An overview of the etiology of anal fissure;

There are many reasons for anal fissure, and injury is the most common direct cause of anal fissure. Dry stool, anal dilatation, finger diagnosis, speculum insertion, childbirth, eating foreign bodies by mistake, chicken bones and fishbones can all damage the anal canal. Infection is the main cause of anal fissure. Whether it is primary infection or secondary infection after injury, if it is not handled properly, it will eventually form a chronic ulcer that will not heal for a long time.

Detailed explanation of anal fissure:

History:

1877 Molliere quoted the records in the literature of anal fistula in 1689, and said that fissure and hemorrhoid are different diseases, hemorrhoid is swollen, while anal fissure is a small and painful ulcer with severe pain but no lump. Recanuer pioneered anal dilatation therapy for anal fissure 1829. 187 1 year, Van Buren pointed out that the elderly have fewer diseases because of muscle relaxation. Kjellberg pointed out in 1876 that middle-aged people have many diseases, and it is not uncommon for minors to have diseases. 1926, Smeth found that there were more women than men with anal fissure. He also quoted Martin's literature that anal fissure can occur in any part of anal canal, but the median position is the most in the future. If there are cracks on both sides of the anal canal, it may be a specific crack. Miles first put forward the comb band amputation in 19 19 to treat anal fissure, and the effect was satisfactory. In 195 1, Edisenhammer denied the existence of comb-like membrane region. The so-called "comb belt" is actually a spasmodic protrusion on the lower edge of the internal sphincter. He renamed "comb band amputation" as internal sphincter amputation.

Etiology:

There are many pathogenic factors of anal fissure, such as injury theory and infection theory, which have not been unified, and are described as follows.

1. Injury is the most common direct cause of anal fissure. As early as 1908, Ball pointed out that the anus was excessively dilated, the anal flap was torn, and the downward linear wound became anal fissure. Such as dry stool, anal dilatation, finger diagnosis, speculum insertion, childbirth, eating foreign bodies by mistake, chicken bones, fishbones and so on. , will damage the anal canal. Allingham proposed in 1854 that congenital anal stenosis is an important cause of anal fissure. 1923, Penington thinks that some congenital anal stenosis are related to the hypoplasia of organs or tissues in the basin. The most common cause is congenital hypoplasia and contraction of lower rectum and sphincter. Anal stenosis caused by trauma and operation is easy to tear the skin of anal canal when the anus is excessively dilated, and then it will be infected to form an ulcer and cause anal fissure. This view was supported by Molliere in 1977. Blaisdell pointed out in 1937 that the superficial muscle bundle of the external sphincter is in the shape of Aya behind the anus, forming two muscle bundles, which meet forward around the anal canal along both sides of the anal canal, forming a weak area before and after the anal canal, lacking the support of levator ani. The end of rectum is connected with anal canal from back to front, forming an anal right angle. When hard stool is discharged, the front and back sides of anal canal, especially the back wall, are most vulnerable to fecal pressure, so anal fissure is mostly in the middle and back. Zhang in China also pointed out that this kind of injury is a common cause of anal fissure. If the infection after injury is controlled in time, even if the patient has ischemia, he can heal smoothly by fumigation, dressing or anal plug with suppository for about 1 week. If it is not treated in time, it will be difficult to repair the ruptured anus due to many fibrous tissues in the back of the anus, poor blood supply and weak elasticity, and then secondary infection will become a chronic ulcer, which will not heal for a long time, and will be complicated by anal valve anal sinusitis, anal papillitis or hypertrophy due to repeated stimulation of inflammation. This statement has been confirmed by clinical experiments, so most scholars at home and abroad believe that injury is the direct cause of anal fissure.

2. Infection is the main cause of anal fissure.

One is the secondary infection caused by the above injury not being treated in time, and the other is the primary infection of anal sinusitis. Rankin et al. proposed that anal sinus infection can cause anal fissure, which is a varicose ulcer. Due to subcutaneous varicose veins of anal canal, anal sinusitis can lead to phlebitis, which in turn leads to skin lesions, loss of resistance to trauma and anal fissure. Cantar also believes that anal sinusitis is the cause of anal fissure. 1943, Whiney suggested that anal gland infection caused a small abscess, which broke into anal canal to form anal fissure. That is, anal sinusitis and anal gland infection failed to spread outward and were localized, and migrated along the anus and spread downward to the subcutaneous area, forming a small abscess, leading to superficial skin necrosis and rupture, and then forming anal fissure. The skin at the lower end of the fissure is stimulated by inflammation, and the superficial vein and lymphatic reflux are blocked, resulting in edema and tissue hyperplasia, forming sentinel hemorrhoids (cracked hemorrhoids). There is also a chronic anal fissure with complications, which is due to the accumulation of inflammatory substances at the lower end of anal fissure and prominent swelling, and hemorrhoids eventually fester and fester, forming subcutaneous fistula (fissure fistula). This is the same as the whole body skin mucosa. Without bacterial infection, ulcers will not form. So infection is the main cause of anal fissure.

Whether it is primary infection or secondary infection after injury, if it is not handled properly, it will eventually form a chronic ulcer that will not heal for a long time. 1982 Shafik of Egypt suggested that the anal sinus epithelium remained in the proper anal canal, but the anal sinus epithelium below it was not exposed when the skin on the surface of the anal canal was damaged, that is, the fresh anal fissure healed quickly in the early stage. Once the deep laceration of anal canal skin exposes the secondary infection of anal sinus epithelium, this epithelial tissue is poorly differentiated and buried under the skin, which makes the wound unable to heal like a "dead bone". However, there are also a few chronic anal fissure, which can sometimes heal itself because of serious infection and destruction of residual epithelium. However, in 1986, Dohrenbuach and others repeated shafiq's observation and found that the so-called residual epithelium was actually anal gland tissue, so the hypothesis could not be established. At present, most scholars believe that discharging hard feces every day stimulates wound pain, causing reflexive excessive contraction of internal sphincter, resulting in spasm and high anal pressure; Repeated infection and inflammatory stimulation make the internal sphincter fibrotic, lose the ability of relaxation and contraction, aggravate anal fissure and fail to heal. The anal canal pressure of patients with anal fissure is as high as (127.5 42.2) kPa [(130 43) cmH2O], while that of normal people is only (86.3 33.3) kPa [(88 34) cmH2O]. 199 1 year Wang Qiulin and other research results show that the resting pressure of anal canal in patients with chronic anal fissure is significantly higher than that in normal adult control group (P < 0.0 1). Schouten et al.' s research in 1996 showed that the average maximum resting pressure (MARP) of patients with anal fissure was significantly higher than that of the normal control group [(121.0716.97) mmhg and (68.78±24.48)mmHg]]]]. Because internal sphincter spasm and anal hypertension can lead to ischemia in the skin area of anal canal and form ischemic ulcer, it has been clinically proved that cutting the internal sphincter can cure anal fissure, which has been recognized.

In recent years, it has been proposed that internal sphincter spasm leads to anal fissure, and it is denied that injury and infection are the causes. However, internal sphincter achalasia and persistent spasm can cause intractable constipation, but anal fissure rarely occurs due to ischemia. In addition, it is denied that inflammatory stimulation and pain cause reflex spasm of internal sphincter, but it will not explain the phenomenon of periodic pain caused by defecation. Some anal fissures were cured by non-surgical treatments such as softening feces, diminishing inflammation and relieving pain, fumigation and washing, and plugging anus with suppository, but the cause of internal sphincter spasm still exists. How to explain it? Some patients suffer from chronic anal fissure due to untreated or improper treatment in acute stage.

Because of constant infection in defecation every day, it is complicated with anal sinusitis, anal papillitis, hemorrhoids and fistula. Defecation stimulates anal fissure, causing periodic pain, leading to adductor spasm and becoming ischemic ulcer. Chronic anal fissure is an ischemic ulcer, which is the result of injury and infection. So it cannot be denied that injury and infection are the causes of anal fissure.

pathology

The anal fissure caused by the above factors is mostly infectious ulcer. There are five typical clinical and pathological changes in anal fissure, but not all anal fissure have these pathological changes:

Fusiform ulcer

The skin of anal canal is torn and infected to form an ulcer.

(2) Anorectal nipple hypertrophy

The upper end of the ulcer is connected with dental floss, and the inflammation spreads, which often causes anal sinusitis and anal papillitis, and finally forms anal papilla hypertrophy.

(3) Outpost hemorrhoids

The skin at the lower end of the fissure changes due to inflammation, and the superficial vein and lymphatic reflux are blocked, causing edema and tissue hyperplasia, forming connective tissue external hemorrhoids, also known as sentinel hemorrhoids.

(4) Comb belt

The comb membrane thickens and hardens, forming a comb membrane band, which is exposed to the ulcer base, preventing sphincter relaxation and affecting ulcer healing.

(5) Potential fistula

At the bottom of the anal sinus, the fistula is usually connected with the ulcer. This is because the anal sinus is infected and suppurated, which leads to the rupture of the small abscess.

Classification:

There are many classification methods for anal fissure, but there is no unified classification method at home and abroad. The main methods are introduced as follows.

1. Two-stage classification

Foreign countries are divided into acute phase and chronic phase. From 65438 to 0975, China National Anorectal Academic Conference divided anal fissure into early stage and late stage. Acute anal fissure is called fresh anal fissure; Chronic anal fissure is also called late anal fissure and chronic anal fissure.

2. Three-stage classification 1978 Yinchuan National Anal Fissure Symposium established the diagnostic criteria of the first, second and third stages of anal fissure in stages. 199 1 year, Guilin national anal fissure academic seminar was originally scheduled for four periods, and then changed to three periods. 1993 puts forward the three-level classification of anal fissure in the standard of diagnosis and treatment of TCM diseases and syndromes.

3. Four-level classification Some scholars in China divide anal fissure into one, two, three and four levels according to its characteristics.

4. Five-type classification Some foreign scholars divide anal fissure into narrow type, prolapsed type, mixed type, fragile type and symptomatic type.

There are also seven classifications, namely acute simple anal fissure, subacute anal fissure, chronic anal fissure, multiple anal fissure, anal fissure (accompanied by internal hemorrhoid, external hemorrhoid, rectal polyp, etc. ), special anal fissure and anal skin chapped.

symptom

Symptoms of anal fissure

(1) Pain: There is severe knife-like pain in anus during defecation or after defecation, which is caused by continuous spasm of anal sphincter and stimulation of nerve endings at ulcer. Pain often lasts for several minutes, which makes patients afraid of defecation, thus aggravating constipation and causing a vicious circle.

(2) Bleeding: Every defecation will aggravate the wound of anal fissure. The wound often has a small amount of bleeding and is bright red, which is the characteristic of anal fissure.

(3) Constipation: I don't want to defecate because of anal pain, which causes constipation and dry feces over time. Constipation will aggravate anal fissure and form a vicious circle.

(4) anal pruritus: The secretion from the ulcer surface of anal fissure and subcutaneous fistula can stimulate the skin of anal margin, cause eczema and anal pruritus of anus, and pollute underwear, so the anus is often wet and uncomfortable.

(5) Systemic symptoms: Severe pain can affect patients' rest, increase mental burden and even cause neurasthenia. Some patients will deliberately reduce their food intake for fear of defecation, which will lead to mild anemia and malnutrition in the long run. Women can also have irregular menstruation and lumbosacral pain. During the infection period of anal fissure, fever, swelling and pain and purulent blood may appear.

cheque

Anal fissure examination

Except for anal examination, special examination is generally not needed, but if the cause is unknown or complicated with other diseases, the appropriate examination scheme should be selected according to the specific situation.

1, digital rectal examination and endoscopy For anal fissure that is difficult to be diagnosed, digital rectal examination and anoscopy can be performed as appropriate, and the operation should be gentle to avoid causing severe pain to the patient.

2. Histopathological examination For chronic ulcer in lateral position, rare lesions such as tuberculosis, cancer, Crohn's disease and ulcerative colitis need to be thought of, and biopsy can be used for differential diagnosis.

diagnose

Diagnosis of anal fissure

(1) Diagnostic examination:

When pulling the anus with both hands, you can see that there is a spindle-shaped crack at the lower edge of the anal canal, which hurts when you gently touch the lower end. Therefore, finger diagnosis and anal peep cannot be performed. If necessary, it can be performed under anesthesia (before operation), as shown in the previous classification. If you need research and treatment, you can do pressure measurement and anal canal diameter measurement, but it is very painful, so it is not a routine examination.

The resting pressure of anal canal in patients with anal fissure is significantly higher than that in normal people, the former is (127.5 42.2) kPa [(130 43) cmH2O], while the latter is only (86.3 33.3) kPa [(88 34) cmH2O], and the anal canal contraction wave is obvious. Measure the diameter of anal canal in lateral position, that is, after the conical anal canal diameter measurer is oiled, aim at the anus, gently push it in until it can no longer be pushed in, and read the data from the scale. According to Wang Qiulin's preoperative measurement of chronic anal fissure, the minimum diameter is 1.5cm, the maximum diameter is 2.2cm, the average value is 1.95cm, and the standard deviation is 0. 19cm.

(2) Staging diagnosis: The staging of anal fissure is based on local lesions. There are generally two stages: three-stage classification and two-stage classification. The second classification diagnosis is more commonly used in clinic.

1.Ⅲ stage classification

(1) Stage I anal fissure: short course, neat ulcer edge, no scar formation. The crack is new. No obvious fissure hemorrhoids and anal nipple hypertrophy were formed.

(2) Stage Ⅱ anal fissure: there is a history of recurrent attacks. The wound edge is irregularly thickened and has poor elasticity. The ulcer base is purplish red or has purulent secretion, and the surrounding mucosa is obviously congested.

(3) Stage Ⅲ anal fissure: the edge of the ulcer is hard, and the base is purplish red with purulent secretion. The anal papilla near the anal sinus at the upper end is enlarged, and there are fissured hemorrhoids or subcutaneous fistula at the lower end of the wound edge.

2. The second stage classification

(1) Early anal fissure: fresh laceration, no chronic ulcer, mild pain.

(2) Chronic anal fissure: the anal fissure has formed a spindle-shaped ulcer with irregular edges, connective tissue hyperplasia, thickening and hardening, potential fistula, hemorrhoid fissure, anal sinusitis or anal nipple hypertrophy, and periodic pain.

(3) Differential diagnosis

1. Anal rhagadia occurs in any part of anal canal. Cracks are superficial and confined to the skin. It is often seen that several cracks exist at the same time, mostly caused by anal eczema, dermatitis and itching. Slight pain, less bleeding, obvious itching symptoms, no complications such as ulcers and hemorrhoids.

2. Tuberculous ulcer of anal canal has irregular shape, irregular edge, uneven bottom and dark gray, and caseous necrotic tissue and purulent secretion can be seen. The pain is not severe, and the ulcer can occur in any part of the anal canal. Often have a history of tuberculosis.

3. Anorectal cancer ulcer is irregular, the edge is hard, the bottom is uneven, necrotic tissue can be seen on the surface, and it has a special odor. If the pain invades the sphincter, there will be anal relaxation or incontinence, and the patient will have persistent pain, which can be diagnosed by biopsy.

4. Crohn's disease anal ulcer can occur in any part of anal skin. Ulcer has irregular shape, deep bottom and peristalsis at the edge, and often coexists with anal fistula. At the same time accompanied by anemia, abdominal pain, diarrhea, weight loss and other symptoms of Crohn's disease.

5. Syphilitic ulcer ulcer is oval or spindle-shaped, red in color, painless, gray at the bottom, often with a small amount of purulent secretions, many small indurations at the edge, and two swollen inguinal lymph nodes. The secretion smear can detect Treponema pallidum, and Treponema pallidum antibody absorption test or Treponema pallidum micro hemagglutination test is positive.

treat cordially

Treatment of anal fissure

Summary of anal fissure treatment:

Anal fissure can be orally laxative. You can take a bath with 1: 5000 potassium permanganate solution before and after defecation. Apply saline insulin gauze to the crack. Compound Danshen Injection, Compound Angelica Injection, Prednisolone, etc. Anal canal dilatation. Anal fissure excision plus subcutaneous incision of internal and external sphincter is effective and can be used as the first choice.

Detailed treatment of anal fissure:

treat cordially

Treatment principle: treat pain and relieve anal sphincter spasm. Keep the stool unobstructed and local clean, and promote healing. Anal fissure resection is feasible for persistent anal fissure that is ineffective without surgical treatment.

(A) Runchang laxative

Take laxatives orally, such as Guide tablets, liquid paraffin, or senna leaves 10g instead of tea, and take 1 cup every night. To ensure that the feces are thin and soft. Smooth discharge.

(2) fumigation and sitz bath

Before and after defecation, 1: 5000 potassium permanganate solution can be used for sitz bath, or 10g salt and pepper can be used for decoction and smoking before sitz bath to relieve the spasm and pain of anal sphincter during defecation.

(3) drugs for external use

If compound sodium chloride injection 100ml is selected. 80ml of insulin, mixed with 1mg of adrenaline, then immersed in a proper amount of sterile gauze and repackaged for later use. Before taking the medicine, ask the patient to defecate and wash the anus with warm water. Disinfect with 0. 1% bromogeramine, then apply normal saline insulin gauze to the crack, and change the dressing every day 1 time. Generally, fresh anal fissure takes 2-4 times, and chronic anal fissure cures it 4-8 times. Local application of 10% ~ 20% silver nitrate can promote wound healing.

(4) Close

1. Compound Danshen Injection

Extract 4-8ml of 1: 1 Danshen Zushima mixture (fresh anal fissure 4ml, chronic anal fissure 8ml) with a syringe. Puncture the anal fissure at a distance of 0.5 ~ 1.0 cm from the anal margin, with a depth of 3 ~ 5 cm. When injecting the medicine, pull out the needle, then pump it under the skin and inject it into both sides of the anal fissure basement and sphincter muscles, so that the liquid medicine can be injected into the anal fissure basement and sphincter muscles, every 1 ~ 2 days 1 time. Pay attention to keep the anus clean, and apply medicine locally when taking a bath to correct constipation. Generally 1 ~ 3 stitches can cure it.

2. Compound Angelica Injection

20% angelica injection 10ml and 2ml of 2% procaine were added. Needle was inserted into the root of anal fissure with No.6 needle, and the depth of acupuncture under the fissure was about 3cm, so that the anal fissure and surrounding tissues expanded, and the fissure cracked and bled due to expansion. The injection interval is 1 week. I 1-2 times for early anal fissure and 2-4 times for chronic anal fissure can be cured.

3.prednisolone

Knee chest position or lateral position, the skin is routinely disinfected. Take 2% procaine prednisolone suspension 1 ~ 2ml (each ml contains 25mg of prednisolone) and inject it into the sphincter and anal fissure base in a fan shape. After the injection, massage for a while to promote the uniform distribution of the liquid medicine. For anal fissure with anal canal stenosis, you can stretch your fingers to enlarge the anus and sit in warm water after defecation. After injection 1 week. If it is not cured, you can repeatedly inject 1 time, up to 4 times, and rub it for a while after each injection. If there are still different degrees of pain, additional injections are needed. Otherwise, it will affect the curative effect.

(5) Anal canal dilatation

Suitable for acute anal fissure or chronic anal fissure, without nipple hypertrophy and sentinel hemorrhoid. Methods: After local anesthesia, the patient lay on his side. First, expand the anal canal with the second index finger, then gradually extend into the second middle finger, and keep the expansion for 5 minutes. Sphincter spasm can be relieved after anal canal dilatation. Therefore, it can relieve pain and spasm immediately after operation 1 week or so. In order to accelerate the healing of ulcer after anal dilatation. Non-surgical treatment should continue.

(6) Surgical treatment

Anal fissure that does not heal for a long time after conservative treatment can be treated surgically. The surgical treatment of anal fissure has been studied for hundreds of years, and as early as now, there are incision, cauterization and thread-drawing techniques. Later Boyer proposed lateral sphincterotomy in 18 18, Dupuytren proposed anal dilatation in 1833 and Recamier proposed anal dilatation in 1838. In recent years, many new anal fissure excision and flap transfer have appeared, but there is no universal standard operation so far. Mazier counted 32 kinds of anal fissure operations from the literature, and each operation has its advantages and disadvantages. At present, the most commonly used operations in China are: ① unilateral sphincterotomy; ② Multiple sphincterotomy; ③ Anal fissure excision plus subcutaneous internal and external sphincterotomy; ④V-Y anus plasty; ⑤ Anal fissure excision, longitudinal incision and transverse suture, etc. Practice has proved that anal fissure resection plus subcutaneous sphincterotomy has good effect and can be used as the first choice.

Operation method: ① After routine disinfection, spread towels. The fusiform incision goes down from the dentate line along both sides of the fissure, down to 65438±0.0cm outside the hemorrhoid and deep to the ulcer layer. ② Excision of scar tissue at the crack edge, together with sentinel hemorrhoids, subcutaneous fistula, nipple enlargement and anal sinus infection. Probe whether there is a fistula between the fissure base and anal sinus with a probe, and cut it if there is one. ③ Under the guidance of the index finger in anus, the subcutaneous parts of internal sphincter and external sphincter were picked out and cut off under direct vision. The anal canal can hold two fingers. (4) Bandage the edge of the wound, cover it with hemostatic gauze or gelatin sponge, fill the anus with gauze strips, and bandage and fix it.

Matters needing attention during operation: ① The incision size is moderate. If the incision is too small, it is easy to relapse, and if it is too large, it will delay healing. ② The resection range should not be too shallow, so as not to miss the invisible fistula. ③ The subcutaneous parts of internal sphincter and external sphincter were fully released during operation to prevent recurrence.

Postoperative treatment: ① Oral antibiotics to prevent infection. ② The suture method should control defecation for 4-5 days, infusion and liquid food. ③ Fumigation and washing after defecation, and strict disinfection and dressing change after sitz bath.

6. The anal fissure incision of longitudinal transverse seam is open. Some people think that there is no essential difference between incision suture and anal fissure, and advocate suture after resection. There are longitudinal seams, vertical and horizontal seams and vertical and horizontal seams, such as mucosal and skin wounds. Longitudinal slit will make anus narrow and easy to crack, so longitudinal slit and transverse slit are often used. This method is suitable for chronic anal fissure. Intestinal preparation should be done before suture.

Operation method: ① Make a fusiform incision along the center of anal fissure, starting at 0.5cm on the dentate line and ending outside the anal margin 1.0cm. ⑦ Use tweezers to cut off part of the internal sphincter, and at the same time remove the swollen anal nipple, hemorrhoid and fistula. (3) Separate the skin outside the incision, trim the edge of the wound, and then use No.4 silk thread to enter the needle from the upper end of the incision, pass through the lower end of the incision, sew the mucosa and skin horizontally for 3-5 stitches, and tie the suture to make the longitudinal incision into a transverse incision. The suture should be slightly attached to the basal tissue, and the tension of the suture should not be too tight. Then sew intermittently with No.4 silk thread. (4) If too much tissue is removed and the tension is too high, a transverse incision parallel to the suture wound can be made at 1~ 1.5cm outside the lower edge of the incision anus. This kind of incision is incision or vertical suture, which makes the skin move in the direction of anal canal to reduce the tension of longitudinal and transverse suture.

Matters needing attention during operation: ① Strict aseptic operation. When sewing, the needle is inserted from the upper end of the incision and passes through the lower end of the incision to avoid leaving an invalid cavity. ② Fully free the skin at the lower end of the incision to prevent excessive tension after suture.

Postoperative treatment: ① liquid food for 2 days and semi-liquid food for 3 days. ② Oral antibiotics to prevent infection. Control defecation for 4 ~ 5 days, infusion. ③ Fumigation and washing after defecation, and strict disinfection and dressing change after sitz bath. ④ The stitches were removed 5-7 days after operation. If the incision is infected, remove the stitches as soon as possible.

Efficacy: The author cut off the subcutaneous part of the internal sphincter and external sphincter during anal fissure resection, and the scar induration was cleared, which made the wound mouth inclined and the drainage unobstructed, and did not cause defecation and exhaust incontinence. It was an ideal method to radically cure severe anal fissure. Cherich, a scholar in the former Soviet Union, advocated cutting off a part of the subcutaneous part of the external sphincter after cutting off the internal sphincter in the posterior median position, and the depth was 0.7cm for women and 1cm for men. Only 5.9% recurred after operation, 1.8% anal sphincter was weak. This method was widely used in the former Soviet Union. However, it is not suitable for the elderly and children to cut off the subcutaneous part of the internal and external sphincter.

7. Anal fissure incision pedicled flap transfer. There are many kinds of flap transplantation for anal fissure in foreign countries, such as Ruiz-Moreno method, Samson method, Nickell method, Canmel method and so on. Skin transplantation in other places is often difficult to succeed, but it is rarely used now. The transfer of pedicled flap is introduced as follows. It is suitable for patients with stage Ⅲ anal fissure and anal canal stenosis.

Operation method:

① Longitudinal incision along the anal fissure center from 0.5cm on the dentate line to the anal margin. Remove part of the internal sphincter.

(2) Make a bifurcated incision outside the anal margin to make it herringbone, free the anal skin flap, pull the tip of the flap toward the anal canal, and sew it at the longitudinal incision in the anal canal to make the herringbone incision into herringbone suture.

③ Suture the center of skin graft vertically with a needle under pressure, so that the diameter of anal canal can be expanded to more than 2 fingers. In order to reduce and prevent edema, a Sman incision can be made in the center of the skin graft and fixed with pressure after operation. After operation, a hard hose wrapped with vaseline gauze was placed in the anal canal and wrapped with gauze.

Postoperative treatment: the same longitudinal incision and transverse suture.

Samson treated 2072 cases of 1970 anal fissure with this operation, and 10 cases recurred. The skin necrosis rate was 2.4%, and the effect was good. However, Yu Yue and others in Japan think that this method has some shortcomings, such as large skin flap peeling range, tight suture and easy necrosis.

Selection and evaluation of treatment methods for anal fissure;

Because the cause of anal fissure is still not fully understood, the treatment has not made much progress for more than 100 years, and there is no best standardized operation. So far, the curative effect is still unsatisfactory.

1. Non-surgical treatment and surgical treatment of primary anal fissure should be non-surgical, but there are not many cures. According to Locke's statistics of anal fissure cases in St. Kyle's Hospital, after a long-term follow-up of 188 patients, 103 cases were cured by surgery, and only 33 cases were cured by non-surgical treatment, accounting for 20.6%(28 cases). Some non-surgical measures, such as regulating diet, relaxing bowels and local cleaning, are the basis of various therapies.

2. Anal enlargement and internal sphincterotomy The third stage anal fissure surgery is internal sphincterotomy and anal enlargement. However, the recurrence rate and sequela rate of the latter is much higher than that of the former, and the indication of anal dilatation is narrow, which is not suitable for stage ⅲ anal fissure with complications.

Saad compared anal dilatation, posterior internal sphincterotomy and lateral internal sphincterotomy, and thought that lateral sphincterotomy was the fastest in relieving pain and healing wounds, followed by anal dilatation and posterior sphincterotomy was the slowest. Anal enlargement will cause secondary infection, but lateral incision will not; In terms of defecation control disorder and recurrence rate, lateral incision is far lower than anal dilatation. Therefore, he thinks that lateral incision is the best method for stage ⅲ anal fissure surgery.

3. Posterior incision and lateral incision are still important surgical methods for stage Ⅲ anal fissure. But its biggest drawback is that it has "keyhole deformity" Lateral incision is an improved surgical method of posterior incision, aiming at eliminating the sequelae of keyhole deformity and glandular fluid overflow. Although the two operations are similar to the postoperative recovery, the posterior incision wound is easy to be infected, while the lateral incision wound heals quickly, and it can heal in about 2 weeks. Goldberg conducted a comparative study of two surgical methods in 250 patients, and the results showed that the lateral incision group was better than the posterior incision group. Therefore, lateral incision has been listed as the first choice for anal fissure. However, lateral incision can not remove posterior hemorrhoid, anal nipple hypertrophy and anal sinusitis at the same time, and another incision is needed. To this end, some people advocate that after hemorrhoidectomy, people should be pricked with curved pliers from the back wound, and then slide slightly along the subcutaneous part of the anal canal, rising to the dentate line between the internal and external sphincter, picking out the internal sphincter and cutting it off. In this way, the shortcomings of the posterior incision are avoided, and the advantages of the lateral incision are brought into play, leaving only one wound, thus achieving the best of both worlds.

4.Keighley( 1993) compared the advantages and disadvantages of the two methods according to various reports.

Selection of treatment methods: patients with stage ⅰ anal fissure should be treated conservatively first; Anal dilatation is the first choice for those who have not recovered for 2 weeks. Posterior incision and resection of complications should be the first choice for the later stage ⅲ anal fissure. The author thinks that the improved small triangular incision should be chosen, which has good effect and no sequelae. Anterior or lateral stage Ⅲ anal fissure. Transverse incision is preferred. Anterior Ⅲ anal fissure, especially in female anterior position, still has vaginal sphincter. If the internal sphincter is cut in the anterior position, it is easy to damage the vaginal sphincter, and it is not necessary to cut off the anal nipple and hemorrhoids that are enlarged in the anterior position too much. Open or subcutaneous incision should be adopted according to the operator's experience and habits.

keep fit

Health care of anal fissure

hygiene

1. Take medicine according to the doctor's advice.

Diet should be light, eat less spicy, fried, fried, spirits and other indigestible and irritating foods, and eat more fruits, vegetables and fibrous foods. Especially laxative foods such as bananas and honey. Drink plenty of water to ensure that people get 2000~3000ml of water every day, which is especially important in dry season.

3. Develop the habit of defecat5ming regularly for 5 minutes in daily life, so that you can't bear to defecate, and avoid squatting for a long time, sitting for a long time, and forcibly defecating. Don't defecate for too long each time, and it is appropriate to take about 5 minutes; Keep the anus clean, and clean the anus in time after defecation (soap solution is prohibited). Change underwear every day.

4. Don't stand and exercise for a long time, and appropriately increase the amount of exercise T, especially the levator ani exercise. Appropriate participation in sports activities, such as doing exercises, running, playing Tai Ji Chuan, etc.

5. Emotional anal fissure is a kind of severe pain in anal diseases, and patients generally show emotional tension. We should alleviate patients' mental anxiety and avoid delaying defecation time and aggravating constipation because of fear of anal pain during defecation, thus aggravating defecation pain and forming a vicious circle. Encourage patients to listen to energetic, cordial, fresh, cheerful and clear music such as Blue Danube, Bamboo Silk Music in the South of the Yangtze River and March of Light Cavalry, so as to free them from anxiety and pain and keep a comfortable mood, which is conducive to the rehabilitation of the disease.

6. According to the doctor's advice regular follow-up review. If the anus hurts during defecation, blood in the stool, etc. , seek medical attention in time.

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Prevention of anal fissure

Anal fissure is one of the more painful anal diseases, which can be accompanied by a variety of anal discomfort. Therefore, we should pay attention to the prevention of anal fissure.

1) Keep defecation unobstructed and get into the habit of defecation regularly every day. When we find that the stool is dry and hard, don't blame the defecation, but inject warm saline enema or kaisai dew into the anus to moisten the intestines and relax the bowels.

2) Treat anal recess inflammation in time to prevent ulcer and subcutaneous fistula after infection.

3) When using the anoscope, it is forbidden to use the speculum for rough operation and damage the anal canal.

4) Timely treatment of various diseases causing anal fissure, such as ulcerative colitis, to prevent anal fissure.

5) Drink less, don't eat spicy food, don't eat too much food, match the thickness, eat as much fiber-rich food as possible, and keep the stool normal.

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