Pediatric Surgery for Anal Fissure Treatment & Management

Updated: Apr 08, 2016
  • Author: Brian P Gillett, MD; Chief Editor: Philip Glick, MD, MBA  more...
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Treatment

Approach Considerations

Surgical intervention is rarely required for acute fissures in children, and symptoms from an acute fissure often resolve within 10-14 days of conservative medical management. However, if an anal fissure does not heal after 6-8 weeks of medical therapy and the diagnosis is not in question, surgery may be indicated.

Relative contraindications to operative treatment of anal fissure include inflammatory bowel disease (IBD) and profound immunosuppression (ie, absolute neutrophil counts <100/μL; see the Absolute Neutrophil Count calculator).

Treatment of anal fissures has advanced significantly over the past decades. Local reconstruction with advancement flaps has been described as an effective adjunct to chronic fissure excision. Reversible chemical sphincterotomy is a promising development in the treatment of acute (and possibly chronic) anal fissures.

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Medical Therapy

Acute fissures usually improve with conservative management, which includes dietary modification, stool softeners, and sitz baths. Increasing the patient's fluid consumption and fiber intake may be sufficient. If a stool softener is used, it should be carefully titrated to avoid the development of diarrhea and dehydration. The stool softener of choice is an osmotic agent that causes water to be retained with the stool (eg, polyethylene glycol), and the dosage is titrated for the patient's size. It is available as a powder that is mixed with 8 oz of water before administration.

Although 10-14 days of conservative medical management is often sufficient for resolution of acute fissure symptoms, as long as 6-8 weeks may be necessary for the actual tear to heal. After 6-8 weeks, the fissure is considered chronic, and more active measures (eg, chemical or surgical sphincterotomy) may be considered. Although studies validating the use of chemical sphincterotomy in the pediatric population remain limited, the available literature appears promising. [2]

Glyceryl-trinitrate (GTN) is the most widely used agent for chemical sphincterotomy. [3, 4, 5] GTN 0.2% ointment is applied topically to the lower anal canal two or three times daily until the fissure heals. Although the safety of GTN therapy in this setting is well established, poor compliance due to GTN-induced headaches can be a barrier to its use (see Complications below). [6]

Topical diltiazem (available as an extemporaneously prepared 2% gel) may be a potential alternative to GTN that has fewer adverse effects; however, additional evidence is required before recommendations regarding the use of this agent can be made. Topical diltiazem therapy appears to be more effective than oral diltiazem therapy, with fewer adverse effects. [7, 8]

Topical nifedipine with lidocaine has also been employed and appears to be safe and effective, with a low recurrence rate. [9]

Botulinum toxin injections reduce internal anal sphincter tonicity by inhibiting the release of acetylcholine into the synaptic gap. This therapeutic option appears to be more effective than isosorbide dinitrate (ISDN) ointment for the primary treatment of chronic anal fissures in the adult population, with fewer adverse effects. [10] However, dosing, ideal site(s) of administration, and experience with this drug are lacking in the pediatric population. Botulinum toxin may be used for multiple, wide-based, and nonhealing fissures.

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Surgical Therapy

As noted, surgical treatment is rarely needed for most infants and children with an acute anal fissure. Some fissures may take as long as 8 weeks to resolve with conservative management. It is important to keep in mind that if the fissure has not healed following medical therapy, the diagnosis may be in question, and an examination under anesthesia is warranted. If the fissure persists despite medical management, the operative procedure in children and infants is an open lateral internal sphincterotomy.

Excision of a chronic ulcer may be warranted in addition to the sphincterotomy. All excised tissue should be evaluated by a pathologist. Because any associated anal stenosis is relieved successfully with the sphincterotomy, advancement flaps to treat the associated refractory stenosis typically are not needed.

Operative details

Treatment of children with anal fissures is slightly different from treatment of adults in that an outpatient open lateral internal sphincterotomy is the procedure of choice. This relieves the spasm and, ultimately, the vicious circle that characterizes the constellation of symptoms ascribed to anal fissure. Anal dilatation to treat anal fissure has been abandoned because of the 30-40% rate of recurrence.

In addition, if the history and physical examination reveal a lifelong history of constipation or failure to pass stool in the first 48 hours of life, an ectopically placed anus and Hirschsprung disease must be considered in the differential diagnosis, and a careful rectal evaluation and rectal biopsy should be performed with the same anesthetic.

Open lateral internal sphincterotomy is performed with the patient in the lithotomy position under a light anesthetic administered via a laryngeal mask. The intersphincteric groove is palpated, and the submucosa is injected with 0.25% bupivacaine with 1:200,000 epinephrine. A 1-cm curvilinear incision is made overlying the intersphincteric groove. The internal sphincter is medial to the external sphincter and lateral to the submucosa of the anus. The sphincter is identified and elevated, and an electrocautery device is used to divide a segment as far proximal as the fissure itself. The overlying incision is closed.

Closed lateral sphincterotomy is also advocated in children. The knife blade is positioned in much the same manner as in an open sphincterotomy, but the difference is that the knife is inserted in the intersphincteric groove, rotated 90°, and advanced toward the anal mucosa. Hemostasis is achieved by means of direct pressure, and this puncture wound is not closed.

Chronic anal fissures should be treated with excision of the fissure along with its sentinel tag (pile) and internal sphincterotomy at the base of the ulcer. The wound is left open and should heal in 7-14 days without scarring. Compulsive wound care, consisting of washing the area with soap and water after each bowel movement, is essential for a successful outcome.

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Complications

Headache and diarrhea are the most common complications of administering topical nitrates and stool softeners, respectively. Significant hypotension with topical nitrate administration has not been reported in the literature. However, during the first office visit, children and their families should be questioned about a history of vascular headaches, and blood pressure should be taken before the initial application of topical nitrates. Incontinence has not been associated with these therapeutic regimens.

Short-term complications of operative therapy include urinary retention, hematoma formation, and incontinence. Long-term complications, such as difficulty controlling flatus, daytime soiling of underwear, and nighttime incontinence, are noted with both open and closed internal sphincterotomy. The exact incidence of long-term incontinence is not clear in the pediatric literature. The incidence of this complication is likely to remain unclear because medical management, including chemical sphincterotomy, is increasingly favored over surgery for chronic fissures.

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Long-Term Monitoring

Dietary modifications, stool softeners, and sitz baths should be continued for several weeks after operative treatment. A follow-up visit is scheduled for 2-3 weeks after the procedure.

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