Discipline of Surgery, Lambe Institute, National University of Ireland, Galway, Ireland; Department of Colorectal Surgery, University Hospital Galway, Galway, Ireland.
Discipline of Surgery, Lambe Institute, National University of Ireland, Galway, Ireland.
Int J Surg. 2018 Jan;49:16-21. doi: 10.1016/j.ijsu.2017.12.002. Epub 2017 Dec 9.
Chronic anal fissures (CAF) are common and associated with reduced quality of life. Lateral internal sphincterotomy (LIS) is frequently carried out but carries a significant risk of anal incontinence. Anal advancement flap (AAF) has been advocated as an alternative, 'sphincter-preserving' procedure. We aimed to perform a systematic review and meta-analysis to compare the efficacy of both techniques in the treatment of CAF.
The online databases of PubMed/Medline, CINAHL, EMBASE and Cochrane Central Register of Controlled Trials were searched from inception to January 2017. All studies that investigated and reported outcomes of LIS and AAF for treatment of CAF were included. The primary outcome measure was anal incontinence while secondary outcomes included unhealed fissure and wound complication rates. Random effects models were used to calculate pooled effect size estimates.
Four studies (2 randomized controlled trials and 2 retrospective studies) describing 300 patients (150 LIS, 150 AAF) fulfilled our inclusion criteria. There was significant clinical heterogeneity among the trials. On random effects analysis, AAF was associated with a significantly lower rate of anal incontinence compared to LIS (OR = 0.06, 95% CI = 0.01 to 0.36, p = .002). However, there were no statistically significant differences in unhealed fissure (OR = 2.21, 95% CI = 0.25 to 19.33, p = .47) or wound complication rates (OR = 1.41, 95% CI = 0.50 to 4.99 p = .51) between AAF and LIS.
AAF is associated with less incontinence, but similar wound complications as well as a similar rate of unhealed fissures compared to LIS. However, further well-executed, multi-centre randomized trials are required to provide stronger evidence.
慢性肛裂（CAF）很常见，并且与生活质量下降有关。外侧内括约肌切开术（LIS）经常进行，但有明显的肛门失禁风险。肛门推进皮瓣（AAF）已被提倡作为一种替代的“括约肌保留”手术。我们旨在进行系统评价和荟萃分析，以比较两种技术在治疗 CAF 中的疗效。
从开始到 2017 年 1 月，我们在在线数据库 PubMed/Medline、CINAHL、EMBASE 和 Cochrane 对照试验中心注册库中进行了搜索。所有调查和报告 LIS 和 AAF 治疗 CAF 结果的研究均包括在内。主要结局测量是肛门失禁，次要结局包括未愈合的肛裂和伤口并发症发生率。使用随机效应模型计算汇总效应大小估计值。
四项研究（2 项随机对照试验和 2 项回顾性研究）描述了 300 例患者（150 例 LIS，150 例 AAF）符合纳入标准。试验之间存在显著的临床异质性。在随机效应分析中，AAF 与 LIS 相比，肛门失禁的发生率明显较低（OR=0.06，95%CI=0.01 至 0.36，p=0.002）。然而，未愈合的肛裂（OR=2.21，95%CI=0.25 至 19.33，p=0.47）或伤口并发症发生率（OR=1.41，95%CI=0.50 至 4.99，p=0.51）在 AAF 和 LIS 之间没有统计学上的显著差异。
AAF 与 LIS 相比，失禁发生率较低，但伤口并发症发生率相似，未愈合的肛裂发生率也相似。然而，需要进一步执行良好的多中心随机试验来提供更强的证据。
