Long-Term Outcomes of Surgical vs. Conservative Management of Chronic Anal Fissures

Dr. Yasir Adnan Hassan Zwain; Dr. Osama Abdul-Razaq Khalaf Twayej; Dr. Safa Neamah Mohammed

Authors

Dr. Yasir Adnan Hassan Zwain M.B.Ch.B., F.I.C.M.S. \ (General Surgery) Iraqi Ministry of Health, Al-Najaf Alashraf Health Department, Al-Najaf Alashraf Teaching Hospital, Al-Najaf, Iraq.
Dr. Osama Abdul-Razaq Khalaf Twayej M.B.Ch.B., ABHS (Gen. Surgery) /JMC (Gen. Surgery) Iraqi Ministry of Health, Al-Najaf Alashraf Health Department, Al-Najaf Alashraf Teaching Hospital, Al-Najaf, Iraq.
Dr. Safa Neamah Mohammed M.B.Ch.B., C.A.B.S. \ (General Surgery) Iraqi Ministry of Health, Al-Najaf Alashraf Health Department, Al-Hakim Hospital, Al-Najaf, Iraq.

Keywords:

Long-Term, Conservative Management, Anal Fissure, Chronic Anal Fissure, SR, LIS, Symptoms, Pregnancy, Anaesthesia, Topical Diltiazem

Abstract

Background. Chronic anal fissure is highly prevalent, and the decision to undertake pharmacological sphincter relaxation (SR) versus lateral internal sphincterotomy (LIS) remains a matter of debate. While the short-term healing rates are well established, the long-term outcomes greater than two years and the relationship with continence are less predictable. Aim. To compare long-term healing, recurrence, pain, continence, quality of life, and patient satisfaction following surgical versus conservative management of adult patients with chronic anal fissure, and to elucidate predictors of long-term treatment failure. Methods. Using a cross-sectional design, a tertiary colorectal unit identified all adult patients treated for chronic anal fissure from 01/01/25 until 31/3/26. Patients were followed up with history, clinical examination, a visual analogue scale for pain, the Wexner score for anal incontinence, the Euro Qol 5D 5L (EQ-5D-5L), and an interview by a colorectal surgeon unfamiliar with the index intervention. Statistical analysis employed the independent samples t-test, Mann-Whitney U test, Chi-square or Fisher's exact test, and binary logistic regression. Statistical significance was set at p < 0.05. Results. The mean (standard deviation) age of patients was 38.6 (11.2) years and 34.2 (7.9) months from intervention. Both groups were comparable at baseline. Long-term healing rates were greater with LIS at 71/78 (91.0%) vs. 52/81 (64.2%) SR patients ( 2.30-13.91, 7.558.66 OR, p < 0.001), and there was less recurrence at 7.7% versus 38.3% ( 2.80-203.08, 20.80OR, p < 0.001) and crossover or re-intervention rates at 5.1% versus 27.2% (p < 0.001). Pain at follow-up was less after LIS at VAS 1.2 (1.1) vs. 2.6 (1.8) ( 2.31, 6.946.94, p < 0.001), while EQ-5D-5L scores were better at 0.89 (0.09) vs. 0.81 (0.13) ( 2.94, 5.414.21, p < 0.001). The rate of any continence disturbance was higher after LIS at 11.5% (9/78) versus 2.5% (2/81) (p = 0.030); however, these were limited to slight soiling or flatus, and there was no incontinence to solid stool. Multivariate logistic regression revealed conservative management (1.09-5.11, 2.48-11.79, p < 0.001), persistent constipation (1.32-6.55, 2.94, p = 0.009), and duration of symptoms > 1 year (1.09-5.11, 2.36, p = 0.011) independently predicted long-term failure. Conclusion. Although sphincterotomy provided significantly greater and more durable resolution of symptoms than medical therapy at a mean follow-up of 38 months, the residual risk of a minor continence disturbance was low. Conservative management remains appropriate; however, those with chronicity or untreated constipation should be made aware that definitive intervention is unavoidable.

References

[1] G. Elisha, S. Halder, D. A. Carlson, W. Kou, P. J. Kahrilas, J. E. Pandolfino, and N. A. Patankar, “A mechanics-based perspective on the function of human sphincters during functional luminal imaging probe manometry,” Journal of Biomechanical Engineering, vol. 146, no. 2, Art. no. 021001, 2024.

[2] V. Joppin, C. Masson, D. Bendahan, and T. Bege, “A review of ventral hernia biomechanics,” Journal of the Mechanical Behavior of Biomedical Materials, Art. no. 107159, 2025.

[3] Z. Mao, S. Suzuki, H. Nabae, S. Miyagawa, K. Suzumori, and S. Maeda, “Machine learning-enhanced soft robotic system inspired by rectal functions to investigate fecal incontinence,” Bio-Design and Manufacturing, vol. 8, no. 3, pp. 482–494, 2025.

[4] P. Senanayake, H. Salati, E. Wong, K. Bradshaw, Y. Shang, N. Singh, and K. Inthavong, “The impact of nasal adhesions on airflow and mucosal cooling—A computational fluid dynamics analysis,” Respiratory Physiology & Neurobiology, vol. 293, Art. no. 103719, 2021.

[5] P. Trybek, M. Nowakowski, J. Salowka, J. Spiechowicz, and L. Machura, “Sample entropy of sEMG signals at different stages of rectal cancer treatment,” Entropy, vol. 20, no. 11, Art. no. 863, 2018.

[6] I. N. Figueiredo, C. Leal, G. Romanazzi, and B. Engquist, “Homogenization model for aberrant crypt foci,” SIAM Journal on Applied Mathematics, vol. 76, no. 3, pp. 1152–1177, 2016.

[7] P. Fergus, C. Chalmers, W. Henderson, D. Roberts, and A. Waraich, “Pressure ulcer categorisation using deep learning: A clinical trial to evaluate model performance,” arXiv preprint arXiv:2203.06248, 2022.

[8] B. L. Møller, B. Z. S. Lo, J. Burisch, F. Bendtsen, I. Vind, B. Ibragimov, and C. Igel, “Building an AI support tool for real-time ulcerative colitis diagnosis,” KI—Künstliche Intelligenz, vol. 38, no. 3, pp. 169–176, 2024.

[9] E. Schwab, G. O. Cula, K. Standish, S. S. Yip, A. Stojmirovic, L. Ghanem, and C. Chehoud, “Automatic estimation of ulcerative colitis severity from endoscopy videos using ordinal multi-instance learning,” Computer Methods in Biomechanics and Biomedical Engineering: Imaging & Visualization, vol. 10, no. 4, pp. 425–433, 2022.

[10] B. Jahnny and J. V. Ashurst, “Anal fissures,” in StatPearls [Internet]. Treasure Island, FL, USA: StatPearls Publishing, 2022. [Online]. Available: https://www.ncbi.nlm.nih.gov/books/NBK526063/

[11] D. W. Mapel, M. Schum, and A. Von Worley, “The epidemiology and treatment of anal fissures in a population-based cohort,” BMC Gastroenterology, vol. 14, Art. no. 129, 2014.

[12] K. N. Zaghiyan and P. Fleshner, “Anal fissure,” Clinics in Colon and Rectal Surgery, vol. 24, p. 22, 2011.

[13] E. Breen, R. Bleday, M. Weiser, L. S. Friedman, and W. Chen, “Anal fissure: Clinical manifestations, diagnosis, prevention,” in UpToDate, T. W. Post, Ed. Waltham, MA, USA: UpToDate, 2015. [Online]. Available: https://www.uptodate.com/contents/anal-fissure-clinical-manifestations-diagnosis-prevention

[14] B. Klosterhalfen, P. Vogel, H. Rixen, and C. Mittermayer, “Topography of the inferior rectal artery: A possible cause of chronic, primary anal fissure,” Diseases of the Colon & Rectum, vol. 32, pp. 43–52, 1989.

[15] W. R. Schouten, J. W. Briel, J. J. A. Auwerda, and E. J. R. de Graaf, “Ischaemic nature of anal fissure,” British Journal of Surgery, vol. 83, pp. 63–65, 1996.