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Objective: To assess the effectiveness, feasibility and acceptability of botulinum toxin in healing chronic anal fissures in our population. Study Design: Prospective observational study. Place and Duration of Study: Combined Military Hospital, Multan, from Jan 2019 till Dec 2019. Methodology: Eighty patients were enrolled in the study out of which 72 completed the study. 33 IU of botulinum toxin A was injected in the intersphincteric groove in the perianal region. Outcome measures for effectiveness included pain score and fissure healing rates at 2, 6, 16 and 24 weeks after the injection. Healing rate was calculated as percentage and pre and post injection pain scores were compared by using paired sample t-test. Patient acceptability was assessed based on the proportion of patients who accepted the treatment. The average treatment cost was also calculated. Results: A total number of 250 patients were found to be eligible for the study. A purposive sampling technique was used. Eighty patients took part in the study with an acceptability rate of 32%. Seventy two patients completed the study with a completion rate of 90%. Amongst 72 patients, 47 (65.3%) were female and 25 (34.7%) were male. The complete healing rate after 3 months of botulinum toxin injection was 49 (68.1%). There was a significant reduction in pain scores at 2, 6, 16, and 24 weeks of study (p

Aim Treatment of transsphincteric fistulas (TSFs) with fistulotomy after an indwelling seton is tempered by risks of incontinence and litigation. Thus, ligation of the TSF tract has been popularized as an alternative option. We previously reported on 107 patients who underwent ligation of the intersphincteric fistula tract (LIFT), with a 46% failure rate. Posterior fistula was the only predictor of recurrence. The aim of the present work was to investigate whether the length, width or depth of the fistula measured on preoperative MRI was correlated with recurrence. Method Following institutional review board approval, a retrospective analysis of our prospective Complex Anal Fistula Database from 1 January 2011 to 31 August 2019 was performed. Patients with TSF who underwent preoperative MRI and LIFT were included. Fistula location was classified as anterior, posterior or lateral. MRI measurements of fistula length, width and depth (in the intersphincteric groove) were performed. The type and rate of postoperative recurrence were analysed. Results 173 patients underwent MRI for an anal fistula; of these 40 underwent LIFT and 22/40 (55%) had preoperative MRI. There was no difference in the length, width or depth of anterior (n = 9), posterior (n = 7) or lateral (n = 6) fistula tracts. The overall recurrence rate was 9/22 (41%). Posterior TSFs had the highest recurrence rate (5/7, 71%). Conclusion The mean length, width, and depth of the fistula tract, measured at the preoperative site of LIFT in the intersphincteric groove, did not correlate with recurrence regardless of fistula location.

The Ligation of Intersphincteric Fistula Tract (LIFT) procedure is a recent sphincter-preserving procedure added to the surgical armamentarium of managing anal fistulas. It has gained popularity for its simple, easy-to-learn technique and success rate reliably exceeding 70%. Studies using validated continence scores have verified its advantage in preserving continence. The procedure is aimed at the cryptoglandular source of infection within the intersphincteric space. This is achieved through a small incision parallel to the intersphincteric groove and corresponding to the internal opening. After excision of the intersphincteric portion of the fistula tract, the openings on the internal and external sphincter are suture-ligated. Wound care is simple with minimal post-operative pain. Pre-operative imaging with endoanal ultrasonography helps to position the incision. Most failures or recurrences occur in the intersphincteric wound. This can be treated successfully with simple fistulotomy. The use of a seton before a LIFT procedure has not been proven beneficial. This technique has also been applied to Crohn׳s disease-related fistulas with similar success. Modifications to the technique using bioprosthetic inserts have also been reported to confer better results albeit at a greater cost.

Chronic anal fissure is a frequent and disabling disease, often affecting young adults. Botulinum toxin and lateral internal sphincterotomy are the main therapeutic options for refractory cases. Botulinum toxin is minimally invasive and safer compared with surgery, which carries a difficult post-operative recovery and fecal incontinence risk. The long-term efficacy of Botulinum toxin is not well known.The aim of this study was to evaluate the long-term efficacy and safety of Botulinum toxin in the treatment of chronic anal fissure.This was a retrospective study at a single center, including patients treated with Botulinum toxin from 2005 to 2010, followed over at least a period of 5 years. All patients were treated with injection of 25U of Botulinum toxin in the intersphincteric groove. The response was registered as complete, partial, refractory and relapse.Botulinum toxin was administered to 126 patients, 69.8% (The use of Botulinum toxin to treat patients with chronic anal fissure was safe and effective in long-term follow-up.

Background Ligation of the intersphincteric fistula tract (LIFT) is a sphincter-preserving operation for anal fistulas. Although it has advantages in preserving continence after surgery, it is difficult to perform owing to the narrow field of view. We performed a modified surgical procedure based on the LIFT to overcome these drawbacks. Materials and methods Twenty-eight patients who were scheduled to undergo high ligation of the anal fistula tract by the lateral approach for the treatment of transsphincteric anal fistulas were prospectively studied. Instead of making a new stab incision on the intersphincteric groove, we dissected along the fistula tract from the external opening until the intersphincteric space appeared. The fistula tract was then ligated close to the internal anal sphincter with absorbable sutures, and the distal part of the ligation was cut off. A cored-out wound was left open for drainage. Results The median follow-up was 16 months (range, 8–27 months). Of the 28 patients, 19 (68%) had simple transsphincteric fistulas and 9 (32%) had complex transsphincteric fistulas. Successful fistula closure was achieved in 21 patients (75%), with a median healing time of 4 weeks (range, 3–7 weeks). None of the patients complained of any incontinence symptoms after the procedure. Of the seven patients (25%) who failed to heal successfully, two (7%) did not heal up to 2 months after surgery and five (18%) experienced recurrence after complete healing. Conclusion High ligation of the anal fistula tract by lateral approach may be a useful sphincter-sparing procedure for transsphincteric anal fistulas.

Background The ligation of intersphincteric fistula tract (LIFT) procedure for trans-sphincteric fistula-in-ano has been studied with variable success rates compared with initial reports. Failures occur mostly in the intersphincteric wound. Recently, we proposed a modification to LIFT, unroofing the fistula from internal opening to intersphincteric groove, ligating the fistula tract, but preserving the external sphincter. Methods This retrospective review assesses outcomes of patients undergoing the modified LIFT for trans-sphincteric fistulae. Results Sixty-six modified LIFT procedures were performed. The main cohort consisted of 56 patients, predominantly men (76.7%). Median operative time was 16 minutes. Median follow-up was 20.98 weeks. Overall cure rate was 71.42%, with a recurrence rate of 5.35% and fistula persistence in 16.07%. There was no persistent fecal incontinence. Conclusion Modified LIFT is a safe procedure that is easily performed, has short operative time, eliminates the intersphincteric space, and has cure rates equal to or better than the original LIFT.

To save the sphincter, understanding the anatomy of anal sphincter complex is essential. The anal canal extends from the level of the levator ani muscle to the anal verge. The muscularis propria of the rectum is consisted of the inner circular and outer longitudinal smooth muscle layer. The internal and external sphincters together can maintain anal continence. Intersphincteric groove lies between the subcutaneous external anal sphincter and the internal anal sphincter. This is one of the landmarks for intersphincteric resection. In the middle and low rectal cancer, total mesorectal excision should be performed. For distal rectal cancer, a 1-cm distal margin may be acceptable. To avoid positive circumferential resection margin, the surgeons should follow the principles of total mesorectal excision and perform en bloc resection of contiguous tissues when clinically indicated.

The Ligation of Intersphincteric Fistula Tract (LIFT) procedure is a recent sphincter-preserving procedure added to the surgical armamentarium of managing anal fistulas. It has gained popularity for its simple, easy-to-learn technique and success rate reliably exceeding 70%. Studies using validated continence scores have verified its advantage in preserving continence. The procedure is aimed at the cryptoglandular source of infection within the intersphincteric space. This is achieved through a small incision parallel to the intersphincteric groove and corresponding to the internal opening. After excision of the intersphincteric portion of the fistula tract, the openings on the internal and external sphincter are suture-ligated. Wound care is simple with minimal post-operative pain. Pre-operative imaging with endoanal ultrasonography helps to position the incision. Most failures or recurrences occur in the intersphincteric wound. This can be treated successfully with simple fistulotomy. The use of a seton before a LIFT procedure has not been proven beneficial. This technique has also been applied to Crohn׳s disease-related fistulas with similar success. Modifications to the technique using bioprosthetic inserts have also been reported to confer better results albeit at a greater cost.

Aim Ligation of the intersphincteric fistula tract and reinforcement with a bioprosthetic graft are two recently reported procedures that have shown promise in the treatment of anal fistula. This study was undertaken to validate combining ligation of the intersphincteric fistula tract plus bioprosthetic anal fistula plug and report our preliminary results and experience. Method Twenty-one patients with transsphincteric anal fistula were treated with ligation of the intersphincteric fistula tract plus concurrent bioprosthetic plug of the anal fistula. We evaluated healing time, fistula closure rate and postoperative anal function according to the Wexner continence score. Results No mortality or major complications were observed. Median operative time was 20 (range 15–40) min. After a median follow-up of 14 (range 12–15) months, the overall success rate was 95% (20/21), with a median healing time of 2 (range 2–3) weeks for external anal fistula opening and 4 (range 3–7) weeks for intersphincteric groove incision. Only 1 (5%) patient reported rare incontinence for gas postoperatively (Wexner score 1). Conclusions Ligation of the intersphincteric fistula tract plus a bioprosthetic anal fistula plug is an easy, safe, effective and useful alternative in the management of anal fistula. Further randomized controlled studies are necessary to better evaluate long-term results.

PURPOSE: The ligation of the intersphincteric fistula tract is a new surgical procedure without any use of biologic material. The purpose of this study is to present our early results with this novel technique. METHODS: A retrospective review of patients who underwent the procedure for high transsphincteric fistulas was analyzed. The procedure was performed by a single surgeon. Patient and fistula characteristics, complications, and recurrences were reviewed. RESULTS: Twenty-five patients underwent the ligation of intersphincteric fistula tract procedure. All the patients had transsphincteric fistulas that were not suitable for fistulotomy. All patients underwent the procedure on an outpatient basis with a median follow-up of 24 weeks (range, 8-52 wk). Of the 25 patients, 17 (68%) healed completely and did not require any further surgical treatment. Eight of the 25 patients had persistent symptoms: 5 patients had a clear tract with an internal opening, 2 patients had a draining sinus without an identifiable internal opening, and 1 patient presented with an intersphincteric fistula, which was at the site of the intersphincteric groove incision. There were no statistically significant differences in recurrence rates with regard to the presence of a seton at the time of surgery, history of previous operations such as mucosal advancement flap, or seton placement. CONCLUSION: The ligation of intersphincteric fistula is a promising sphincter-preserving procedure that is simple and safe, and it does not require expensive biologic material. Our early data confirm a low recurrence rate with a primary healing rate of 68%.

The novel modified approach through the intersphincteric plane for the treatment of fistula-in-ano, known as LIFT (ligation of inter sphincteric fistula tract) procedure, is described in detail. LIFT procedure is based on secure closure of the internal opening and removal of infected cryptoglandular tissue through the intersphincteric approach. Essential steps of the procedure include, incision at the intersphincteric groove, identification of the intersphincteric tract, ligation of intersphincteric tract close to the internal opening and removal of intersphincteric tract, scraping out all granulation tissue in the rest of the fistulous tract, and suturing of the defect at the external sphincter muscle. Attention to detail is the key for a favorable outcome.

Constipation is a collective term with different definitions and manifestations. In the present communication, I hope to shed light on the pathogenesis, investigation, and treatment of these manifestations. The levator ani is the principal muscle of defecation; together with anorectal reflex actions, it conducts the act of defecation. Strainodynia is the term I give to excessive and exhaustive straining at defecation. Band strainodynia has normal stool character but elevated rectal neck pressure due to the presence of a fibrous band in the rectal neck. Diet strainodynia presents with lower stool weight and frequency than normal; the internal anal sphincter is fibrous. The stools in levator strainodynia have been repeatedly obstructed at defecation due to levator dysfunction. Idiopathic oligofecorrhea or infrequent defecation was studied in 146 patients. Three stages could be identified: the deep and the everted intersphincteric groove and the cone anus. Fecoflowmetry is introduced as a new method for investigating anorectal disorders. It measures the defecated volume per time unit, and provides quantitative as well as qualitative data concerning the act of defecation. Changes in the fecal flow parameters or curve configuration from normal point to a defecation disorder.

The efficacy and pharmacokinetics of botulinum toxin for chronic anal fissure continues to be debated. Addressing both issues we prospectively assessed the manometric impact of botulinum toxin on internal anal sphincter pressure, correlating this impact with chronic anal fissure healing. Sixty patients with chronic fissures were assessed. Fifty-seven patients had a total of 20 units of botulinum toxin injected into the intersphincteric groove at four o’clock and eight o’clock. Patients were prospectively assessed with a linear analog pain score, bleeding score, clinical fissure score, modified St. Mark’s continence score, and anorectal manometry. Each parameter was reassessed two weeks following treatment and again at three months. Fifty-six patients (30 female), median age 43 (range, 17–80) years, were followed for a median of five (range, 3–15) months with fissure healing assessed 12 weeks after treatment. Physical healing and symptom control were dependent on the baseline maximum anal resting pressure and baseline fissure score (P = 0.003, P = 0.009, respectively). Although maximum anal resting pressure fell by 17 (mean, range, 0–71) percent, pressure reduction did not correlate with clinical outcome (P > 0.2). Seventeen patients reported a mean 17 percent increase in continence score. There was no correlation between deterioration in continence and baseline or subsequent reduction in maximum anal resting pressure. Patients with Grade 1 lower-pressure fissures are more likely to heal following treatment with 20 units of botulinum toxin. Healing does not appear to be dependent on a reduction in maximum anal resting pressure.

The nerve supply of the lining tissue of the anal canal had three origins.The first was the MEISSNER'S plexus, which laid only upper end of the anal canal in foetus and newborn.The second was extrinsic nerve fibers coming from the pelvic space to pass through the longitudinal muscle and pass through/under the internal sphincter. The fibers were numerous in foetus but diminished with getting older.The third was extrinsic nerve fibers which passed through the external sphincter, under the internal sphincter, and went upward as far as the dentate line making nerveplexus and sensory endings.Sensory endings consisted of free nerve ending, organized ending and hair plexus. Free endings were found in foetus as well as in adult. Organized endings were found in subjects aged of four years and adult: many of them were "glomerular type" endings and a few genital corpuscle. Special baroreceptors such as arborised ending (SUNDER-PLASSMANN) were found especially adjacent to the hemorrhoidal plexus. At anal valve, some nerve fibers, showed extensive neurofibrillar swelling which presumably play some role to extend the sensory area of nerve element.Out of the intersphincteric groove was shown to be innervated by fibers which passed under the external sphincter.

Introduction: Lateral internal sphincterotomy (LIS) is a safe and effective surgical treatment, commonly used in patients with chronic anal fissures (CAFs). Although LIS is a simple surgical technique, it may cause several complications. Open LIS is usually performed through an incision made in the intersphincteric groove; radial or circumferential incisions, used according to the surgeon's preference. However, differences in clinical outcomes and wound healing, based on type of skin incision, are unclear. We investigated incision site wound healing and other clinical outcomes, after open LIS, according to the type of skin incision employed. Methods: We retrospectively reviewed the data of the electronic medical records of 602 patients who underwent open LIS for CAFs between March 2005 and February 2010 at Yang Hospital, Seoul, Korea. Results: Of the 602 patients, 298 patients received radial incisions and 304 received circumferential incisions. Circumferential incisions of the anus reduced the wound healing time compared to radial incisions (19.1 vs. 24.0 days, p