الفهرس 
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Abstract
Anal fissure is a common, painful condition that causes significant morbidity, mostly in young adults. Acute anal fissures often heal spontaneously or with the help of medical treatment. Recurrence rates range from 30% to 70% if treatment is abandoned after the fissure is healed (Ibrahim, 2010).
chronic anal fissure is a non-healing linear tear in the distal anal mucosa below the dentate line. An anal fissure is likely to be non-healing if the fissure persists beyond 6 weeks. A chronic fissure can be identified by the presence of indurated edges, visible internal sphincter fibres at the base of the fissure, a sentinel polyp at the distal end of the fissure or afibroepithelial polyp at the apex. A chronic fissure classically occurs at the posterior midline position (6 o’clock position), with the anterior midline position occurring in 10% of females and 1% of males (Van, 2006).
Tailored lateral sphincterotomy described by Littlejohn and Newstead, (1997) as adjusting the sphincterotomy height to the length of the fissure produce clinically significant reduction in the incontinence rates and has recognized unquoted conservative practice of many surgeons. However it doesn’t solve the problem of long fissure in short anal canal with variation in the length of the fissure.
The present study included 60 adult patients with chronic anal fissure, their ages ranged between 21 to 60 years old (mean age 38 ). It was similar to the statement that most patients who develop anal fissures are young to middle aged adults. However, patients of all ages, including infants and the elderly, can develop an anal fissure as reported by Castillo and Margolin (2004).
The sex distribution in the two groups is similar and mainly females 65% to 35% males.
The clinical presentation in the two groups showed that pain was almost always present in 100% in all the patients of the two groups ,bleeding, Pruritus, discharge, were present in patients of the two groups with more or less similar incidences between them.
Constipation was a frequent finding in the two groups (80% and 70% respectively)
In this study , we compared the effect of tailored internal sphincterotomy with the conventional procedure in treatment of chronic anal fissure ,and according to the method of treatment the patient were divided into two groups:
Group (I): included 30 patients with chronic anal fissure which agree to have surgical treatment with tailored internal sphincterotomy ,complete healing of the fissure occurred in 100% of patients by the end of the third month with rapid pain relief 90% of patients by the end of the 1st month, 2 patients develop temporary incontinence to flatus and no one of the patient develop recurrence 0% by the end of the 6th month.
Group (II): also included 30 patients with chronic anal fissure and treated with conventional internal sphincterotomy, complete healing occurred in 80% of patients, 6 patients have incomplete healing by the end of the 3rd month. with delayed pain relief 60% of patients by the end of the 1st month, 20% of patients by the end of the 3rd month, and another 20% of the patients by the end of the 6th month. 3 patients develop bleeding ; 9 patients develop temporary incontinence, 3 of them lack of flatus and 6 of them soiling of underwear ; 6 patients develop recurrence within 6 month.
Regarding the healing rate in the present study, there was a highly significant success with complete healing after treatment with Tailored internal anal sphincterotomy 100% compared to 80% with conventional anal sphincterotomy.
Patients treated by Tailored internal sphincterotomy have rapid healing rate which occurred in 100% of patients within 3 months. These findings were near similar to the healing rates approaching 90% to 100% in some clinical trials carried by Hsu et al., (1984), Jensen et al., (1984), Walker et al., (1985), Gingold (1987),Romano et al., (1994), Mentes et al., (2003), Tocchi et al., (2004), Arroyo et al., (2005).
Patients in group (II) have slower healing rate which occurred in 60% of patients by the end of the 1st month ,20% by the end of the 3rd month and 6 patients remains after the end of the 6th month.
In the present study incontinence was reported in 2 patients of group(I) tailored sphincterotomy which was in the form of temporary lack of flatus control and that improved within 4 weeks after healing of the fissure, this result was supported by results carried by Floyd et al., (2006)
On the other hand, 9 patients in group(II) develop incontinence 3 of them (10%) lack of flatus and 6 of them (20%) soiling of underwear.
These findings were in agreement with the clinical trials carried by Nyam and
Pemberton (1999), Hyman (2004) and Nelson (2005) in which continence
disturbance had shown to be <10% and primarily involved incontinence to flatus.
In the present study there was 20% incidence of recurrence in the patients of group (II) within 6 month follow up.
In contrast to the present findings of recurrence rate, a study by Keighley
(1981) on 71 patients underwent conventional internal sphincterotomy showed that about 100% of fissures were healed. 25% of cases showed recurrence after 12 months follow up.
In a study by Arroyo et al., (2005) carried on 40 patients after conventional internal sphincterotomy, the recurrence rate was 7.5% after 3years follow up.
Long period of follow up and number of patients were responsible for differences between results in the study, while in our study follow up was for 6 months only.
Regarding complications after treatment in the present study, the complications included pain, bleeding and infection with insignificant differences between the two groups either by Tailored or conventional surgical sphincterotomy.