International Journal of Surgery 49 (2018) 16–21

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International Journal of Surgery

journal homepage: www.elsevier.com/locate/ijsu

Review

Anal advancement flap versus lateral internal sphincterotomy for chronic T

anal fissure- a systematic review and meta-analysis
Shaheel Mohammad Saheballya,b,∗, Stewart Redmond Walsha, Waqas Mahmooda,
Thomas Michael Ahernea, Myles Richard Joyceb
a
Discipline of Surgery, Lambe Institute, National University of Ireland, Galway, Ireland
b
Department of Colorectal Surgery, University Hospital Galway, Galway, Ireland

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Chronic anal fissures (CAF) are common and associated with reduced quality of life. Lateral internal
Anal fissure sphincterotomy (LIS) is frequently carried out but carries a significant risk of anal incontinence. Anal ad-
Chronic vancement flap (AAF) has been advocated as an alternative, ‘sphincter-preserving’ procedure. We aimed to
Internal sphincterotomy perform a systematic review and meta-analysis to compare the efficacy of both techniques in the treatment of
Advancement flaps
CAF.
Incontinence
Methods: The online databases of PubMed/Medline, CINAHL, EMBASE and Cochrane Central Register of
Controlled Trials were searched from inception to January 2017. All studies that investigated and reported
outcomes of LIS and AAF for treatment of CAF were included. The primary outcome measure was anal incon-
tinence while secondary outcomes included unhealed fissure and wound complication rates. Random effects
models were used to calculate pooled effect size estimates.
Results: Four studies (2 randomized controlled trials and 2 retrospective studies) describing 300 patients (150
LIS, 150 AAF) fulfilled our inclusion criteria. There was significant clinical heterogeneity among the trials. On
random effects analysis, AAF was associated with a significantly lower rate of anal incontinence compared to LIS
(OR = 0.06, 95% CI = 0.01 to 0.36, p = .002). However, there were no statistically significant differences in
unhealed fissure (OR = 2.21, 95% CI = 0.25 to 19.33, p = .47) or wound complication rates (OR = 1.41, 95%
CI = 0.50 to 4.99 p = .51) between AAF and LIS.
Conclusions: AAF is associated with less incontinence, but similar wound complications as well as a similar rate
of unhealed fissures compared to LIS. However, further well-executed, multi-centre randomized trials are re-
quired to provide stronger evidence.

1. Introduction
Anal fissure, also known as fissure-in-ano, is an ulcer-like, long-
itudinal tear in the squamous epithelium of the anal canal, typically
running distal to the dentate line up to the anal verge. While the ma-
jority (90%) of idiopathic fissures are located in the posterior midline
[1], a laterally-located fissure should alert the physician to other pos-
sible underlying conditions, such as Crohn's disease, syphilis, anal
carcinoma, human immunodeficiency virus (HIV) and tuberculosis [2].
It represents a common complaint encountered in coloproctology
clinics and its overall annual incidence is estimated at 1.1 per 1000
person-years, with a peak incidence in females during adolescence and
young adulthood, and during middle age in men [3]. Anal fissures
usually manifest with proctalgia during and after defecation, as well as
bright red rectal bleeding on wiping [1]. They are usually associated
with spasm of the internal anal sphincter (IAS), which may lead to local
ischemia and impaired healing [4]. An acute fissure is characterised by
a simple tear in the anoderm, where as a chronic fissure, defined by
symptoms lasting longer than 8–12 weeks, is often seen together with a
sentinel skin tag, hypertrophied anal papillae and visible fibres of the
IAS in the ulcer base [1]. Whist acute fissures usually heal with con-
servative measures (such as sitz baths, dietary modification and phar-
macological agents) alone, most chronic fissures require surgical in-
terventions [5]. Surgery, although costly and not without risks, has
been consistently shown to be superior to pharmacological manage-
ment [6,7] and options include lateral internal sphincterotomy (LIS,
either open or closed), fissurectomy, anal advancement flaps (ano-
plasty) and historically anal stretch and balloon dilatation.
LIS, involving partial division of the IAS fibres in an attempt to
reduce sphincter pressure and ameliorate healing is commonly

∗
Corresponding author. Department of Surgery, University College Hospital Galway, Newcastle Road, Galway, Ireland.
E-mail address: sahebalm@tcd.ie (S.M. Sahebally).

https://doi.org/10.1016/j.ijsu.2017.12.002
Received 20 September 2017; Received in revised form 17 November 2017; Accepted 1 December 2017
Available online 09 December 2017
1743-9191/ © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
S.M. Sahebally et al.
performed following failure of medical management. However, the
main limitation of this technique is the risk of anal incontinence (flatus
and/or faecal), which can be as high as 14% [8]. This potentially de-
bilitating complication has driven the search for ‘sphincter-preserving’
strategies, which include fissurectomy and anal advancement flap
(AAF) [9]. Fissurectomy involves excision of the underlying fissure,
effectively converting a chronic fissure to an acute one whilst main-
taining the integrity of the IAS complex. On the other hand, AAF in-
volves the transfer of well-vascularized, healthy tissue onto the fissure
base and when combined with fissurectomy, improves wound healing
and reduces risk of anal stenosis [10]. Various flap techniques have
been described in the literature, including V-Y flaps [11], rotation flaps
[12] and island advancement flaps [13]. Guidelines from the American
Society for Colon and Rectal Surgeons (ASCRS) state that AAF re-
presents an alternative surgical treatment modality to LIS, but the re-
commendation is weak because most studies suffer from small sample
sizes [14]. We aimed to perform a systematic review and meta-analysis
and appraise the evidence regarding LIS and AAF to determine the
optimal surgical technique for refractory anal fissures.
2. Materials and methods
This systematic review and meta-analysis was conducted according
to the Preferred Reporting Items for Systematic Review and Meta-
Analysis (PRISMA) guidelines [15]. There was no published protocol
for this review.
2.1. Eligibility criteria
We searched for all studies that directly compared LIS versus AAF
for the treatment of CAF. Randomized controlled trials (RCT's) as well
as non-randomized studies were included. Unpublished reports were
excluded from this review, as were studies that examined acute fissures
only or those that examined chronic fissures in children and those that
examined anal stenosis/stricture. Studies that evaluated LIS (or AAF)
only, without direct comparison to the other technique were not eli-
gible for inclusion.
2.2. Search strategy
The online literature was searched using the following combination
of medical subject heading (MeSH) terms [‘Anal fissure’ OR ‘Fissure-in-
ano’ OR ‘Chronic anal fissure’] AND [‘Sphincterotomy’ OR ‘Lateral in-
ternal sphincterotomy’’] AND [‘Anal flaps’ OR ‘Anoplasty’]. The online
databases of Medline, CINAHL, EMBASE, Cochrane Central Register of
Controlled Trials as well as Google Scholar and colorectal conference
abstracts were searched for relevant articles. There were no language or
publication date restrictions. The search was performed from November
1963 till January 2017, with the latest search performed on January
31st. Two authors (SMS and SRW) independently examined the title
and abstract of citations, and full texts of potentially eligible studies
were obtained. Only studies that directly compared LIS with AAF for
the management of CAF were included for analysis. Disagreement was
resolved by discussion, and if remained unsettled, the opinion of the
senior author (MRJ) was sought. The bibliographies of retrieved studies
were further screened for potential additional studies for inclusion. The
primary end point for this review was anal incontinence rate. Secondary
end points included unhealed fissure rates, fissure recurrence and
wound complication rates.
2.3. Data collection
SMS and SRW independently extracted data from the included
studies on a Microsoft Excel spreadsheet, using a predefined template.
The following information regarding each eligible study was recorded:
authors' names, journal, year of publication, gender, mean age, sample
17
International Journal of Surgery 49 (2018) 16–21
size, type of study, fissure location, anal incontinence rates, fissure re-
currence rates, unhealed fissure rates, wound complications and length
of follow up.
2.4. Data analysis
All pooled outcome measures were determined using the random
effects model as described by DerSimonian and Laird, and the Odds
Ratio (OR) was estimated with its variance and 95% confidence interval
(CI) [16]. The random effects analysis weighted the natural logarithm
of each study's OR by the inverse of its variance plus an estimate of the
between-study variance in the presence of between-study hetero-
geneity. The existing heterogeneity between OR's for the same outcome
between different studies was assessed by the I2 inconsistency test. The
I2 inconsistency test describes the percentage of total variation across
studies, which is due to heterogeneity rather than chance. A value of
0% indicates no observed statistical heterogeneity, while larger values
signify increasing heterogeneity. The quality of included studies was
assessed using the Downs and Black scale [17], a validated tool for
methodological quality assessment of both randomized and non-ran-
domized studies, consisting of 27 items evaluating study reporting,
external and internal validity and power. However, publication could
not be assessed, as there were fewer than 10 studies included in the
final analysis. Analyses were conducted using Review Manager software
(RevMan, version 5.3. Copenhagen: The Nordic Cochrane Centre, The
Cochrane Collaboration, 2012).
3. Results
3.1. Study selection and characteristics
Four published studies comprising 300 patients met our inclusion
criteria. There were 150 patients each in the AAF and the LIS group. A
flow diagram of the selection process is shown in Fig. 1. The study
characteristics are summarised in Table 1. Relevant studies retrieved
from the initial search but excluded from the final analysis are shown in
Table 2, together with their respective outcomes and reasons for ex-
clusion.
CAF was clearly described in all 4 studies (Leong [18], Hancke [19],
Patel [20] and Magdy [21] et al.), as was LIS and the flap procedure.
An open LIS technique was used in all 4 studies.
A rectangular dermal skin flap was used in Hancke et al. [19], a V-Y
advancement flap in Magdy et al. [21], a triangular flap in Patel et al.
[20] and a rhomboid flap in Leong et al. [18].
All 4 studies provided data on gender, mean/median age and fissure
location. There were 175 males and 125 females. Most fissures (272/
300) were located posteriorly.
Anal incontinence was clearly described in all 4 studies. In Leong
et al. [18], it was described as the inability to control liquid or solid
stool in the patient's normal manner; Hancke et al. [19] evaluated
minor anal incontinence, defined in turn as the presence of any in-
voluntary flatus, diarrhoea and/or soiling where as Magdy et al. [21]
used the Pescatori incontinence system and Patel et al. [20], the Fecal
Incontinence Severity Index.
Magdy et al. [21] defined complete fissure healing as complete
epithelisation of the scar or no sign of fissure while the other 3 studies
provided no formal definition for this outcome.
Wound complications were explicitly defined only in Magdy et al.
[21] but were reported in all 4 studies and included flap ischemia/
necrosis, superficial infection, hematoma or abscess formation.
3.2. Primary outcome
3.2.1. Anal incontinence
All 4 studies reported anal incontinence rates although these were
assessed at different time points (shortest follow up was 6.5 months in
S.M. Sahebally et al. International Journal of Surgery 49 (2018) 16–21

Fig. 1. PRISMA diagram of studies included in the

meta-analysis.

Leong et al. [18] and longest, 70–94 months in Hancke et al.[19]), and
varying definitions were used. There were 150 patients in each group.
On random effects analysis, AAF was associated with a statistically
significantly lower rate of incontinence compared to LIS (OR = 0.06,
95% CI = 0.01 to 0.36, p = .002; Chi2 = 0.01 (df = 1), p = .92;
I2 = 0%) (Fig. 2).
3.3. Secondary outcomes
3.3.1. Unhealed fissures
All 4 studies reported healing failure rates, with 150 patients in each
group. On random effects analysis, although there was a higher rate of
unhealed fissures associated with AAF, the difference failed to reach
statistical significance (OR = 2.21, 95% CI = 0.25 to 19.33, p = .47;
Chi2 = 9.63 (df = 2), p = .008; I2 = 79%) (Fig. 3). However, there was
significant heterogeneity among the trials.
3.4. Wound complications
All 4 studies provided data on wound complications. There were
150 patients in each group. On random effects analysis, the difference
was not statistically significant (OR = 1.41, 95% CI = 0.50 to 4.00,

Table 1
Characteristics of included studies.

Author, setting Type of LIS arm/AAF Relevant outcome Follow up Downs and General comments
study arm measures Black score

Leong et al. [18], 1995,
Singapore
Hancke et al. [19], 2010,
Germany
Patel et al. [20], 2011, UK
Magdy et al. [21], 2012,
Egypt
RCT 20/20 patients Anal incontinence 26 (6–48) weeks in LIS group, 19 Unsure if fissurectomy performed in the
Fissure healing 16 (6–40) weeks in AAF group AAF group.
Wound complications Rhomboid AAF used.
Open LIS used.
No data on recurrences.
Retro 30/30 patients Anal incontinence 78.5 (6.9) months 13 Longest follow up.
Fissure healing for LIS, 88.4 (2.3) months for Open LIS used.
Wound complications AAF group Rectangular skin flap used.
Fissure recurrence Minor anal questionnaire used but not
provided.
Retro 50/50 patients Anal incontinence 22 (12.5) months for LIS, 20 16 Open LIS used.
Fissure healing (12) months for AAF group Triangular AAF used.
Wound complications Inclusion/exclusion criteria not defined
and high selection bias.
RCT 50/50 patients Anal incontinence 12 months 23 No fissurectomy done.
Fissure healing Open LIS used.
Wound complications V-Y flaps used.
Fissure recurrence All patients had elevated resting anal
pressures.

LIS: Lateral internal sphincterotomy.

AAF: Anal advancement flap.
RCT: Randomized controlled trial.

18
S.M. Sahebally et al. International Journal of Surgery 49 (2018) 16–21

Table 2
Characteristics of excluded studies.

Study Design Total number of patients Outcome Reasons for exclusion

Farouk et al. [30], Ann R Col Surg
Eng, 1998
Theodoropoulos et al. [29], Am Surg
2015
Patti et al. [28], Am Surg 2010
Retrospective 188 (5 AAF, 183 LIS) Anal incontinence rate in LIS: 2.1% High rate of selection bias
Unhealed fissure rate in LIS: 1% Unanalyzable data
Wound complication rate in AAF: 20% Only 3% of patients were treated
with AAF
Retrospective 62 (30 had combined LIS and AAF; Combined LIS/AAF associated with better LIS combined with AAF in single
32 had LIS only) healing and less pain than LIS alone treatment arm
Prospective 26 patients treated with Anal incontinence at 1 year: 11% LIS not examined
fissurectomy and AAF

Fig. 2. Meta-analysis of anal incontinence rates.

Fig. 3. Meta-analysis of unhealed fissure rates.

Fig. 4. Meta-analysis of wound complication rates.

p = .51; Chi2 = 2.02 (df = 2), p = .36; I2 = 1%)) (Fig. 4).
3.5. Fissure recurrence
Only 2 studies (Hancke et al. [19], Magdy et al. [21]) reported
fissure recurrence rates (n = 160). Hence it was not appropriate to
compute the summative outcome from the available data.
4. Discussion
The current study demonstrates that AAF is associated with a lower
rate of anal incontinence compared to LIS, but that there is no differ-
ence in unhealed fissure or wound complication rates between the two
techniques. However, these results have to be interpreted with caution
as the studies suffer from significant clinical heterogeneity and are of
poor quality as shown by the respective Downs and Black scores
(Table 1). Manometric data were only reported in Magdy et al. [21], in
turn impairing the ability of the present meta-analysis to determine the
optimal surgical strategy for hypotonic, normotonic and hypertonic
sphincters. More importantly, the same authors only randomized pa-
tients who had elevated anal resting manometry pressures and excluded
those with normal or below-normal pressures. Had they included pa-
tients with normotonic or hypotonic sphincters, the resultant incon-
tinence rates might have been different. Although there was a clinically
meaningful higher rate of unhealed fissures in the AAF group, the dif-
ference failed to reach statistical significance, likely due to inadequate
sample size. In the study by Patel et al. [20], there was a significantly
higher proportion of females (with potentially lower resting anal
pressures) in the AAF group, reflecting case selection bias. Fissure re-
currence was reported in only 2 studies [19,21] and therefore it was
difficult to compute the summative outcome from the available data.
All fissure recurrences were observed in Magdy et al. [21] at 1 year
postoperatively but it is important to highlight that none of the patients
in the AAF group in the latter study had a fissurectomy performed.
Instead they simply had a V-Y anocutaneous flap advanced to cover the
fissure defect. There was a non-significant higher rate of both unhealed

19
S.M. Sahebally et al.
fissures and wound complications in the AAF group compared to the LIS
group on overall analysis. The unhealed fissure rate of 20% associated
with AAF is consistent with published reports in the literature, with
some AAF series describing unhealed fissure rates of 15–19% [12,13].
This finding is quite surprising given that wound healing would be
expected to be superior with the advancement of a flap together with its
vascular pedicle to the fissure base. On the other hand, wound com-
plications are more commonly encountered with anoplasty since this
technique involves more tissue dissection and mobilization as well as a
longer operative time.
Both the ASCRS [14] and ACPGBI (Association of Coloproctology of
Great Britain and Ireland) [22] recommend LIS as the first line surgical
strategy in patients with CAF that are refractory to medical manage-
ment. Internal sphincterotomy for CAF can be performed via either the
open (division of IAS under direct vision) [23] or closed (blind division
of IAS) [24] method. Both techniques appear similar in efficacy [6]. A
recent meta-analysis [8] evaluating the long-term incidence of anal
incontinence after LIS and including 4512 patients showed an overall
continence disturbance risk of 14%; however, on severity analysis,
flatus incontinence (9%) and soilage/seepage (6%) were much com-
moner than frank incontinence to liquid (0.67%) or solid (0.83%) stool.
Certain subgroups of patients seem to be at higher risk of continence
disturbance such as age ≥50, multiparous women with prior vaginal
delivery and patients having a second anorectal procedure carried out
in addition to LIS (such as haemorrhoidectomy). These patients may be
better served with a ‘sphincter-preserving’ procedure.
The rationale behind performing fissurectomy for CAF is that it
excises scar tissue and refreshes wound edges while preserving the
anatomo-functional integrity of the IAS complex. However, faecal
soiling resulting from the anal canal defect has been reported [25]. The
addition of AAF to fissurectomy introduces healthy, well-vascularized
skin to the ischemic area, promoting wound healing and avoiding the
potential risk of anal stricture associated with healing by secondary
intention [10]. Most series evaluating fissurectomy with AAF for the
management of refractory anal fissures are small but show promising
healing rates and low rates of incontinence and wound complications
[12,26]. Patti et al. [27] showed that fissurectomy with AAF is a safe
and effective procedure in CAF patients with either elevated IAS pres-
sures or those with normal or low-normal pressures [28]. Un-
fortunately, combined fissurectomy and anoplasty was only performed
in 2 of the included studies (Hancke et al. [19], Patel et al. [20]), while
Leong et al. [18] report ‘freshening’ the fissure edges, without explicit
fissure excision. Anoplasty without fissurectomy was performed in
Magdy et al. [21]. These inconsistencies make it difficult to generalize
our observed findings. It is worth pointing out that the study by Magdy
et al. [21] comprised a third treatment arm that evaluated the combi-
nation of tailored LIS with AAF, and that this dual procedure was as-
sociated with superior fissure healing and less recurrence. These find-
ings were corroborated by Theodoropoulos et al. [29], who also showed
that the combined treatment strategy resulted in significantly less
postoperative pain.
Our study has several limitations. Firstly the studies included had
low methodological quality with inherent biases and most suffered from
small sample sizes. Moreover, differing definitions for the same out-
come measures (e.g. anal incontinence) as well as non-uniformity of
surgical technique (anoplasty with or without prior fissurectomy, dis-
similar AAF configurations) were employed in the studies. Pre- and
postoperative manometric data were only available in one study and
hence we cannot advocate which technique is better for different fissure
pressures. Secondly we did not evaluate patient satisfaction, post-
operative pain scores or length of the actual surgical procedure.
Thirdly, confounding variables such as the co-existing postoperative use
of sitz baths and/or a high-fibre diet and/or topical ointments and/or
stool softeners were present in all studies and their potential impact on
fissure healing cannot be ruled out.
In conclusion, despite the aforementioned shortcomings, and the
20
International Journal of Surgery 49 (2018) 16–21
paucity of well-executed RCT's on this topic, the current systematic
review provides an overall assessment of the efficacy of these different
surgical treatment modalities for CAF. Combined, these data appear to
show that AAF is associated with a lower rate of anal incontinence and
a similar wound complication rate compared to LIS. Importantly, there
was a remarkably higher rate of unhealed fissures with AAF, although
this failed to reach statistical significance. Further sufficiently powered
and well-executed RCT's with objective manometric fissure pressure
data, adequate follow up as well as employing objective continence
scores are needed to definitively answer this important clinical ques-
tion.
Conflicts of interest
None to declare.
Sources of funding
This research received no specific funding.
Ethical approval
N/A.
Research registration unique identifying number (UIN)
Reviewregistry365.
Author contribution
Conceived and designed experiments: SMS, WM, SRW, TMA, MRJ.
Performed the experiments: SMS, WM, SRW, TMA.
Analysed the data: SMS, SRW, TMA.
Wrote the manuscript: SMS, SRW, WM, MRJ.
Guarantor
Shaheel Sahebally.
Myles Joyce.
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