Abstract
ABSTRACT
Objective
To compare characteristics of the chronic fissures which healed with pharmacological agents with those which ultimately required sphincterotomy.
Methods
This cross sectional comparative study was performed on 180 patients who presented with chronic anal fissure. Out of them, 31 patients underwent lateral internal sphincterotomy (LIS) due to non-healing or recurrence despite at least 6 weeks therapy of 0.2% Glyceryl trinitrate (GTN) ointment. The frequency of multiplicity and any association with skin tags or hemorrhoids was noted in two groups using chi-square test for statistical analysis.
Results
Out of 180 patients, 149(82.8%) healed with GTN ointment, 31(17.2%) underwent LIS. 39(21.7%) patients had associated skin tag, 23(12.8%) had hemorrhoids and 12(6.7%) had multiple fissures. There was significant association of skin tags with fissures undergoing LIS (p < 0.001).

Conclusion
Association with a sentinel skin tag is a predictor of failure of medical treatment for chronic anal fissure. (Rawal Med J 2010;35: ).
Key words
Chronic anal fissure, sentinel skin tag, lateral internal sphincterotomy.
INTRODUCTION
Chronic anal fissure is a linear tear in anal mucosa which persists for more than 6 weeks.1-3 It is an extremely painful condition with an incidence of about 10% in general surgical practice.1 It causes significant functional and psychosocial impairment.4 Several treatment options are available and lateral internal sphincterotomy (LIS) was considered as “gold standard” until the successful use of topical agents including nitric oxide donors, calcium channel blockers and botulinum toxin .1,2,5-8 Since surgery is associated with a small but definite risk of permanent incontinence, initial treatment now usually comprises of the topical agents.2,5,8-10 Surgery in most cases is reserved for persistent chronic anal fissures which are resistant to chemical treatment.1,10,11 The chemical treatment although effective has its drawbacks in the form of the need for multiple applications, side effects especially headache, tachyphylaxis, noncompliance and up to 60% recurrence.1-3,10,12,13 It also takes longer time to produce symptomatic relief as compared to the lateral sphincterotomy.1 There are a very few studies in literature regarding any morphological features which can identify the fissures which will prove to be resistant to healing with topical pharmacological agents.8,14 Identification of such features can lead to early operative management reducing the time needed for an unsuccessful trial of chemical treatment.14 Thus, considerable shortening in the duration of treatment can be achieved ultimately improving the quality of life in these patients. The aim of this study was to determine any significant clinical features associated with the chronic anal fissures resistant to “chemical sphincterotomy”.


METHODS
From January 2008 to December 2010, 230 female patients with chronic anal

Key words: Chronic anal fissure, sentinel skin tag, lateral internal sphincterotomy.