ASCRS Ch12 — Anal Fissure and Anal Stenosis

Citation: Tsikitis VL, Marecik S. "Anal Fissure and Anal Stenosis." In: Steele SR, et al. (eds.), The ASCRS Textbook of Colon and Rectal Surgery, 4th ed. Springer Nature Switzerland AG; 2022. pp. 231–248 (PDF pp. 240–257 of the combined textbook file). Source file: raw/ASCRS Textbook 4th Ed.pdf (full 1,198-page textbook; cite by page range within the single PDF). Second chapter of Part II ("Anorectal Disease") — Chapter 11 ("Hemorrhoids") preceded it.

Type: Specialty textbook chapter (reference/background, not primary literature).

Scope

Twelfth chapter of the sequential full-textbook ingest (see ASCRS Ch01 - Anatomy and Embryology for the ingest's scope/plan). Covers two related but distinct entities in one chapter: anal fissure (definition/presentation/etiology, NOS-deficiency and ischemia pathophysiology theories, obstetric fissures, medical treatment ladder — topicals, CCBs, Botox — and operative treatment — dilation, LIS incl. traditional vs. tailored technique, local advancement flaps, fissurotomy/fissurectomy — plus atypical/Crohn's/STI fissures) and anal stenosis (types/causes, symptoms, evaluation, Milsom-Mazier classification, nonoperative bulking/dilation therapy, a full reconstructive flap ladder — Heineke-Mikulicz closure, rectal advancement, Y-V, V-Y, diamond/rhomboid, house, U/island, rotational S — Crohn's-specific stenosis outcomes, and hemorrhoidectomy-technique prevention).

Key content

Split into two new dedicated condition pages rather than one combined page, since fissure and stenosis are distinct clinically-coded entities each warranting their own future cross-links (e.g. from ASCRS Ch47's Crohn's-specific content): Anal Fissure and Anal Stenosis. Flagged one explicit, unresolved discrepancy: this chapter describes Crohn's-associated fissures as "deep, painful ulcerations," directly conflicting with the existing Sabiston-sourced characterization on Crohn Disease of Crohn's fissures as "usually lateral, relatively painless, large, and indolent" — left as an open flagged contradiction rather than silently reconciled. Minor cross-links added to Hemorrhoids (anal stenosis as a hemorrhoidectomy complication, ~90% causal share), Fecal Incontinence (LIS as an iatrogenic sphincter-defect cause), and Colonoscopy & Lower GI Endoscopy (fissure/stenosis as exam contraindications, now backed by a dedicated page).

Limitations

• Textbook chapter, not primary literature; cited trial/meta-analysis figures are the chapter authors' synthesis of primary sources, not independently re-verified.
• The pneumatic-balloon-dilation-vs-LIS incontinence comparison (0% vs. 16% at 24 months) rests on a single study.
• Reconstructive flap technique outcome data for anal stenosis come almost entirely from heterogeneous case series; the chapter itself notes only one randomized comparative study exists (house vs. rhomboid vs. Y-V flap).
• Anal-stenosis-in-Crohn's outcome statistics are drawn from older single-institution cohort studies (not recent, not multicenter).

Relevance

Twelfth entry in the ASCRS ingest. Adds two genuinely new condition pages. Chapter 13 continues Part II with "Cryptoglandular Abscess and Fistula."