Anal Fissure Clinical Practice Guidelines (ASCRS, 2023)

American Society of Colon and Rectal Surgeons

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

March 30, 2023

Guidelines for management of anal fissure were published in February 2023 by the American Society of Colon and Rectal Surgeons (ASCRS) in Dis Colon Rectum.[1]

Nonoperative treatment of acute anal fissures is safe and should typically be first-line treatment.

Topical nitrates may be employed for treatment, but headache symptoms may limit their efficacy. Calcium-channel blockers are comparably efficacious for chronic anal fissures, have a better side-effect profile, and can be used as first-line treatment.

Botulinum toxin injection is comparable to topical therapies as first-line treatment for chronic fissures and yields modestly improved healing rates as second-line treatment after failed topical therapy.

Lateral internal sphincterotomy (LIS) may be offered to selected patients with chronic anal fissure who have not been treated pharmacologically. It is the treatment of choice for chronic fissures in selected patients without baseline fecal incontinence (FI).

Either open or closed techniques may be used for LIS; results are similar. Compared with traditional LIS extending to the dentate line, LIS tailored to fissure length yields similar healing rates and lower FI rates.

Limited short-term outcome data suggest that repeat LIS or botulinum injection for recurrent anal fissure yields good healing rates with a low risk of FI.

Anocutaneous flap is a safe surgical alternative for chronic fissure, with healing rates comparable to those of LIS and a lower risk of FI. Addition of an anocutaneous flap to botulinum toxin injection or LIS may reduce postoperative pain and allow for primary wound healing.

For more information, please go to Anal Fissure, Surgery for Anal Fissure, and Pediatric Surgery for Anal Fissure.


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