease of its application and patient compliance (12). In a study assessing the Persian medical effect on fissure treatment, constipation was considered to be a cause of fissures (12) and it was therefore recommended that avoidance of some foods and commercial baked goods was potentially beneficial. In contrast, our study noted the benefits of dietary changes were correlated with stool consistency, not to any specific food intake or avoidance. Then second most commonly used conservative treatment identified in this study was the use of warm sitz bath, which has been speculated to have an analgesic effect as well improve healing by relieving sphincter spasm. A study undertaken by Jensen et al (13) who used warm sitz baths along with unprocessed bran to treat anal fissures in 96 patients argued that this treatment combination yielded the same results as topical analgesics and anti-inflammatory ointments while avoiding their side-effects and costs. (13) Another study performed by Alnasser et al. (14) on 519 patients has shown that the use of conservative management protocol consisting of salty warm sitz bath three times daily, 2 grams glycerin suppositories per rectum 20 minutes before defecation and bulk-forming fiber daily yielded complete fissure healing in 379 (70.3%) patients with a duration range from 3–7 weeks. The remaining 160 (29.7%) patients who did not heal ultimately had surgical intervention with a 0% recurrence rate. Topical or oral painkillers were also a conservative method of treatment chosen by a large group of our physicians. The use of topical or oral calcium channel blockers have shown effectiveness in treating anal fissures by alleviating painful symptoms and by vasodilation, therefore accelerating the healing process. This has led others to stress that the use of topical painkillers should be considered before considering surgical options (15). The major limitations of painkillers are cost, temporary benefits and higher relapse rates, leading some to recommend LIS for patients that have failed to respond to first-line conservative therapy, or for those who relapsed with medical management (16). A prospective controlled trial that compared the effect of 2% diltiazem and LIS for treatment of chronic anal fissures found LIS was more effective complete healing at 6 weeks (96% v 71%), and for pain relief (15). The use of botulin toxin was not frequently used by our physicians with 6.6% using it to treat chronic anal fissures and only 0.7% in acute cases. When used as first-line therapy for chronic anal fissures, botulinum toxin produces comparable results to topical therapies, however when used as second-line therapy after topical therapies, the use of botulinum toxin would only slightly improves healing rates (7). A pooled analysis of studies indicated a 13.5% increase in the absolute rate of healing and a 38% increase in the rate of healing in comparison to placebo or Lidocaine alone (18). A survey from American Society of Colon and Rectal Surgeons (ASCRS) (19) showed that the majority of surgeons (90%) were using 50-100U of botulinum toxin, with a majority of respondents (64%) injecting the internal sphincter and a majority of participants (53%) injecting it into 4 quadrants of the anal canal circumference. Most procedures were performed under MAC anesthesia (56%). In fact an increase in usage of botulin toxin by our physicians was noticed when treating chronic cases with 6.6% in comparison with only 0.7% used in acute cases. A similar study supported the use of botulinum toxin in chronic, uncomplicated anal fissures with an increased sphincter tone due to its tolerability, ability to be administered in outpatient settings and low probability to cause incontinence (20). A study by Altomare et Al. (21) stated that for acute anal fissures, conservative treatment can provide a cure in 87% of cases, but only 50% in cases of chronic anal fissures. They concluded, that if conservative treatments fail to provide a definitive treatment, physicians usually resort to the use of invasive procedures. This is also supported by recently issued guidelines (7) and was seen in our survey. A LIS was the procedure of choice for physicians participating in this study (22) due to its effectiveness and low risk of fecal incontinence. This was found to be in line with other studies regarding healing, patient satisfaction and low recurrence rates (23, 24). Fecal incontinence after LIS ranges from 'sometimes' to 'frequently' and includes lack of control of flatus (35.1%), soiling of underclothing (22%) and accidental bowel movements (5.3%) - but following sphicterotomy these numbers might be overestimated (25). According to our survey, patients who had treatment did not develop worsening fecal incontinence. Changes in the Wexner score before and after treatment showed improvement from 96% of patients who had a score of 10 or lower (indicating continence) to 100% with score of 10 or lower, showing the efficacy and safety overall of fissure treatments. A main issue expressed by researchers that have undertaken similar studies on anal fissures was the length of the follow up period where one study had 6 weeks follow up while another had a 4 week follow up, this has unfortunately proven to be insufficient. At least an 8-week post-treatment follow-up visit is required for the assessment of the status of the fissure. Most patients show improvement in this period, as shown in our study. The period of 8 weeks is essential to conclude which intervention has a better response and can be used for future treatment (26). Although this global survey included patients with anal fissure from all continents, it has some limitations. Firstly, the inclusion of the patients may be biased as there was no regulating/validating body. Secondly, there was not a complete certainty whether the patients adhered to the diet change or the medication regiment prescribed by physicians. However, these common issues encountered by doctors everywhere and therefore may not have significant effects on our data. Moreover, the demographic figures present in this study also give a limited data about age by which it did not mention the age range in which most anal fissures occur. Finally, some of the patients were contacted via phone without possibility to perform the digital examination and the healing was decided solely upon resolution of the symptoms. Conclusion Our survey is the first anal fissure study to include colorectal surgical specialist physicians across the globe, and showed the vast majority of experts use conservative therapy as the initial treatment, and lateral internal sphincterotomy as definitive treatment for refractory cases. In addition, there was overall improvement with fecal continence after fissure treatment. Declarations Funding Statement No funding was received. Conflict of Interest Disclosures Authors declare no conflicts of interest Ethics approval statement This work followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines. 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Open versus closed lateral sphincterotomy performed as an outpatient procedure under local anesthesia for chronic anal fissure: Prospective randomized study of clinical and manometric longterm results. Journal of the American College of Surgeons, 2004:199(3), 361–367. https://doi.org/10.1016/J.JAMCOLLSURG.2004.04.016 Khubchandani IT, Reed JF. Sequelae of internal sphincterotomy for chronic fissure in ano. Br J Surg 1989;76(5):431–4 Anal Fissure Expanded Information | ASCRS . (n.d.). Retrieved November 12, 2022, from https://fascrs.org/patients/diseases-and-conditions/a-z/anal-fissure-expanded-information Additional Declarations No competing interests reported. Supplementary Files Suppelmentary1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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18:53:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4622979/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4622979/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60618150,"identity":"e18c0f09-f9f2-4d3f-8ec2-122ddca463c7","added_by":"auto","created_at":"2024-07-18 20:34:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":8288,"visible":true,"origin":"","legend":"\u003cp\u003ePain visual analog scale for patients with anal fissure\u003c/p\u003e","description":"","filename":"Onlinedrawingimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4622979/v1/c864c9983a87698779929d4c.png"},{"id":60619219,"identity":"46e148fd-1bd2-44d4-87b6-1881712e3050","added_by":"auto","created_at":"2024-07-18 20:42:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":15261,"visible":true,"origin":"","legend":"\u003cp\u003eConservative treatments for patients with anal fissure prior to this encounter\u003c/p\u003e","description":"","filename":"Onlinedrawingimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4622979/v1/c962053d28a5a9d150ebc2b2.png"},{"id":60618141,"identity":"3e61e24a-0202-483a-81da-8f47f0f90349","added_by":"auto","created_at":"2024-07-18 20:34:55","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":5482,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical treatments for patients with anal fissure prior to encounter\u003c/p\u003e","description":"","filename":"Onlinedrawingimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-4622979/v1/a6c781dfad433c655fccbd13.png"},{"id":60618143,"identity":"52a3ab0c-74c1-46ec-9a9a-2d3f8a9b068b","added_by":"auto","created_at":"2024-07-18 20:34:55","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":12825,"visible":true,"origin":"","legend":"\u003cp\u003eConservative treatment used during current encounter for patients with anal fissure\u003c/p\u003e","description":"","filename":"Onlinedrawingimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-4622979/v1/fc4d258ff6ccf95dff38771b.png"},{"id":68389745,"identity":"e319c1f9-4235-41ba-b054-74e4d78f2ed6","added_by":"auto","created_at":"2024-11-06 18:46:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":401452,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4622979/v1/3331beae-cdb8-4705-b25e-b458cb5af3db.pdf"},{"id":60618140,"identity":"95eab531-49aa-4dc2-bd3b-fdf48201dc5c","added_by":"auto","created_at":"2024-07-18 20:34:55","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":13330,"visible":true,"origin":"","legend":"","description":"","filename":"Suppelmentary1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4622979/v1/db4b8d55369cfc410a66784b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Anal fissure treatment in 2022 - A global snapshot audit conducted by the International Society of University Colon and Rectal Surgeons (ISUCRS)","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAnal fissure is one of the most common causes of anal pain and bleeding with 235,000 new cases occurring every year in the United States alone (1). It accounts for overall incidence of 1.1 per 1000 person-years and to an average life time risk of 7.8% (2).\u003c/p\u003e \u003cp\u003eAnal fissure is described as a longitudinal tear in the mucosa of the anal canal, more specifically in the perineal skin, distal to the dentate line. It is believed that this pathology occurs due to an over distention or disease of the anal mucosa which leads to a laceration of the anoderm. (3). A spasm the exposed internal anal sphincter leads to pulling along the laceration, which impairs healing and worsens the extent of laceration with each bowel movement. It is believed that the posterior commissure has a poor blood supply, therefore predisposing it to ischemia (4, 5, 6).\u003c/p\u003e \u003cp\u003eAnal fissures are usually managed conservatively (7), whether it is done with the use of calcium channel blockers (Nifedipine or Diltiazem), Nitrates, warm sitz bath, oral painkillers or Botulin Toxin. All of which have been deemed acceptable with few adverse effects and high cure rates. Guidelines set by the American Society of Colon and Rectal Surgeons supported the use of the previously mentioned conservative treatment methods and urged medical professionals to use non-surgical treatment modalities as a first line treatment since they are considered safe since they have few side effects (8).\u003c/p\u003e \u003cp\u003eSurgically, however, lateral internal sphincterotomy (LIS) still remains the gold standard to treat anal fissures permanently, more often in chronic cases (9), with a low rate of complications and a reduced cost burden. Whether it is performed using an opened or closed approach, both can achieve similar recovery and complication rates (10).\u003c/p\u003e \u003cp\u003eAlthough this pathology is very common, there is unfortunately few articles describing the real world data on treatment and management practice worldwide.\u003c/p\u003e \u003cp\u003eOur aim from this study was to evaluate the treatment of anal fissures and to compare the success rate of treatment procedures in the follow-up in different countries.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003eAfter all approvals were issued according to each nation's laws and consent to participate in the study was obtained by signature from patients, a prospective cohort audit was performed.\u003c/p\u003e \u003cp\u003e All the members of ISUCRS seeing at least 5 patients with anal fissures per month were invited to participate in the study. The inclusion period was any two weeks between June and July 2022. All the consecutive patients were included. Patient data from twenty-one countries were obtained with the cooperation of 56 doctors in a form of an electronic database.\u003c/p\u003e \u003cp\u003eThe Inclusion criteria were covered all the consecutive patients coming to the clinic for anal pain/bleeding, diagnosed with fissure using digital rectal examination and/or endoscopic evaluation (subjective classification). Moreover, the state of fissure (acute vs chronic) was decided by the treating physician upon examination (presence of sentinel piles or thick borders were signs of chronic fissure). Patients who had a psychiatric history, who were currently pregnant / breast feeding, immunosuppressed, with Crohn\u0026rsquo;s, concomitant anal fistulas, abscesses or anal tuberculosis were excluded from the research.\u003c/p\u003e \u003cp\u003eThe demographic information was collected from the medical records of the patients and the American Society of Anesthesiologist's classification system assessed the comorbidities associated with the anal fissure. All records of the past medical history, obstetrics history, vaginal delivery, number of vaginal deliveries, history of episiotomy, and history of perineal tear were taken into consideration.\u003c/p\u003e \u003cp\u003eTo assess the effect of the intervention of the anal fissures, the patient's current symptoms were recorded, and a pain visual analog scale was used to assess the severity of the pain. The greater the number in the pain visual analog scale, the greater the pain intensity is. Patients diagnosed at the time of the current intervention were considered the acute case, and those who had an anal fissure for more than six weeks (or the fissure had sentinel piles or harder boarders upon examination) were regarded as the chronic case.\u003c/p\u003e \u003cp\u003eWexner score was used to assess the continence (11). The number 0 referred to patients who had no incontinence, and the number 20 was given to patients who had the worst continence.\u003c/p\u003e \u003cp\u003eThe record of the treatment and surgical intervention done before the encounter was noted to assess the success of the current treatment as compared to the prior treatment. Later the intervention for the treatment of anal fissure was done and compared with the conditions above, and the data about the procedures, complications, and outcomes were recorded. Treatment success was recorded when resolution of symptoms was achieved (during follow up or a telephonic conversation with the patient in question) or the complete healing was noticed upon examination.\u003c/p\u003e \u003cp\u003eAll the details of the patient's demographic data, pre-and post-treatment details, and outcomes were noted. The success of the current treatment that was given to patients was assessed at an 8-week follow-up.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003e This report has been prepared in accordance to guidelines set by the STROBE (strengthening the reporting of observational studies in epidemiology) statement for observational studies Student's t-test was used for normal, continuous data, Mann-Whitney U test for non-normal continuous data or Chi-squared test for categorical data. Data analysis was undertaken using R Studio V3.1.1 (R Foundation, Boston, MA, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAfter excluding patients with psychiatric history, 302 patients were included in the study in which a higher prevalence was found in women with 155 patients (51.35%) than men with 147 individuals (48.65%). ASA I was assessed in 198 patients (65.6%), ASA II was found in 93 individuals (30.4%), while ASA III and ASA IV were recorded in nine and two (0.7%) subjects respectively\u003c/p\u003e \u003cp\u003eConsidering the medical history relevant to our study, a number of patients were grouped according to similar pathologies they encountered (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePast medical history of patients included in the study.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePast medical history\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of Patients\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemorrhoids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaginal childbirth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnal Fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnorectal trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHIV / AIDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsoriasis at genital area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGenital Herpes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e164\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFocusing on the female cohort, 95 females were found to have had obstetrics history before this encounter with 78 patients having an account of vaginal deliveries, out of which 1 (1.2%) of patient having zero vaginal deliveries, 25 (32%) of individuals with one delivery, 35(46%) with two deliveries and 11 (14%) with three vaginal deliveries. Six females (7%)) had four or more vaginal deliveries. Moreover, 48 female patients were found to have had a history of episiotomy while two patients had perineal tears. Leading symptoms were painful defecation (n\u0026thinsp;=\u0026thinsp;280, 92.7%) followed by anal bleeding (n\u0026thinsp;=\u0026thinsp;194, 64.2%) and painful bleeding during defecation (n\u0026thinsp;=\u0026thinsp;182, 60.2%) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnesthetic technique used during surgical interventions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnesthetic technique\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of patients who underwent mentioned technique\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntravenous anesthesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (8.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocal anesthesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (12.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombination of Local and Intravenous anesthesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (14%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegional block\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (29.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral anesthesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89 (34.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe severity of the pain experienced by patients at the time of encounter was taken into account and categorized using the pain visual analog scale (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Of all, 106 patients (35%) had acute anal fissure while 196 (65%) patients were found to have chronic fissures. Before this encounter, a number of patients underwent various treatment methods, ranging from conservative (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) to surgical approaches (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Moreover, 142 of them had some surgical treatment with 53 of them having already LIS undergone. Moreover, five patients had fissurectomy and later LIS. Thirty four patients had more than one surgical procedure. In the current encounter, conservative medical and surgical treatment was used as well for anal fissures. Conservative medical treatment ranged from the use of warm sitz baths to topical appliance of nifedipine/diltiazem (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). In surgical intervention which totaled 256 interventions, 155 (60.5%) patients were given the ambulatory surgical procedure, whereas 101 (39.5%) patients were given inpatient admission with several anesthetic techniques used during interventions (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Sixty six patients underwent different surgical procedures, ranging from anal dilatation (22), to botulin toxin injection (24) and other.\u003c/p\u003e \u003cp\u003eTreatment complications were seen in 18 patients, out of which 15 (83%) experienced headaches, one (5%) individual had reported allergy to anal fissure medication, one (5%) patient had hypotension, one presented perineal sepsis, two (10%) presented with anal bleeding, one (5%) with urinary retention while one (5%) experienced anesthetic complications and four (22%) declared to have had other forms of complications. Upon assessing the Wexner fecal incontinence score during the course of our study, we noticed a change in the pretreatment vs post-treatment score. In fact, the average Wexner score for individuals in between the range of 0 to 10 in the pretreatment was 1.07 compared to a post-treatment average of 1.31. However, in regards to a patients being scored in the range of 11 and above, only the pretreatment cohort indicated an average of 11.61 with no individual post-treatment possessing a score higher than 10. Of the total patients, 268 received follow-ups within eight weeks after the current treatment, of which 224 (84%) patients did the actual visit with the doctor and 44 (16%) had the virtual visit. After the treatment, 119 (44.4%) of patients were free of anal fissures. 86 (32.2%) showed marked improvements with no medications after intervention; 46 (17.1%) showed gradual improvement, needing medications every now and then. Sixteen (6.0%) of patients reported no change in the condition. One had worse (0.3%) symptoms.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur survey is the first to include colorectal surgical specialist physicians from across the globe encompassing (56 surgeons, from 21 countries including all continents). Over 300 patients are included with an 8 week follow up results.\u003c/p\u003e \u003cp\u003eIn our prospective cohort study, we found that surgeons started treatment in almost every patient (85%) with a conservative approach. The most common initial treatment was dietary modification due to the ease of its application and patient compliance (12). In a study assessing the Persian medical effect on fissure treatment, constipation was considered to be a cause of fissures (12) and it was therefore recommended that avoidance of some foods and commercial baked goods was potentially beneficial. In contrast, our study noted the benefits of dietary changes were correlated with stool consistency, not to any specific food intake or avoidance.\u003c/p\u003e \u003cp\u003eThen second most commonly used conservative treatment identified in this study was the use of warm sitz bath, which has been speculated to have an analgesic effect as well improve healing by relieving sphincter spasm. A study undertaken by Jensen et al (13) who used warm sitz baths along with unprocessed bran to treat anal fissures in 96 patients argued that this treatment combination yielded the same results as topical analgesics and anti-inflammatory ointments while avoiding their side-effects and costs. (13)\u003c/p\u003e \u003cp\u003eAnother study performed by Alnasser et al. (14) on 519 patients has shown that the use of conservative management protocol consisting of salty warm sitz bath three times daily, 2 grams glycerin suppositories per rectum 20 minutes before defecation and bulk-forming fiber daily yielded complete fissure healing in 379 (70.3%) patients with a duration range from 3\u0026ndash;7 weeks. The remaining 160 (29.7%) patients who did not heal ultimately had surgical intervention with a 0% recurrence rate.\u003c/p\u003e \u003cp\u003eTopical or oral painkillers were also a conservative method of treatment chosen by a large group of our physicians. The use of topical or oral calcium channel blockers have shown effectiveness in treating anal fissures by alleviating painful symptoms and by vasodilation, therefore accelerating the healing process. This has led others to stress that the use of topical painkillers should be considered before considering surgical options (15).\u003c/p\u003e \u003cp\u003eThe major limitations of painkillers are cost, temporary benefits and higher relapse rates, leading some to recommend LIS for patients that have failed to respond to first-line conservative therapy, or for those who relapsed with medical management (16). A prospective controlled trial that compared the effect of 2% diltiazem and LIS for treatment of chronic anal fissures found LIS was more effective complete healing at 6 weeks (96% v 71%), and for pain relief (15).\u003c/p\u003e \u003cp\u003eThe use of botulin toxin was not frequently used by our physicians with 6.6% using it to treat chronic anal fissures and only 0.7% in acute cases. When used as first-line therapy for chronic anal fissures, botulinum toxin produces comparable results to topical therapies, however when used as second-line therapy after topical therapies, the use of botulinum toxin would only slightly improves healing rates (7). A pooled analysis of studies indicated a 13.5% increase in the absolute rate of healing and a 38% increase in the rate of healing in comparison to placebo or Lidocaine alone (18).\u003c/p\u003e \u003cp\u003e A survey from American Society of Colon and Rectal Surgeons (ASCRS) (19) showed that the majority of surgeons (90%) were using 50-100U of botulinum toxin, with a majority of respondents (64%) injecting the internal sphincter and a majority of participants (53%) injecting it into 4 quadrants of the anal canal circumference. Most procedures were performed under MAC anesthesia (56%). In fact an increase in usage of botulin toxin by our physicians was noticed when treating chronic cases with 6.6% in comparison with only 0.7% used in acute cases. A similar study supported the use of botulinum toxin in chronic, uncomplicated anal fissures with an increased sphincter tone due to its tolerability, ability to be administered in outpatient settings and low probability to cause incontinence (20).\u003c/p\u003e \u003cp\u003eA study by Altomare et Al. (21) stated that for acute anal fissures, conservative treatment can provide a cure in 87% of cases, but only 50% in cases of chronic anal fissures. They concluded, that if conservative treatments fail to provide a definitive treatment, physicians usually resort to the use of invasive procedures. This is also supported by recently issued guidelines (7) and was seen in our survey. A LIS was the procedure of choice for physicians participating in this study (22) due to its effectiveness and low risk of fecal incontinence. This was found to be in line with other studies regarding healing, patient satisfaction and low recurrence rates (23, 24).\u003c/p\u003e \u003cp\u003eFecal incontinence after LIS ranges from 'sometimes' to 'frequently' and includes lack of control of flatus (35.1%), soiling of underclothing (22%) and accidental bowel movements (5.3%) - but following sphicterotomy these numbers might be overestimated (25).\u003c/p\u003e \u003cp\u003eAccording to our survey, patients who had treatment did not develop worsening fecal incontinence. Changes in the Wexner score before and after treatment showed improvement from 96% of patients who had a score of 10 or lower (indicating continence) to 100% with score of 10 or lower, showing the efficacy and safety overall of fissure treatments.\u003c/p\u003e \u003cp\u003eA main issue expressed by researchers that have undertaken similar studies on anal fissures was the length of the follow up period where one study had 6 weeks follow up while another had a 4 week follow up, this has unfortunately proven to be insufficient. At least an 8-week post-treatment follow-up visit is required for the assessment of the status of the fissure. Most patients show improvement in this period, as shown in our study. The period of 8 weeks is essential to conclude which intervention has a better response and can be used for future treatment (26).\u003c/p\u003e \u003cp\u003eAlthough this global survey included patients with anal fissure from all continents, it has some limitations. Firstly, the inclusion of the patients may be biased as there was no regulating/validating body. Secondly, there was not a complete certainty whether the patients adhered to the diet change or the medication regiment prescribed by physicians. However, these common issues encountered by doctors everywhere and therefore may not have significant effects on our data. Moreover, the demographic figures present in this study also give a limited data about age by which it did not mention the age range in which most anal fissures occur. Finally, some of the patients were contacted via phone without possibility to perform the digital examination and the healing was decided solely upon resolution of the symptoms.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur survey is the first anal fissure study to include colorectal surgical specialist physicians across the globe, and showed the vast majority of experts use conservative therapy as the initial treatment, and lateral internal sphincterotomy as definitive treatment for refractory cases. In addition, there was overall improvement with fecal continence after fissure treatment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding Statement\u003c/p\u003e\n\u003cp\u003eNo funding was received.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConflict of Interest Disclosures\u003c/p\u003e\n\u003cp\u003eAuthors declare no conflicts of interest\u003c/p\u003e\n\u003cp\u003eEthics approval statement\u003c/p\u003e\n\u003cp\u003eThis work followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines. The study was reviewed and approved by the Institutional Review Board\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatient consent statement\u003c/p\u003e\n\u003cp\u003eInformed consent was gained from all the patients\u003c/p\u003e\n\u003cp\u003ePermission to reproduce material from other sources\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eClinical trial registration\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJahnny B, Ashurst JV. Anal Fissures. [Updated 2022 Nov 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. 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PMID: 36337820; PMCID: PMC9622030\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJonas M, Neal KR, Abercrombie JF, Scholefield JH. A randomized trial of oralvs. topical diltiazem for chronic anal fissures. Dis Colon Rectum 2001;44:1074\u0026ndash;1078. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/BF02234624\u003c/span\u003e\u003cspan address=\"10.1007/BF02234624\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVaithianathan R, Panneerselvam S. Randomised prospective controlled trial of topical 2% diltiazem versus lateral internal sphincterotomy for the treatment of chronic fissure in ano. Indian J Surg. 2015;77:1484-7. doi: 10.1007/s12262-014-1080-z. Epub 2014 May 11. PMID: 27011607; PMCID: PMC4775569.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoder PB, Kamm MA, Nicholls RJ, Phillips RKS. 'Reversible chemical sphincterotomy' by local application of glyceryl trinitrate. Br J Surg. 1994;81(9):1386\u0026ndash;1389. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/BJS.1800810949\u003c/span\u003e\u003cspan address=\"10.1002/BJS.1800810949\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNelson RL, Thomas K, Morgan J, Jones A. Non surgical therapy for anal fissure. Cochrane Database Syst Rev. 2012;2012(2):CD003431. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/14651858.CD003431.pub3\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD003431.pub3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 22336789; PMCID: PMC71737\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorsuk DJ, Studniarek A, Park JJ, Marecik SJ, Mellgren A, Kochar K. Use of botulinum toxin injections for the treatment of chronic anal fissure: results from an american society of colon and rectal surgeons survey. 2023;89(3):346\u0026ndash;354. doi: 10.1177/00031348211023446. Epub 2021 Jun 7. PMID: 34092078..\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJost, WH. One hundred cases of anal fissure treated with botulin toxin. Dis Colon Rectum. 1997;9:1029\u0026ndash;1032. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/BF02050924\u003c/span\u003e\u003cspan address=\"10.1007/BF02050924\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAltomare DF, Binda GA, Canuti S, Landolfi V, Trompetto M, Villani RD. The management of patients with primary chronic anal fissure: a position paper. Tech Coloproctol. 2011;15(2):135\u0026ndash;41. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10151-011-0683-7\u003c/span\u003e\u003cspan address=\"10.1007/s10151-011-0683-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2011 May 3. PMID: 21538013; PMCID: PMC3099002.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAL-Ubaide AF, Al-Rubaye SM, Al-Ani RM. Lateral internal anal sphincterotomy of chronic anal fissure: an experience of 165 cases. Cureus, 2022:14(10). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7759/CUREUS.30530\u003c/span\u003e\u003cspan address=\"10.7759/CUREUS.30530\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbcarian H. Surgical correction of chronic anal fissure: results of lateral internal sphincterotomy vs. fissurectomy\u0026ndash;midline sphincterotomy. Dis Colon Rectum. 1980;23(1):31\u0026thinsp;\u0026ndash;\u0026thinsp;6. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/BF02587197\u003c/span\u003e\u003cspan address=\"10.1007/BF02587197\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 7379649.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArroyo A, P\u0026eacute;rez F, Serrano P, Candela F, Calpena R. Open versus closed lateral sphincterotomy performed as an outpatient procedure under local anesthesia for chronic anal fissure: Prospective randomized study of clinical and manometric longterm results. Journal of the American College of Surgeons, 2004:199(3), 361\u0026ndash;367. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/J.JAMCOLLSURG.2004.04.016\u003c/span\u003e\u003cspan address=\"10.1016/J.JAMCOLLSURG.2004.04.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhubchandani IT, Reed JF. Sequelae of internal sphincterotomy for chronic fissure in ano. Br J Surg 1989;76(5):431\u0026ndash;4\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cem\u003eAnal Fissure Expanded Information | ASCRS\u003c/em\u003e. (n.d.). Retrieved November 12, 2022, from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://fascrs.org/patients/diseases-and-conditions/a-z/anal-fissure-expanded-information\u003c/span\u003e\u003cspan address=\"https://fascrs.org/patients/diseases-and-conditions/a-z/anal-fissure-expanded-information\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"anal fissure, chronic anal fissure, fissure treatment, lateral sphincterotomy","lastPublishedDoi":"10.21203/rs.3.rs-4622979/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4622979/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAn anal fissure is a longitudinal tear in the mucosa of the anal canal, distal to the dentate line. It is usually situated in the posterior midline but can occur in any quadrant. This condition affects both genders and is associated with pain, bleeding, anal discomfort, amongst other symptoms.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eThe aim of this study is to evaluate the global treatment and follow-up of patients with anal fissures in different countries and continents.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eA prospective cohort audit database was created with the cooperation of fifty-six doctors from twenty-one different countries. The patients were evaluated according to the type of anal fissure they had, treatment they underwent and results of 8-week post-treatment.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOverall, 302 patients were included, with 106 (35%) diagnosed with an acute anal fissure and 196 (65%) a chronic anal fissure. Leading symptoms were painful defecation (n\u0026thinsp;=\u0026thinsp;280, 92.7%) followed by anal bleeding (n\u0026thinsp;=\u0026thinsp;194, 64.2%) and painful bleeding during defecation (n\u0026thinsp;=\u0026thinsp;182, 60.2%). A total of 111 (36.8%) underwent surgical treatment. Out of the 264 (87%) who underwent follow-up at 8-weeks, 116 patients (44%) were cured, 86 (32.6%) showed marked improvements, 46 patients (17.4%) showed some improvement, 16 (5.0%) reported no change and one patient (0.3%) had worsened symptoms. Complications arising after treatment was recorded in 18 (6%) patients, with 15 (83%) complaining of headaches, 2 (5%) indicated hypotension, perineal sepsis, anal bleeding and/or allergies to medications used during treatment. Comparing pre-treatment and post-treatment Wexner Incontinence Scores, no patients had worsening fecal incontinence, 95.7% showed stable scores, while 13 (4.3%) showed improved scores.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe majority of surgeons chose a non-surgical approach as a first line treatment for anal fissures whether acute or chronic. Overall, 94% of all patients had resolution or improved symptoms, with none of the surgically treated patients developing fecal incontinence afterwards.\u003c/p\u003e","manuscriptTitle":"Anal fissure treatment in 2022 - A global snapshot audit conducted by the International Society of University Colon and Rectal Surgeons (ISUCRS)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 20:34:50","doi":"10.21203/rs.3.rs-4622979/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8530d80d-427e-49bd-a465-cb533a3bbcef","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-11-06T18:38:42+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-18 20:34:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4622979","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4622979","identity":"rs-4622979","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}