The Royal Ann R Coll Surg Engl 2000; 82: 254-257 College of Surgeons of England Original article Fissurectomy as a treatment for anal fissures 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 a 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] 254 Ann R Coll Surg Engl 2000; 82 FISSURECTOMY AS A TREATMENT FOR ANAL FISSURES IN CHILDREN LAMBE 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. Methods 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 Patients 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 Results 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 LAMBE Figure 3 Final result following closure of defect with interrupted sutures 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. Discussion 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 256 FISSURECTOMY AS A TREATMENT FOR ANAL FISSURES IN CHILDREN 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 option. 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 FISSURECTOMY AS A TREATMENT FOR ANAL FISSURES IN CHILDREN 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. References 1. O'Connor nj. Pediatric proctology. Dis Colon Rectum 1975; 18: 126-7. 2. Doig CM. ABC of colorectal diseases. Paediatric conditions 1. 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