الفهرس 
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Abstract
Anal fissure is a painful tear or split in the distal anal canal. Most acute fissures heal spontaneously but a proportion become chronic; this review article is restricted to the management of chronic fissure. chronicity is defined by both chronology and morphology. The chronological definition is rather loose, but most surgeons regard persistence beyond 6 weeks as a reasonable point when an acute fissure, now unlikely to heal with conservative treatment, may be considered chronic. Morphologically, the presence of visible transverse internal anal sphincter fibres at the base of a fissure typifies chronicity and provides a more clear-cut definition. Associated features include indurated edges, a sentinel pile and a hypertrophied anal papilla. Widely differing healing rates have been reported and for the future it is important that chronic fissures should be defined, and the defining criteria made clear in published studies. Some studies have used a mix of chronological and morphological definitions, as noted above, but it would be useful if a universal definition for trial entry could be agreed and used.
A reasonable definition might be ‘the presence of visible transverse internal anal sphincter fibres at the base of an anal fissure of duration not less than 6 weeks’. chronic fissure is usually associated with internal anal sphincter spasm, the relief of which is central to promoting fissure healing. Treatment has undergone a transformation in recent years from surgical to medical1, both approaches sharing the common goal of reducing this spasm. There is both anatomical and physiological evidence that the anal canal is relatively poorly perfused, especially in the posterior midline, and this relative ischaemia is rendered critical when compounded by the internal anal.