Surgical treatment of anal fissures under local anesthesia. Comparative Study of Conventional Lateral Internal Sphincterotomy, V-Y Anoplasty, and Tailored Lateral Internal Sphincterotomy with V-Y Anoplasty in the Treatment of Chronic Anal Fissure Chronic fissure-in-ano: A randomized study comparing open and subcutaneous lateral internal sphincterotomy Open versus closed lateral sphincterotomy performed as an outpatient procedure under local anesthesia for chronic anal fissure: prospective randomized study of clinical and manometric longterm results. Surgical treatment of chronic fissure-in-ano: a prospective randomised study. Anal sphincter function after treatment of fissure-in-ano by lateral subcutaneous sphincterotomy versus anal dilatation Randomized clinical trial of transcutaneous electrical posterior tibial nerve stimulation versus lateral internal sphincterotomy for treatment of chronic anal fissure. Comparative study of lateral internal sphincterotomy versus local 0.2% glyceryl trinitrate ointment for the treatment of chronic anal fissure. Randomised Prospective Controlled Trial of Topical 2 % Diltiazem Versus Lateral Internal Sphincterotomy for the Treatment of Chronic Fissure in Ano Internal sphincterotomy versus topical nitroglycerin ointment for chronic anal fissure. Lateral sphincterotomy compared with anal advancement flap for chronic anal fissure [Mucosa advancement flap anoplasty in treatment of chronic anal fissures: a prospective, multicenter, randomized controlled trial]. Lateral subcutaneous sphincterotomy versus anal dilatation in the treatment of fissure in ano in outpatients: a prospective randomised study. Open versus closed lateral internal anal sphincterotomy in the management of chronic anal fissures: a prospective randomized study. A prospective randomized trial betwen subcutaneous lateral internal sphincterotomy with radiofrequency bistoury and conventional parks' operation in the treatment of anal fissures. Evaluation of Healing and Complications After Lateral Internal Sphincterotomy for Chronic Anal Fissure: Marginal Suture of Incision vs. Open Left Incision: Prospective, Randomized, Controlled Study Unilateral versus bilateral lateral internal sphincterotomy: a randomized controlled trial for chronic fissure in ano.
OBJECTIVE To evaluate lateral sphincterotomy under a mixture of local anesthesia versus general anesthesia in the treatment of anal fissures . METHODS A r and omized clinical trial of 62 consecutive patients requiring lateral sphincterotomy was carried out at Princess Haya Al-Hussein Hospital in Jordan . One group underwent  lateral sphincterotomy under general anesthesia , while the 2nd group had topical anesthetic cream ( xylocaine 2 % ) applied followed by local anesthesia . RESULTS There were no differences between the 2 groups in terms of operating time , postoperative pain , nausea or vomiting , pain-free interval after operation , analgesia requirements or patients satisfaction with the method of anesthesia . CONCLUSION Topical anesthetics and local anesthesia can be used effectively for lateral sphincterotomy and provides an alternative to general anesthesia Background Lateral internal sphincterotomy has been proven highly effective in curing anal fissure but with a high incidence of postoperative incontinence . Objective We compared conventional lateral internal sphincterotomy , V-Y advancement flap , and combined tailored lateral internal sphincterotomy with V-Y advancement flap in treating anal fissure . Patients Consecutive patients treated for anal fissure at our colorectal unit were evaluated for inclusion . Participants were r and omly allocated to receive conventional sphincterotomy ( GI ) , V-Y advancement flap ( GII ) , or combined tailored lateral sphincterotomy with V-Y advancement l flap (GIII).Main Outcome Measures The primary outcome measure was the incontinence rate ; secondary outcomes included healing rate , operative time , anal manometery , and recurrence rate . Results One hundred fifty patients with chronic anal fissure were r and omized . Healing rate after 1 year was 84 % in GI , 48 % in GII , and 94 % in GIII , respectively ( P = 0.001 ) . The recurrence rate was 4 % in G1 , 22 % in GII , and 2 % in GIII ( P = 0.01 ) . Incontinence rate was 14 % in GI , 0 % in GII , and 2 % in GIII ( P = 0.03 ) . Conclusion Although all three procedures are simple and easy to perform , tailored lateral internal sphincterotomy with V-YF appears to produce the greatest healing rate , with the fewest complications and less rate of recurrence A prospect i ve study comparing open and subcutaneous lateral internal sphincterotomy for chronic anal fissure was conducted . One hundred twelve patients were r and omized to open ( n=54 ) or subcutaneous ( n=58 ) sphincterotomy . There was no significant difference in acute complications between the subcutaneous ( 8.6 percent ) and open ( 7.4 percent ) groups . Postoperative length of stay was significantly shorter for the subcutaneous group ( 1.7±0.2 days ) than for the open group ( 2.3±0.1 days;P<0.001 ) . Although the response rate to a pain question naire was < 50 percent , the data suggest a lower level of postoperative pain in the subcutaneous group . Fissure healing was similar between the subcutaneous ( 96.6 percent ) and open ( 94.4 percent ) groups . We conclude that subcutaneous lateral internal sphincterotomy for chronic fissure-in-ano is effective and may result in significantly less postoperative discomfort , shorter postoperative lengths of stay , and a comparable rate of complications compared with the open technique BACKGROUND The aim of this prospect i ve r and omized trial was to compare the effectiveness and morbidity of open and closed sphincterotomy performed as an outpatient procedure under local anesthesia in the treatment of chronic anal fissure . STUDY DESIGN Eighty patients with chronic anal fissure were treated by open  ( group 1 ) or closed lateral internal sphincterotomy ( group 2 ) . Clinical and manometric results were recorded at the time of admission and at 1-week , 2-month , 6-month , 1-year , and 2-year followup visits . RESULTS Overall healing after 2 years was 92.5 % in the open sphincterotomy group and 90 % in the closed sphincterotomy group ( p > 0.05 ) . Fissures were notably less likely to heal in patients in whom the condition had been present for longer than 12 months and who had a sentinel pile before treatment . At the 2-year revision , incontinence was present in two patients ( 5 % ) in the open sphincterotomy group and one patient ( 2.5 % ) in the closed sphincterotomy group ( p > 0.05 ) . In all cases , the incontinence was mild ( < 4 , Clevel and score ) . Increased mean resting pressure ( 113.9 mmHg ) was found in patients with anal fissure before treatment compared with the healthy control group ( mean resting pressure = 66 mmHg ) ( p < 0.001 ) . The mean resting pressure in patients cured after 2 years was 75.65 mmHg , and in those with a recurrent fissure was 112.85 mmHg ( p < 0.001 ) . CONCLUSIONS Morbidity and recurrence were similar in open and closed sphincterotomies when the procedures were performed under local anesthetic , and sphincterotomy under local anesthesia as an outpatient procedure has several socioeconomic advantages ( high degree of satisfaction and comfort to the patient , rapid solution of the problem , and no admission to the hospital or an operating room and no preoperative studies ) A prospect i ve r and omised study compared anal dilatation ( n = 37 ) , posterior internal sphincterotomy ( n = 21 ) and lateral sphincterotomy ( n = 20 ) in the surgical treatment of chronic anal fissures in 78 consecutive patients . All the operations were performed under general anaesthesia using st and ard techniques . Anal dilatation relieved anal pain early ( immediate relief in 57 % of patients ; the mean pain-days + /- SD of 3.2 + /- 5.4 days ) . Anal fissures after this operation healed in a mean time + /- SD of 20.3 + /- 12.5 days , coming in second place to lateral sphincterotomy . Anal dilatation was followed by insignificant wound infection but its main disadvantage was a high rate of post operative anal incontinence ( in 24.3 % of patients ) . Fissurectomy and posterior internal sphincterotomy was followed by the longest period of post operative anal pain ( mean + /- SD of 32.4 + /- 10 days ) as compared to the other two operations . It was the least favourable operation . Lateral sphincterotomy was followed by early relief of pain ( immediate relief in 95 % of patients ) . It was not followed by wound infection . It had the quickest healing time for the fissures ( a mean + /- SD of 14.7 + /- 8.7 days ) . It was followed by anal incontinence in only one patient . In conclusion lateral sphincterotomy was the most favourable operation and it is perhaps the operation of choice to perform in patients with chronic anal fissures needing surgical treatment Twenty patients with chronic anal fissure were r and omized into two groups . Ten patients were treated with lateral subcutaneous sphincterotomy and 10 with anal dilatation . Anal dilatation was carried out preoperatively , and at 1 and 3 months after the operation in all patients . Preoperatively there was a significantly increased maximal resting pressure in the 20 fissure patients ( 80 mmHg median ) compared with 20 control subjects ( 50 mmHg median ) . Postoperatively a significant decrease in pressure occurred in the dilated group ( 49 mmHg medianp<0.05 ) , whereas the pressure was not significantly reduced in the group that underwent sphincterotomy ( 65 mmHg medianp<0.05 ) . At 1 year three patients complained of recurrent symptoms of anal fissure in the dilated group compared with one in the sphincterotomy group . Minor continence disturbance was noted in two patients in both groups OBJECTIVES The objective of this study was to evaluate the efficacy of transcutaneous electrical posterior tibial nerve stimulation in treatment of patients with chronic anal fissure and to compare it with the conventional lateral internal sphincterotomy . PATIENTS AND METHODS Consecutive patients with chronic anal fissure were r and omly allocated into two treatment groups : transcutaneous electrical posterior tibial nerve stimulation group and lateral internal sphincterotomy group . The primary outcome measures were number of patients with clinical improvement and healed fissure . Secondary outcome measures were complications , VAS pain scores , Wexner 's constipation and Peascatori anal incontinence scores , anorectal manometry , and quality of life index . RESULTS Seventy-three patients were r and omized into two groups of 36 patients who were subjected to transcutaneous electrical nerve stimulation and 37 patients who underwent lateral internal sphincterotomy . All ( 100 % ) patients in lateral internal sphincterotomy group had clinical improvement at one month following the procedure in contrast to 27 ( 75 % ) patients in transcutaneous electrical nerve stimulation group . Recurrence of anal fissure after one year was reported in one ( 2.7 % ) and 11 ( 40.7 % ) patients in lateral internal sphincterotomy and transcutaneous electrical nerve stimulation groups respectively . Resting anal pressure and functional anal canal length were significantly reduced after lateral internal sphincterotomy . CONCLUSION Transcutaneous electrical posterior tibial nerve stimulation for treatment of chronic anal fissure is a novel , non-invasive procedure and has no complications . However , given the higher rate of clinical improvement and fissure healing and the lower rate of fissure recurrence , lateral internal sphincterotomy remains the gold st and ard for treating chronic anal fissure The gold st and ard surgical treatment of chronic anal fissure is lateral internal sphincterotomy which lowers the resting anal pressure and effectively heals the majority of fissures . Local application of 0.2 % glyceryl trinitrate ointment has been used as an agent for chemical sphincterotomy , causing temporary alleviation of sphincter spasm and allowing the fissure to heal without compromising the anal continence . The aim of the present study was to compare the results of surgical sphincterotomy with that of local 0.2 % glyceryl trinitrate ointment in the treatment of chronic anal fissure . Seventy adult patients between the age of 18 and 50 years with chronic anal fissure were r and omized in a prospect i ve trial to receive either surgical sphincterotomy or 0.2 % glyceryl trinitrate ointment locally . Patients were followed up at 2 weeks ' interval for 10 weeks . Symptom relief , fissure healing and continence scores were the outcomes assessed . Six patients were excluded for protocol violations .  Surgical sphincterotomy was significantly more effective in providing pain relief and was associated with significantly better fissure healing rates at 6 weeks and 10 weeks ( both p < 0.001 ) . There were substantial problems with compliance in ointment group related to slow healing and longer time needed for symptomatic relief . Minor incontinence was 6 % in sphincterotomy group and none in ointment group ( p > 0.05 ) . Considering early symptomatic relief , rapid fissure healing and better patient compliance  surgical sphincterotomy is the treatment of choice for chronic anal fissure Fissure in ano is a very common disorder of the anorectal region . Internal sphincter hypertonia with decreased relaxation coupled with mucosal ischemia of posterior anal canal are the major pathologies in chronic anal fissure ( CAF ) . Though lateral internal sphincterotomy ( LIS ) remains the gold st and ard of treatment for the disease , it is accompanied by the potential complication of incontinence to both flatus and faecal matter . The aim of our study was to explore the role of topical diltiazem as an effective and a safe alternative to sphincterotomy for chronic anal fissure . Ninety patients with CAF were r and omly assigned to group A and group B , with 45 patients each . Group A patients received 2 % diltiazem topical application , twice daily , and group B patients underwent LIS . All the patients were review ed at first , fourth and sixth week after initiation of treatment . Visual analogue scores for pain and healing of fissure by visual inspection were recorded and compared . In group A , 71 % had complete healing of fissure at 6 weeks , with fair amount of pain relief ( mean VAS—3.38 ) , and in group B , 96 % showed healing of fissure , with excellent pain relief ( mean VAS—1.87 ) . Headache and flushing were noted in two patients in group A while no patients in group B developed incontinence . We conclude that LIS is more effective than topical diltiazem in the treatment of CAF . Topical diltiazem may be employed as an initial conservative treatment option before considering the surgical alternative BACKGROUND Anal fissure is a common benign condition . An anorectal problem is defined as a split in the anal canal mucosa that extends from the dentate line to the anal verge . Chronic anal fissure is defined by a history of symptoms present for more than 2 months ' duration and with a triad of external skin tags , namely , a hypertrophied anal papilla , an ulcer with rolled edges , and a base exposing the internal sphincter . Because complications such as incontinence are associated with surgical treatment , chemical sphincterotomy is currently favored . OBJECTIVES The objective of this study is to compare the difference in outcome between open partial lateral anal sphincterotomy and application of topical 0.2 % nitroglycerin ointment for the treatment of chronic anal fissure . METHODS This was a quasi-experimental study carried out between January 16 , 2007 and January 15 , 2008 in the Surgical Department of Jinnah Hospital , Lahore , Pakistan . Sixty consecutive cases with a clinical diagnosis of chronic anal fissure were recruited in the study . All recruited patients met the study inclusion criteria and were r and omly assigned to one of the two groups . Group A was managed conservatively using topical 0.2 % nitroglycerin ointment , whereas Group B underwent open partial lateral anal sphincterotomy . Both groups were followed up at 1 week , 2 weeks , 4 weeks , and 6 weeks after the treatment . RESULTS All the patients complained of pain . A total of 43 ( 71.7 % ) patients had pain with constipation , whereas 31 ( 51.7 % ) patients had bleeding per rectum . Upon clinical ly examining the anal area , tenderness was elicited in all 60 ( 100 % ) patients . Group A included 30 ( 11 females and 19 males ) cases treated with topical 0.2 % nitroglycerin ointment and Group B included 30 ( 11 females and 19 males ) cases who underwent open partial lateral anal sphincterotomy . In Group A , only 15 patients with fissures were successfully treated ( 50 % ) . By contrast , 28 ( 93 % ) patients with fissures in Group B were successfully treated , and only two ( 7 % ) remained uncured . These two patients ( 6.6 % ) in Group B suffered from incontinence due to flatus and feces as a complication of the procedure . CONCLUSION This quasi-experimental study demonstrates that open partial lateral internal sphincterotomy is superior to topical 0.2 % nitroglycerin application in the treatment of chronic anal fissure , with good symptomatic relief , high rate of healing , fewer side effects , and a very low rate of early continence disturbances PURPOSE : This study was design ed to assess differences between lateral internal anal sphincterotomy and anal advancement flap for chronic anal fissure . METHODS : Forty patients with chronic anal fissure were prospect ively studied . Patients r and omized to the sphincterotomy group ( n=20 ; median age , 34 ( range , 16–61 ) years ) underwent lateral internal anal sphincterotomy . Patients r and omized to the  flap group ( n=20 ; median age , 32 ( range , 20–44 ) years ) had an anal advancement flap . RESULTS : All fissures in the sphincterotomy group healed following surgery compared with three patients that failed to heal in the flap group ( P= 0.12 ) . No patient in either group was incontinent to any degree following surgery . Patient satisfaction with surgery was similar in both groups . CONCLUSION : Anal advancement flap is an alternative to lateral sphincterotomy for chronic anal fissure BACKGROUND Anal fissure is one of the most common anal-rectum diseases , and approximately 10 percent patients with chronic anal fissure ultimately receive surgery . Relieving postoperative pain and protecting functions of the sphincter are central issues for coloproctologists . OBJECTIVE To evaluate the efficacy and safety of anoplasty in the treatment of chronic anal fissures . DESIGN , SETTING , PARTICIPANTS AND INTERVENTIONS In this prospect i ve , multicenter , r and omized controlled trial , 120 adult patients with chronic anal fissure were referred from Department of Coloproctology of Yueyang Hospital of Integrated Traditional Chinese Medicine Affiliated to Shanghai University of Traditional Chinese Medicine , Shanghai Ninth People 's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine and Shanghai Municipal Hospital of Traditional Chinese Medicine . The patients were enrolled from January 2009 to April 2010 and r and omly divided into study ( mucosa advancement flap anoplasty , abbreviated as anoplasty ) group and control ( fissurectomy ) group . The two groups were assessed separately , and the main outcome measures were observed for 2 weeks , with a short-term follow-up for 6 weeks . MAIN OUTCOME MEASURES Degree of pain , haemorrhage and anal canal pressure were observed and recorded preoperatively , and on the third day , the fourteenth day and the sixth week postoperatively . The wound healing time was also recorded . Surgical complications of the two groups were recorded and compared on the third day and the sixth week postoperatively . The curative effects associated with the surgery were analyzed on the fourteenth day and the sixth week after surgery and the therapeutic results were evaluated . RESULTS Three patients were dropped out due to the early discharge from hospital and losing connection ( 1 in study group and 2 in control group ) . Overall the surgery showed that the anoplasty group had better results than the fissurectomy group in the curative effect on the sixth week after operation ( P<0.05 ) . Time of wound healing in the anoplasty group was ( 17.22 ± 4.41 ) d and was better than ( 21.24 ± 7.44 ) d of the fissurectomy group ( P<0.05 ) . Concerning the relief of wound pain , the anoplasty group achieved better results than the fissurectomy group at the third day , the fourteenth day and the sixth week after operation ( P<0.05 ) . Anoplasty reduced bleeding and had better efficacy than the fissurectomy at the third day and the fourteenth day after operation ( P<0.05 ) , however , there was no statistical difference at the sixth week after operation ( P>0.05 ) . There were no significant differences in relieving the anal canal pressure ( P>0.05 ) and the surgical complications ( dysuria , edema of anal margin , fever , infection , anal incontinence and anal deformation ) between the two groups ( P>0.05 ) . None of the patients suffered postoperative complications by the sixth week after operation . Furthermore , there was no recurrence in either of the two groups at six weeks after operation . CONCLUSION The results indicate that anoplasty for chronic anal fissures has advantages such as better therapeutic effects , less postoperative pain , a shorter healing time and no incidence of anal incontinence Fifty eight patients with idiopathic chronic anal fissure were included in a r and omised prospect i ve trial of lateral subcutaneous sphincterotomy versus simple anal dilatation carried out as outpatient procedures . Operations were performed under local anaesthesia and the patients review ed 10 - 30 months later ( median follow up time 18 months ) . Altogether 30 patients were treated by lateral subcutaneous sphincterotomy and 28 by anal dilatation .  No serious complications were observed in either group . One recurrence was observed in the group treated by sphincterotomy , whereas eight occurred in the other group ( p less than 0.05 ) . Functional results with respect to impaired control of flatus and soiling of underwear were significantly better after sphincterotomy ( p less than 0.002 ) . It is concluded that lateral subcutaneous sphincterotomy is the treatment of choice for idiopathic chronic anal fissure resistant to conservative measures OBJECTIVE Chronic anal fissure is a benign disorder that is associated with considerable discomfort . Surgical treatment in the form of lateral sphincterotomy has long been regarded as the gold st and ard of treatment . This study compared the open and closed techniques of lateral sphincterotomy in terms of their postoperative outcomes . METHODS A prospect i ve , r and omized comparative study was conducted between October 2010 and August 2012 . A total of 136 patients were r and omly assigned to each of two groups . Patients were followed up postoperatively for more than 1 year to assess any complications . The outcomes were compared among the two groups using the Chi-square test and Student t test . RESULTS The mean age at presentation was 40.13 years . The male to female ratio was 1.47:1 . The typical presentation was  painful defecation . Fissures were most often located in the posterior midline and associated with a sentinel pile . Delayed postoperative healing was found in 4.4 % of the group of patients undergoing open lateral sphincterotomy . The mean pain score and duration of hospital stay were lower with the closed technique . CONCLUSION Closed lateral internal sphincterotomy is the treatment of choice for chronic fissures as it is effective , safe , less expensive , and associated with a lower rate of complications than the open sphincterotomy technique BACKGROUND Anal fissure is a frequent proctologic disease . There are many and various treatments adopted to cure this disease . In this study we applied radiofrequencies to the subcutaneous lateral internal sphincterotomy and we compared the techniques in a r and omised trial . METHODS Patients have been r and omized in two groups : in group A 18 patients underwent subcutaneous lateral internal sphincterotomy using radiofrequency bistoury while in group B 17 patients underwent the conventional lateral internal sphincterotomy described by Parks .  RESULTS The mean values for operative time were 6.6 min for group A and 9.1 min for group B. According to pain score , patients ' mean values were 1.8 for group A and 1.9 for group B. Healing of the wound was faster in group A than group B , while healing of the anal fissure was approximately the same . CONCLUSION Lateral subcutaneous sphincterotomy is the most advantageous operation for the treatment of the idiopathic anal fissure . The radiofrequency bistoury easies the procedure , lessens operating times and healing process of the surgical wounds Purpose Internal sphincterotomy remains the st and ard for treatment of anal fissure , but it is associated with risks of infection , bleeding , and incontinence . Recent studies have suggested that the complications after lateral internal sphincterotomy are related to surgical technique . This study was design ed to assess the incidence of early and late complications after lateral internal sphincterotomy with marginal sutured incision .  Fissure healing , pain , and complications were compared in patients undergoing a procedure involving three interrupted marginal sutures after open lateral internal sphincterotomy procedure . Methods Ninety patients of chronic anal fissure were r and omly assigned to two groups . Both groups received open lateral internal sphincterotomy via st and ardized method . The incisions of the patients in Group 1 ( n = 45 ) were sutured marginally with three interrupted sutures using 2 - 0 chromic catgut , whereas the incisions of the patients in Group 2 ( n = 45 ) were left open . The patients were assessed at 12 weeks postoperatively by an independent observer . Results The fissure-healing rate was not significantly different in both groups ( 95 and 93.1 percent , respectively ) . The pain score was slightly higher in Group 2 , and it was statistically significant . Four cases of bleeding and two abscesses were observed in Group 2 . These complications were not observed in Group 1 . One case of incontinence was observed at the beginning in Group 1 and four in Group 2 , but the incontinence was transient in both cases . Conclusions Marginal sutures of incision after lateral internal sphincterotomy may be beneficial to reduce complications related to early wound healing BACKGROUND St and ard treatment for Chronic Anal Fissure ( CAF ) is unilateral Internal Sphincterotomy ( UIS ) . Still there is recurrence and the risk of of incontinence .  Bilateral Internal Sphincterotomy ( BIS ) as a treatment for CAF has not been adequately evaluated . METHODS A prospect i ve r and omized controlled trial of UIS at 3 o'clock compared with BIS at 3 and 9 ' O ' clocks . The outcome variables were : post operative pain , recurrence and incontinence . RESULT There was 104 and 107 cases in UIS and BIS group respectively with similar age and sex . There were 12 recurrences in UIS and only one in the BIS group ( p < 0.001 ) with no change in the continence . BIS group had less pain ( p < 0.001 ) . CONCLUSION BIS for CAF result ed in less postoperative pain , lower recurrence with no increase in the incontinence . However , further study is required with pre and post operative anal manometry
Anal stretch has a higher risk of fissure persistence than internal sphincterotomy and also a significantly higher risk of minor incontinence than sphincterotomy .
The combined results of open versus closed partial lateral internal sphincterotomy show little difference between the two procedures both in fissure persistence and risk of incontinence .
AUTHORS ' CONCLUSIONS Anal stretch and posterior midline internal sphincterotomy should probably be ab and oned in the treatment of chronic anal fissure in adults .
For those patients requiring surgery for anal fissure , open and closed partial lateral internal sphincterotomy appear to be equally efficacious .
BACKGROUND Operative techniques commonly used for fissure in ano include : anal stretch , open lateral sphincterotomy , closed lateral sphincterotomy , posterior midline sphincterotomy and to a lesser extent dermal flap coverage of the fissure .
Reports of direct comparisons between operative techniques for anal fissure are variable in their results .
These reports are either subject to selection bias ( in non-r and omized studies ) or observer bias ( in all studies ) or have inadequate numbers of patients enrolled to answer the question of efficacy .
OBJECTIVES To determine the best technique for fissure surgery .