INTRODUCTION  介紹 — 

An anal fissure is a tear or ulceration in the lining of the anal canal below the mucocutaneous junction (dentate line) (figure 1). Most commonly caused by local trauma, anal fissures cause pain during defecation that persists for one to two hours. Persistence of an anal fissure is typically associated with anal spasm or high anal pressure. Medical management is typically used as the initial treatment for an anal fissure [1,2]. Surgery is reserved for patients who fail medical therapy [3-6].
肛裂是皮膚黏膜交界處（齒狀線）下方肛管內壁的撕裂或潰瘍 （ 圖 1）。肛裂最常由局部外傷引起，在排便時引起疼痛，持續一到兩個小時。肛裂的持續存在通常與肛門痙攣或高肛門壓力有關。藥物治療通常用作肛裂的初始治療[1,2]。手術僅供藥物治療失敗的患者使用[3-6]。

Surgical modalities of anal fissure treatment, including lateral internal sphincterotomy and botulinum toxin injection, are discussed in this topic. The clinical presentation, diagnosis, prevention, and medical management of anal fissure are discussed elsewhere. (See "Anal fissure: Clinical manifestations, diagnosis, prevention" and "Anal fissure: Medical management".)
本專題將討論肛裂治療的手術方式，包括外側內括約肌切開術和肉毒桿菌毒素注射。肛裂的臨床表現、診斷、預防和內科治療詳見其他專題。（參見 “肛裂的臨床表現、診斷和預防” 和 “肛裂的內科治療”）

TYPICAL ANAL FISSURE REFRACTORY TO MEDICAL THERAPY
藥物治療難治的典型肛裂 — 

Medical treatment heals a typical anal fissure in most patients. (See "Anal fissure: Medical management", section on 'Initial management of typical fissures'.)
藥物治療可以治癒大多數患者的典型肛裂。（參見 “肛裂的內科治療”，關於'典型肛裂的初始處理'一節 ）

Surgical treatment may be offered to patients whose fissure does not heal with medical therapy. Patients who are willing to undergo surgical treatment are further triaged based upon their risk of fecal incontinence. Women who have had multiple vaginal deliveries and older patients may have a weak anal sphincter complex, which puts them at a high risk of developing fecal incontinence after surgical treatment of anal fissure. Such patients should undergo one of the procedures that do not require division of the anal sphincter muscle (eg, botulinum toxin injection, fissurectomy, or anal advancement flap). Other patients who are not at risk of developing fecal incontinence may undergo lateral internal sphincterotomy, which is considered the most effective treatment for anal fissure (algorithm 1) [7-9].
對於裂隙無法通過藥物治療癒合的患者，可以進行手術治療。願意接受手術治療的患者根據大便失禁的風險進一步分類。多次陰道分娩的女性和老年患者可能肛門括約肌復合體較弱，這使得她們在肛裂手術治療后發生大便失禁的風險很高。此類患者應接受不需要肛門括約肌分割的手術之一（例如，肉毒桿菌毒素注射、裂隙切除術或肛門前移皮瓣）。其他無大便失禁風險的患者可行外側內括約肌切開術，這被認為是治療肛裂最有效的方法 （流程圖 1）[7-9]。

Patients with low risk of incontinence: Sphincterotomy — A lateral internal sphincterotomy provides prompt symptomatic relief and heals anal fissures in over 95 percent of patients within three weeks [10-18]. In patients who are at a low risk of developing fecal incontinence, the lateral internal sphincterotomy is the gold standard for the operative management of an anal fissure secondary to hypertonicity or hypertrophy of the internal anal sphincter [7-9]. As the gold standard, lateral internal sphincterotomy has been compared with all other therapies for anal fissure, including topical nitroglycerin [3,19], botulinum toxin A injection [6,20], and oral nifedipine [21]. Lateral internal sphincterotomy remains superior in its efficacy to all other therapies, according to a 2017 systematic review [22].
尿失禁風險低的患者：括約肌切開術  —  外側內括約肌切開術可迅速緩解癥狀，並在 3 周內治癒超過 95%的患者[10-18]。對於發生大便失禁的風險較低的患者，外側內括約肌切開術是繼發於肛內括約肌高滲或肥大的肛裂手術治療的金標準[7-9]。作為金標準，外側內括約肌切開術已與所有其他肛裂療法進行了比較，包括局部硝酸甘油 [3,19]、A 型肉毒桿菌毒素注射[6,20]和口服硝苯地平 [21]。2017 年的一項系統評價顯示，外側內括約肌切開術的療效仍然優於所有其他療法[22]。

A Lord's, or four-finger, dilatation in the operating room had been previously used for the treatment of anal fissures before lateral sphincterotomy [23]. Although this treatment can improve the spasm in the internal anal sphincter, it is associated with a high incidence of sphincter tears and fecal incontinence and therefore has been abandoned [24,25]. Neuromodulation has also been studied as a sphincter-sparing treatment for anal fissure [26]; however, experience is limited with this technique, and it has not been compared directly with other approaches. A midline posterior sphincterotomy was found to be inferior to lateral internal sphincterotomy and is rarely performed because it can result in a "keyhole deformity" [24]. However, for fissures associated with anal stenosis, a posterior sphincterotomy combined with a VY advancement flap is appropriate [27]. (See 'Anal advancement flap' below.)
手術室中的 Lord's 擴張術或四指擴張術以前曾用於治療側側括約肌切開術前的肛裂[23]。雖然這種治療可以改善肛門內括約肌的痙攣，但它與括約肌撕裂和大便失禁的高發生率有關，因此已被放棄[24,25]。神經調控也被研究作為肛裂的括約肌保留治療[26];然而，這種技術的經驗有限，並且尚未與其他方法直接進行比較。研究發現，中線後括約肌切開術不如外側內括約肌切開術，並且很少進行，因為它可能導致“鎖孔畸形”[24]。然而，對於肛門狹窄相關的裂隙，后括約肌切開術聯合 VY 推進皮瓣是合適的[27]。（參見下文 '肛門前移皮瓣'）

Preoperative preparation — Intravenous antibiotics are not generally required for patients undergoing a sphincterotomy. (See "Antimicrobial prophylaxis for prevention of surgical site infection following gastrointestinal surgery in adults", section on 'Colorectal procedures'.)
術前準備  —  括約肌切開術患者通常不需要靜脈注射抗生素。（參見 “成人胃腸道手術后預防手術部位感染的抗菌藥物預防”，關於'結直腸手術'一節 ）

Type of anesthesia — A lateral internal sphincterotomy can be performed in the surgeon's office using a local anesthetic, or in the operating room under regional or general anesthesia. The choice of anesthesia is determined by both patient and surgeon preference, although a retrospective study of 298 patients reported a higher rate of fissure recurrence after a lateral internal sphincterotomy performed under local, as opposed to general, anesthesia (9 of 20 versus 23 of 271) [28].
麻醉  類型 —  外側內括約肌切開術可在外科醫生辦公室使用局部麻醉劑進行，也可以在手術室進行區域麻醉或全身麻醉。麻醉的選擇取決於患者和外科醫生的偏好，但一項回顧性研究納入了 298 例患者，報告稱在局部麻醉下進行側內括約肌切開術后，與全身麻醉相比，裂隙復發率更高（20 例中的 9 例 vs 271 例中的 23 例）[28]。

Patient positioning — Positioning options for lateral internal sphincterotomy include the prone jackknife, lithotomy, and lateral decubitus positions. The location of the fissure does not influence the choice of patient positioning. We prefer to place the patient in a prone jackknife position. Patients with obesity are typically placed in the lateral decubitus position since they frequently do not tolerate the prone jackknife or lithotomy position.
患者體位  —  外側內括約肌切開術的體位選擇包括俯臥位折刀位、截石術和側臥位。裂隙的位置不影響患者體位的選擇。我們更喜歡將患者置於俯臥的折刀位置。肥胖患者通常處於側臥位，因為他們經常不能耐受俯臥位折刀或截石位。

Operative technique — After the patient is properly positioned, gentle anal dilation is performed to allow admittance of a medium (0.75 to 1 inch [1.90 to 2.54 cm]) rectal retractor. Anoscopy is performed using the rectal retractor. The internal sphincter muscle is then divided at a lateral position.
手術技術  —  患者體位正確后，輕輕擴張肛門，以容納中等（0.75-1 英寸[1.90-2.54cm]）直腸牽開器。肛門鏡檢查使用直腸牽開器進行。然後將括約肌內側分開。

Incision — The procedure can be performed in either an open or a closed manner at the surgeon's discretion.
切  口 —  手術可由外科醫生自行決定以開放或封閉方式進行。

●In the open technique, the surgeon incises the anoderm to expose the internal sphincter muscle and divides it under direct vision. Complete division of the internal sphincter muscle fibers is important since an incompletely divided internal sphincter has been associated with a marked increase in fissure recurrence. (See 'Incomplete sphincterotomy' below.)
在開放技術中，外科醫生切開肛胚層以暴露內括約肌，並在直視下將其分開。內括約肌纖維的完全分裂很重要，因為不完全分裂的內括約肌與裂隙復發的顯著增加有關。（參見下文 '不完全括約肌切開術'）

●In the closed technique, the surgeon inserts a blade either directly under the anoderm or into the intersphincteric groove and divides the internal sphincter without widely incising the anal mucosa.
在封閉式技術中，外科醫生將刀片直接插入肛門下方或括約肌間溝中，並在不廣泛切開肛門粘膜的情況下分開內括約肌。

A meta-analysis of five randomized trials with 299 patients found no significant difference between the two techniques in terms of the rate of healing or incontinence [24]. In the largest trial of 79 patients, the rate of fissure healing was 96 percent at six weeks, and new incontinence was diagnosed in five patients (6.8 percent) at 52 weeks for open and closed procedures combined [14].
一項 meta 分析納入了 5 項隨機試驗，涉及 299 例患者，發現兩種技術在癒合率或尿失禁率方面無顯著差異[24]。一項納入 79 例患者的大型試驗顯示，6 周時裂隙癒合率為 96%，5 例患者（6.8%）在 52 周時診斷出新發尿失禁，開放式和封閉式手術合計[14]。

Location — Regardless of the method chosen, most surgeons perform a lateral internal sphincterotomy. We typically perform the sphincterotomy on the right side between the anterior and posterior hemorrhoidal columns to avoid confusion if a repeat procedure is required. A posterior sphincterotomy is rarely performed [13].
位置  —  無論選擇哪種方法，大多數外科醫生都會進行外側內括約肌切開術。我們通常在前痔柱和後痔柱之間的右側進行括約肌切開術，以避免在需要重複手術時造成混淆。後括約肌切開術很少進行[13]。

Extent — The extent of the sphincterotomy remains controversial. We recommend performing a tailored or partial fissure apex sphincterotomy rather than the conventional longer sphincterotomy as described here [29]:
範圍  —  括約肌切開術的範圍仍存在爭議。我們建議進行定製或部分骨尖括約肌切開術，而不是本文所述的常規長括約肌切開術[29]：

●The conventional longer sphincterotomy divides the internal anal sphincter muscle to the level of or just proximal to the dentate line [30,31].
傳統的較長括約肌切開術將肛門內括約肌分開至齒狀線的水準或齒狀線的近端[30,31]。

●The tailored or partial sphincterotomy divides the internal anal sphincter only to the level of the apex of the fissure and therefore is also referred to as the "fissure apex sphincterotomy." Compared with the longer sphincterotomy, this approach preserves more sphincteric muscle fibers [10,32].
定製或部分括約肌切開術僅將肛門內括約肌分開到裂隙頂端的水準，因此也稱為「裂隙頂端括約肌切開術」。。與較長的括約肌切開術相比，這種方法保留了更多的括約肌纖維[10,32]。

Three randomized trials of conventional versus tailored sphincterotomy showed statistically superior fissure healing rates in the conventional arm, but two trials reported worse fecal continence scores in the conventional arm [10,33], whereas one did not [21].
3 項隨機試驗將常規括約肌切開術與定製括約肌切開術進行比較，結果顯示常規組的裂隙癒合率有統計學意義上更高，但 2 項試驗報告常規組的大便失禁評分較差[10,33]，而 1 項則沒有[21]。

The actual fissure may or may not be excised at the time of a lateral sphincterotomy at the surgeon's discretion, but a biopsy should be performed if the fissure has an atypical appearance. (See 'Atypical anal fissure' below.)
根據外科醫生的判斷，在外側括約肌切開術時，實際裂隙可能會或可能不會被切除，但如果裂隙具有非典型外觀，則應進行活檢。（參見下文 '非典型肛裂'）

Postoperative care — Infiltration of the operative site with a local anesthetic before and/or after the sphincterotomy will provide postoperative pain relief [34,35]. Multimodal pain management with gabapentin 300 mg twice daily and naproxen 500 mg twice daily can be used as primary postoperative analgesia. Rarely, oral opioids will be needed for breakthrough pain. The use of multimodal pain management improves analgesia, results in lower opioid usage, and lowers the rate of urinary retention [36,37].
術后護理  —  括約肌切開術前後使用局部麻醉劑浸潤手術部位可緩解術后疼痛[34,35]。加巴噴丁 300 毫克，每日兩次， 萘普生 500 毫克，每日兩次，可作為主要術后鎮痛。在極少數情況下，突破性疼痛需要口服阿片類藥物。採用多模式疼痛管理可改善鎮痛效果，降低阿片類藥物使用量，並降低尿瀦留率[36,37]。

Since a bladder catheter is not typically used, limiting perioperative fluid administration to less than one liter lowers the incidence of postoperative urinary retention [38-40]. Postoperative instructions include recommendations for sitz baths for comfort, adequate intake of fluid and fiber to avoid constipation, and limited activity for a few days. These instructions are primarily derived from clinical experience, rather than specific data. With appropriate postoperative instruction, a lateral sphincterotomy can be performed with a high degree of patient satisfaction [41].
由於通常不使用膀胱導管，因此將圍手術期輸液量限制在 1L 以下可降低術后尿瀦留的發生率[38-40]。術后說明包括建議坐浴以獲得舒適感、攝入足夠的液體和纖維以避免便秘以及限制幾天的活動。這些說明主要來自臨床經驗，而不是具體數據。通過適當的術后指導，可以進行側括約肌切開術，患者滿意度很高[41]。

Risk of fecal incontinence — A major concern with surgery for anal fissures is the risk of fecal incontinence [10,14,24]. Fecal incontinence can be characterized as either minor (defined as inadvertent escape of flatus or partial soiling of undergarments with liquid stool) or major (involuntary excretion of feces). (See "Fecal incontinence in adults: Etiology and evaluation".)
大便失禁  的風險 —  肛裂手術的一個主要問題是大便失禁的風險[10,14,24]。大便失禁可分為輕微（定義為無意中腸胃脹氣逸出或液體糞便部分弄臟內衣）或嚴重（糞便不自主排泄）。（參見 “成人大便失禁的病因和評估”）

Lateral internal sphincterotomy can cause long-term (≥2 years) incontinence of both flatus and stool. In a meta-analysis of 22 retrospective and prospective studies that included 4512 patients who were followed for ≥2 years after a lateral internal sphincterotomy for chronic anal fissure, the overall continence disturbance rate was 14 percent, which included flatus incontinence in 9 percent, soilage/seepage in 6 percent, accidental defecation in 0.91 percent, incontinence to liquid stool in 0.67 percent, and incontinence to solid stool in 0.83 percent of patients [42].
外側內括約肌切開術可導致長期（≥2 年）腸胃脹氣和大便失禁。一項薈萃分析納入了 22 項回顧性和前瞻性研究，納入了 4512 例慢性肛裂外側內括約肌切開術后隨訪 ≥2 年的患者，總體失禁率為 14%，其中 9% 為腸胃脹氣尿失禁，6% 為污垢/滲漏，0.91% 為意外排便，0.67% 為液體便失禁， 0.83%的患者出現實便失禁[42]。

Others estimate that 30 to 45 percent of patients experience minor fecal incontinence immediately following lateral internal sphincterotomy, with 6 to 30 percent of patients having persistent symptoms long-term [11,28]. By contrast, only approximately 2 percent of the general population suffers from fecal incontinence [43]. The risk is increased in women, particularly those who have had previous vaginal deliveries. In one study of 487 patients, women were significantly more likely to develop fecal incontinence after a sphincterotomy than men (53 versus 33 percent) [17].
其他研究估計，30%-45%的患者在外側內括約肌切開術后立即出現輕微大便失禁，6%-30%的患者癥狀持續存在長期[11,28]。相比之下，只有約 2%的一般人群患有大便失禁[43]。女性的風險增加，尤其是那些以前有過陰道分娩的女性。一項納入 487 例患者的研究顯示，括約肌切開術后發生大便失禁的可能性明顯高於男性（53% vs 33%）[17]。

Patients with high risk of incontinence — For patients who are at a high risk of developing fecal incontinence (eg, multiparous women or older patients), options for surgical management of anal fissure include botulinum toxin A injection, V-Y advancement flap, and subcutaneous fissurectomy. These alternatives to lateral sphincterotomy do not require the internal sphincter muscle to be divided and thereby reduce the risk of fecal incontinence.
尿失禁  高風險患者 —  對於發生大便性尿失禁的高風險患者（如，經產婦或老年患者），肛裂手術治療的選擇包括注射肉毒桿菌毒素 A、V-Y 推進皮瓣和皮下裂切除術。這些外側括約肌切開術的替代方案不需要分割內括約肌，從而降低大便失禁的風險。

Botulinum toxin injection — Botulinum toxin is a potent inhibitor of the release of acetylcholine from nerve endings and has been used successfully for decades to treat certain spastic disorders of skeletal muscle such as blepharospasm and torticollis. It has also been used to treat spastic disorders of the gastrointestinal tract such as achalasia and anal fissure.
肉毒桿菌毒素注射  —  肉毒桿菌毒素是神經末梢乙醯膽鹼釋放的有效抑製劑，幾十年來已成功用於治療某些骨骼肌痙攣性疾病，如眼瞼痙攣和斜頸。它還被用於治療胃腸道痙攣性疾病，如賁門失弛緩症和肛裂。

Injection of botulinum toxin into the anal sphincter can help relax the hypertonic anal sphincter muscle and, in turn, improve healing of chronic anal fissures. A commercially prepared form of botulinum toxin type A (eg, Botox, Dysport) is typically given as injections around the anal canal. Doses (ranging from 10 to 100 units) vary depending upon the specific brand and preparation of the botulinum toxin that is used.
將肉毒桿菌毒素注射到肛門括約肌中可以幫助放鬆高滲肛門括約肌，進而改善慢性肛裂的癒合。商業製備的 A 型肉毒桿菌毒素（例如，肉毒桿菌毒素、Dysport）通常作為肛管周圍注射。劑量（範圍從 10 到 100 單位）根據所用肉毒桿菌毒素的具體品牌和製備而有所不同。

In one protocol, 10 units of Botox (0.2 mL of 50 units per mL) each are injected into the internal anal sphincter on either side of the anal fissure with a 27 gauge needle [44]. In a trial of 30 patients with chronic anal fissures, botulinum toxin injection using this protocol resulted in significantly more fissure healing than saline control at one (8 of 15 versus 2 of 15) and two months (11 of 15 versus 2 of 15) [44]. The four patients who had persistent fissures two months after botulinum toxin injection were retreated, and all healed by two months thereafter. One patient developed temporary flatus incontinence after Botox injection. No relapse occurred during an average follow-up of 16 months.
在一種方案中，用 27 號針頭將 10 單位的肉毒桿菌毒素（0.2mL，每 mL50 單位）注射到肛裂兩側的肛門內括約肌[44]。一項納入 30 例慢性肛裂患者的試驗顯示，在 1 個月（15 例中的 8 例 vs 15 例中的 2 例）和 2 個月（15 例中的 11 例 vs 15 例中的 2 例）時，使用該方案注射肉毒桿菌毒素的裂隙癒合率顯著高於生理鹽水對照組[44]。注射肉毒桿菌毒素 2 個月後 4 例持續性裂隙的患者退治，2 個月後均痊癒。一名患者在注射肉毒桿菌毒素后出現暫時性腸胃脹氣尿失禁。在平均 16 個月的隨訪期間沒有復發。

Other studies with longer follow-ups, however, found recurrence rates of 40 to 50 percent after botulinum toxin treatment of anal fissures [45,46]. Patients who relapse may be retreated with botulinum toxin with good results [47]. Temporary fecal incontinence after botulinum toxin therapy has been reported to occur at a rate of approximately 7 percent, which compares favorably with the 30 to 45 percent of patients who experience minor fecal incontinence following lateral sphincterotomy [47,48].
然而，其他隨訪時間較長的研究發現，肉毒桿菌毒素治療肛裂后的復發率為 40%-50%[45,46]。復發的患者可接受肉毒桿菌毒素治療，效果良好[47]。據報導，肉毒桿菌毒素治療后暫時性大便失禁的發生率約為 7%，與側括約肌切開術后出現輕度大便失禁的 30%-45%相比，這一比例相當高[47,48]。

In a Cochrane meta-analysis, botulinum toxin injection was found to be equally efficacious in treating chronic anal fissures as topical nitroglycerin [49]. However, because botulinum toxin is more invasive and is associated with a greater risk of mild incontinence, we generally reserve it for patients who have not responded to first-line medical therapy with one of the topical vasodilators. (See "Anal fissure: Medical management", section on 'Initial management of typical fissures'.)
一項 Cochranemeta 分析發現，肉毒桿菌毒素注射在治療慢性肛裂方面與局部使用硝酸甘油同樣有效[49]。然而，由於肉毒桿菌毒素更具侵入性，並且與輕度尿失禁的風險更大相關，因此我們通常將其保留給對其中一種局部血管擴張劑的一線藥物治療無反應的患者。（參見 “肛裂的內科治療”，關於'典型肛裂的初始處理'一節 ）

Botulinum toxin treatment for anal fissure has been performed safely in patients who developed anal fissures while actively receiving chemotherapy [50].
肉毒桿菌毒素治療肛裂的患者在積極接受化療時發生肛裂的患者中已安全進行[50]。

Fissurectomy — A fissurectomy, or excision of the anal fissure, is also an effective treatment of chronic anal fissure that has a low recurrence rate and a low risk of fecal incontinence. In a study of 53 patients whose chronic anal fissures were successfully treated with fissurectomy, only five patients (11 percent) recurred with a five-year follow-up [51]. Fissurectomy did not affect the rate of fecal incontinence.
肛裂切除術  —  肛裂切除術（或肛裂切除術）也是治療慢性肛裂的有效方法，該肛裂復發率低，大便失禁風險低。一項研究納入了 53 例慢性肛裂患者，這些患者通過裂隙切除術成功治療，只有 5 例患者（11%）在 5 年的隨訪中復發[51]。裂隙切除術不影響大便失禁的發生率。

Fissurectomy has also been performed in conjunction with botulinum toxin injection to treat anal fissures. In two studies, such combination treatment resulted in fissure healing rates of 67 to 83 percent, minor incontinence rates of 3 to 7 percent, and fissure recurrence rates of 0 to 17 percent [52,53].
裂隙切除術也與肉毒桿菌毒素注射相結合，以治療肛裂。2 項研究顯示，這種聯合治療的裂隙癒合率為 67%-83%，輕度尿失禁率為 3%-7%，裂隙復發率為 0%-17%[52,53]。

Anal advancement flap — An anal advancement flap, such as the endoanal V-Y advancement flap (figure 2), does not divide the internal sphincter and is not associated with any increased risk of fecal incontinence [54,55]. It is an alternative to the lateral internal sphincterotomy for patients who are at risk of developing fecal incontinence (eg, older adults, multiparous women, recurrent fissures), especially for those whose fissures are not related to hypertonicity of the sphincter muscle [54,56-60]. A 2018 systematic review with 300 patients found that anal advancement flap was associated with a significantly lower rate of anal incontinence compared with lateral internal sphincterotomy (odds ratio [OR] 0.06, 95% CI 0.01-0.36). There were no statistically significant differences in unhealed fissures (OR 2.21, 95% CI 0.25-19.33) or wound complication rates (OR 1.41, 95% CI 0.50-4.99) between the two treatments [61].
肛門前移皮瓣  —  肛門前移皮瓣，如肛門內 V-Y 前移皮瓣 （ 圖 2），不會分裂內括約肌，也不會增加大便失禁的風險[54,55]。對於有大便失禁風險的患者（如老年人、經產婦、復發性裂隙），尤其是裂隙與括約肌高滲無關的患者，它是外側內括約肌切開術的替代方法[54,56-60]。2018 年一項納入 300 名患者的系統評價發現，與外側內括約肌切開術相比，肛門前移皮瓣與肛門失禁發生率顯著降低相關（OR 0.06,95% CI 0.01-0.36）。兩種治療在未癒合的裂隙（OR 2.21,95%CI 0.25-19.33）和傷口併發症發生率（OR 1.41,95%CI 0.50-4.99）方面無統計學意義[61]。

The same V-Y advancement flap that is used to treat anal fissures can be used to treat anal fistulas. Details are discussed elsewhere. (See "Operative management of anorectal fistulas", section on 'Advancement flaps'.)
用於治療肛裂的相同 V-Y 推進皮瓣可用於治療肛瘺。細節詳見別處。（參見 “肛門直腸瘺的手術治療”，關於'前移皮瓣'一節 ）

PERSISTENT OR RECURRENT ANAL FISSURE AFTER SURGERY
手術后持續或復發性肛裂 — 

Fissures that fail to heal or that recur after lateral internal sphincterotomy have been associated with an incomplete sphincterotomy, sphincter hypertonia, or chronic morphologic changes within the fissure, including fibrosis, a sentinel pile, or rolled edges [62-64]. Patients who have persistent or recurrent anal fissures despite surgery are generally managed conservatively with a high-fiber diet and ample fluid intake [16,62-69]. These conservative measures can heal approximately two-thirds of persistent or recurrent fissures that are unrelated to infection, inflammation, or malignancy [16,17]. The remainder of the patients receive further treatment based upon their symptoms [63,64].
未能癒合或外側內括約肌切開術后復發的裂隙與括約肌切開術不完全、括約肌肌張力亢進或裂隙內的慢性形態學改變有關，包括纖維化、前哨樁或卷邊[62-64]。手術后仍持續或復發性肛裂的患者通常採用保守治療，採用高纖維飲食和充足的液體攝入[16,62-69]。這些保守措施可治癒約 2/3 的與感染、炎症或惡性腫瘤無關的持續性或復發性裂隙[16,17]。其餘患者根據癥狀接受進一步治療[63,64]。

No pain — When a persistent anal fissure bleeds with bowel movements but is not painful, it does not require operative intervention.
無疼痛  —  當持續性肛裂隨排便出血但不疼痛時，無需手術干預。

Minimal pain — When a fissure does not heal and is minimally painful, a subcutaneous fissurectomy can be performed, especially if the fissure has one of the following chronic morphologic changes (see 'Fissurectomy' above):
輕微疼痛  —  當裂隙未癒合併疼痛輕微時，可進行皮下裂切除術，特別是如果裂隙有以下慢性形態學改變之一（參見上文 '裂隙切除術'）：

●Fibrosis  纖維 化

●A sentinel pile  哨兵堆

●Rolled edges  捲邊

Severe pain — When a persistent or recurrent fissure causes severe rectal pain, anal sonography is indicated to assess the extent of the previous lateral internal sphincterotomy. Further management depends upon the completeness of the initial sphincterotomy [16,54,70,71].
劇烈疼痛  —  當持續性或復發性裂隙引起嚴重直腸疼痛時，應進行肛門超聲檢查以評估先前外側內括約肌切開術的程度。進一步的治療取決於初始括約肌切開術的完整性[16,54,70,71]。

Incomplete sphincterotomy — If the lateral internal sphincterotomy was not complete, a repeat procedure is performed to complete the sphincterotomy to the level of the dentate line. The repeat sphincterotomy can be performed on the same side or, more commonly, on the contralateral side to avoid scar tissues from the first procedure. A subcutaneous fissurectomy can also be added at the surgeon's discretion, based upon the presence or absence of the same chronic morphologic changes listed above.
不完全括約肌切開術  —  如果外側內括約肌切開術未完成，則應重複作，將括約肌切開術完成至齒狀線水準。重複括約肌切開術可以在同一側進行，或者更常見的是，可以在對側進行，以避免第一次手術留下疤痕組織。皮下裂切除術也可以由外科醫生根據是否存在上述相同的慢性形態學變化而自行決定增加。

In a review of 51 patients following a lateral internal sphincterotomy, there was a significantly increased risk of fissure recurrence with an incompletely divided internal sphincter compared with a completely divided sphincter (75 versus 10 percent) [62].
一項納入了 51 例外側括約肌內切開術患者的綜述，發現與完全內括約肌相比，內括約肌不完全分裂的裂隙復發風險顯著增加（75% vs 10%）[62]。

Complete sphincterotomy — If the lateral internal anal sphincter muscle is clearly divided to a point proximal to the dentate line, a surgical fissurectomy can be performed, and an endoanal V-Y advancement flap is used to cover the defect. (See 'Anal advancement flap' above.)
完全括約肌切開術  —  如果肛門內括約肌外側明顯劃分至齒狀線近端，可進行手術裂切除術，並使用肛門內 V-Y 前移皮瓣覆蓋缺損。（參見上文 '肛門前移皮瓣'）

ATYPICAL ANAL FISSURE  非典型肛裂 — 

The finding of an atypical anal fissure (multiple, off midline, large, or irregular) should alert the surgeon to the possibility of a secondary manifestation of a systemic illness, such as Crohn disease, tuberculosis, HIV infection, adenocarcinoma, metastatic basal cell carcinoma, lymphoma, or leukemia [16,65-68]. The patient evaluation should include a thorough history and physical examination focusing on secondary manifestations of a systemic disease, wound cultures to identify a possible infection, and an examination under anesthesia with biopsies to rule out malignancy [64]. (See "Perianal and perirectal abscess" and "Perianal Crohn disease" and "Evaluation of anorectal symptoms in men who have sex with men" and "Anal squamous intraepithelial lesions: Epidemiology, clinical presentation, diagnosis, screening, prevention, and treatment" and "Anal fissure: Clinical manifestations, diagnosis, prevention".)
發現非典型肛裂（多發性、偏中線、大裂或不規則）應提醒外科醫生可能繼發出現全身性疾病，如克羅恩病、結核、HIV 感染、腺癌、轉移性基底細胞癌、淋巴瘤或白血病[16,65-68]。患者評估應包括全面的病史和體格檢查，重點關注全身性疾病的繼發表現，傷口培養以識別可能的感染，以及麻醉下檢查和活檢以排除惡性腫瘤[64]。（參見 “肛周和直腸周圍膿腫” 和 “肛周克羅恩病” 和 “男男性行為者肛門直腸癥狀的評估” 和 “肛門鱗狀上皮內病變的流行病學、臨床表現、診斷、篩查、預防和治療” 和 “肛裂的臨床表現、診斷和預防”）

Anal fissures related to an underlying systemic illness are best initially treated with aggressive medical management of that illness. As an example, patients with anal fissures due to Crohn proctitis should be referred to a gastroenterologist for optimal management of their Crohn disease. Anal fissures related to Crohn disease are multiple in approximately one-third of patients. These fissures are usually painless. Thus, excessive rectal pain in a patient with Crohn-related anal fissures should raise suspicion for development of a perirectal abscess and prompt an examination under anesthesia and possibly a drainage procedure [69]. Because sphincter preservation is important for patients who often have chronic diarrhea, anal fissures in Crohn patients are typically treated medically rather than surgically. A lateral sphincterotomy is reserved for Crohn patients with minimal active anorectal inflammation who fail all available nonsurgical therapies [64]. (See "Perianal Crohn disease".)
與潛在全身性疾病相關的肛裂最好首先通過對該疾病進行積極的藥物治療來治療。例如，克羅恩直腸炎引起的肛裂患者應轉診至胃腸病學家，以優化克羅恩病的治療。大約三分之一的患者患有與克羅恩病相關的肛裂。這些裂縫通常是無痛的。因此，克羅恩相關肛裂患者直腸過度疼痛應懷疑發生直腸周圍膿腫，並應進行麻醉檢查，並可能進行引流術[69]。由於保留括約肌對於經常患有慢性腹瀉的患者很重要，因此克羅恩患者的肛裂通常通過藥物治療而不是手術治療。側括約肌切開術僅用於活動性肛腸炎症輕微且所有可用非手術治療均失敗的克羅恩患者[64]。（參見 “肛周克羅恩病”）

SOCIETY GUIDELINE LINKS  學會指南連結 — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Anal fissure".)
來自世界各地選定國家和地區的社會和政府贊助指南的連結另行提供。（參見 “學會指南連結：肛裂”）

INFORMATION FOR PATIENTS
患者教育 — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics". The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
UpToDate 提供兩種類型的患者教育材料，「基礎知識」和“超越基礎知識”。基礎知識患者教育文章是用通俗易懂的語言編寫的，處於 ^{5 至 6 年級}的閱讀水準，它們回答了患者可能對特定病症提出的四到五個關鍵問題。這些文章最適合想要總體概述並喜歡簡短、易於閱讀的材料的患者。超越基礎知識的患者教育文章更長、更複雜、更詳細。這些文章是在 10 ^至 12 ^年級的閱讀水準上寫的，最適合想要深入了解資訊並熟悉一些醫學術語的患者。

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
以下是與此主題相關的患者教育文章。我們鼓勵您將這些主題列印或通過電子郵件發送給您的患者。（您還可以透過搜索“患者資訊”和感興趣的關鍵字來查找有關各種主題的患者教育文章。

●Beyond the Basics topics (see "Patient education: Anal fissure (Beyond the Basics)")
基礎之外的專題（參見 “患者教育：肛裂（基礎之外）”）

SUMMARY AND RECOMMENDATIONS
總結與推薦

●General algorithm for managing anal fissures – Medical treatment heals a typical anal fissure in most patients. Surgery is offered to patients who fail medical therapy (algorithm 1). (See "Anal fissure: Medical management" and 'Introduction' above.)
治療肛裂的通用演算法 – 藥物治療可以治癒大多數患者的典型肛裂。對藥物治療失敗的患者提供手術 （ 流程圖 1）。（參見上文 “肛裂的內科治療” 和 '引言'）

●Typical primary anal fissures – Patients who are willing to undergo surgical treatment are further triaged based upon their risk of fecal incontinence. Women who have had multiple vaginal deliveries and older patients may have a weak anal sphincter complex, which puts them at a high risk of developing fecal incontinence after surgical treatment of anal fissure.
典型的原發性肛裂 – 願意接受手術治療的患者根據大便失禁的風險進一步分類。多次陰道分娩的女性和老年患者可能肛門括約肌復合體較弱，這使得她們在肛裂手術治療后發生大便失禁的風險很高。

•We suggest performing a lateral internal sphincterotomy in patients with a low risk of developing fecal incontinence (Grade 2C). (See 'Patients with low risk of incontinence: Sphincterotomy' above.)
我們建議對發生大便失禁風險較低（2C 級 ）的患者進行側內括約肌切開術。（參見上文 '尿失禁低風險患者的括約肌切開術'）

We recommend performing a tailored or partial sphincterotomy (ie, fissure apex sphincterotomy) rather than a longer sphincterotomy (Grade 1B). The procedure can be performed in an open or closed fashion. (See 'Extent' above.)
我們建議進行定製或部分括約肌切開術（即裂隙心尖括約肌切開術），而不是更長的括約肌切開術（1B 級 ）。該過程可以以開放或封閉的方式進行。（參見上文 '範圍'）

•For patients who are at a high risk of developing fecal incontinence (eg, multiparous women or older patients), surgical options include botulinum toxin A injection, V-Y advancement flap, and subcutaneous fissurectomy. These alternatives to lateral internal sphincterotomy do not require the internal sphincter muscle to be divided and thereby reduce the risk of fecal incontinence. (See 'Patients with high risk of incontinence' above.)
對於發生大便失禁的高風險患者（如經產婦或老年患者），手術選擇包括注射肉毒桿菌毒素 A、V-Y 推進皮瓣和皮下裂切除術。這些外側內括約肌切開術的替代方案不需要分割內括約肌，從而降低大便失禁的風險。（參見上文 '尿失禁高危患者'）

●Anal fissures after sphincterotomy – If a persistent or recurrent anal fissure develops after a lateral internal sphincterotomy was performed and causes the patient severe pain, anal ultrasonography is performed to determine the completeness of the prior sphincterotomy. (See 'Persistent or recurrent anal fissure after surgery' above.)
括約肌切開術后肛裂 – 如果在進行外側內括約肌切開術后出現持續性或復發性肛裂並導致患者劇烈疼痛，則進行肛門超聲檢查以確定先前括約肌切開術的完整性。（參見上文 '術后持續性或復發性肛裂'）

•Patients who have an incomplete sphincterotomy should undergo repeat sphincterotomy on the same or opposite side.
括約肌切開術不完全的患者應在同側或另一側重複進行括約肌切開術。

•Patients who have a complete sphincterotomy should undergo a fissurectomy followed by V-Y advancement flap closure.
接受完全括約肌切開術的患者應接受裂隙切除術，然後進行 V-Y 推進皮瓣閉合術。

●Atypical anal fissures – The finding of an atypical anal fissure (multiple, off midline, large, or irregular) should alert the surgeon to the possibility of a secondary manifestation of a systemic illness, such as Crohn disease, tuberculosis, HIV infection, adenocarcinoma, metastatic basal cell carcinoma, lymphoma, or leukemia. Aggressive and optimal medical management of the underlying medical disease should be performed prior to operative management of an atypical anal fissure. (See 'Atypical anal fissure' above.)
非典型肛裂 – 發現非典型肛裂（多發性、偏中線、大或不規則）應提醒外科醫生注意全身性疾病繼發表現的可能性，例如克羅恩病、肺結核、HIV 感染、腺癌、轉移性基底細胞癌、淋巴瘤或白血病。在對非典型肛裂進行手術治療之前，應對基礎內科疾病進行積極和最佳的藥物治療。（參見上文 '非典型肛裂'）