***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: The conventional treatment of  chronic anal fissure  is lateral sphincterotomy ( LAS ) . The alternative options of tailored sphincterotomy ( TS ) and ‘ chemical sphincterotomy ’ using medication such as nifedipine have recently become available The extent of sphincter division by the subcutaneous or the open technique is examined by comparing the change in anal canal pressure after either method of sphincterotomy in twenty‐eight patients with chronic anal fissure r and omly allocated . In all patients the fissures healed at one month with significant reduction ( P < 0.01 ) of anal canal pressures to 52 ( 17–75 ) cmH2O after subcutaneous and 47.5 ( 35–100 ) cmH2O after open sphincterotomy , a 51 ( 22–77 ) and 50 ( 11–68 ) per cent reduction of their respective pre‐operative measurements . Adequate sphincterotomy can be achieved by both techniques BACKGROUND Anal fissure is a frequent proctologic disease . There are many and various treatments adopted to cure this disease . In this study we applied radiofrequencies to the subcutaneous lateral internal sphincterotomy and we compared the techniques in a r and omised trial . METHODS Patients have been r and omized in two groups : in group A 18 patients underwent subcutaneous lateral internal sphincterotomy using radiofrequency bistoury while in group B 17 patients underwent the conventional lateral internal sphincterotomy described by Parks .  RESULTS The mean values for operative time were 6.6 min for group A and 9.1 min for group B. According to pain score , patients ' mean values were 1.8 for group A and 1.9 for group B. Healing of the wound was faster in group A than group B , while healing of the anal fissure was approximately the same . CONCLUSION Lateral subcutaneous sphincterotomy is the most advantageous operation for the treatment of the idiopathic anal fissure . The radiofrequency bistoury easies the procedure , lessens operating times and healing process of the surgical wounds Nitric oxide donors , such as isosorbide dinitrate ointment ( ISDN ) , are considered as first‐choice agents in the treatment of chronic anal fissure .  Injection with botulinum toxin A in the internal anal sphincter is often used as a second‐line therapy , although it may give better results and fewer side effects than nitric oxide donors . The aim of this r and omized clinical trial was to investigate whether botulinum toxin A ( Dysport ® ) is more effective than ISDN  in the primary treatment of chronic anal fissure Background Lateral internal sphincterotomy has been proven highly effective in curing anal fissure but with a high incidence of postoperative incontinence . Objective We compared conventional lateral internal sphincterotomy , V-Y advancement flap , and combined tailored lateral internal sphincterotomy with V-Y advancement flap in treating anal fissure . Patients Consecutive patients treated for anal fissure at our colorectal unit were evaluated for inclusion . Participants were r and omly allocated to receive conventional sphincterotomy ( GI ) , V-Y advancement flap ( GII ) , or combined tailored lateral sphincterotomy with V-Y advancement l flap (GIII).Main Outcome Measures The primary outcome measure was the incontinence rate ; secondary outcomes included healing rate , operative time , anal manometery , and recurrence rate . Results One hundred fifty patients with chronic anal fissure were r and omized . Healing rate after 1 year was 84 % in GI , 48 % in GII , and 94 % in GIII , respectively ( P = 0.001 ) . The recurrence rate was 4 % in G1 , 22 % in GII , and 2 % in GIII ( P = 0.01 ) . Incontinence rate was 14 % in GI , 0 % in GII , and 2 % in GIII ( P = 0.03 ) . Conclusion Although all three procedures are simple and easy to perform , tailored lateral internal sphincterotomy with V-YF appears to produce the greatest healing rate , with the fewest complications and less rate of recurrence Purpose . This study was design ed to evaluate the role of maintenance therapy with partially hydrolyzed guar gum ( PHGG ) after topical application of glyceryl trinitrate ( GTN ) in the conservative treatment of chronic anal fissure ( CAF ) . Methods . From all the patients with CAF observed during the study period , 165 subjects with healed CAF after st and ard therapy with topical GTN 0.4 % ointment  were r and omized to receive ( group II ) or not ( group I ) maintenance therapy with PHGG for 10 months . Clinical and manometric followup was carried out 6 and 12 months after treatment . Results . At six-month followup , median visual analogue scale score was significantly higher in group I if compared with group II . The success and recurrence rate at 12-month followup were , respectively , 38.3 % ( 28/73 ) in group I versus 58.5 % ( 41/70 ) in group II ( P = 0.019 ; Fisher 's exact test ) and 30.2 % ( 13/43 ) in group I versus 14.5 % ( 7/48 ) in group II ( P = 0.0047 ; Fisher 's exact test ) . Conclusion . The maintenance therapy with PHGG in patients with healed CAF after chemical sphincterotomy by topical application of GTN 0.4 % ointment seems associated with a significant reduction of recurrence rate and with a significant increase of success rate at 12-month followup PURPOSE : Internal sphincterotomy remains the “ gold st and ard ” for treatment of anal fissure but is associated with a risk of imperfect continence . Recent studies have suggested that surgical technique ( open vs. closed ) may influence incontinence rates after sphincterotomy . This study was design ed to assess the short-term and long-term incidence of incontinence after open and closed internal sphincterotomy . METHODS : Seventy-nine patients were r and omly assigned to open or closed internal sphincterotomy  , performed in st and ardized fashion by trainee staff . St and ardized question naires assessing continence ( modified Wexner score ) were administered preoperatively and at 1 , 6 , and 52 weeks . Postoperative stay , pain scores , complications , and fissure healing were prospect ively assessed by an independent observer . RESULTS : Three patients were lost to follow-up , leaving 36 closed ( 16 males ; mean age , 45.1 years ) and 40 open ( 21 males ; mean age , 47.9 years ) internal sphincterotomy patients for assessment . All operations were performed as day case procedures with no readmissions . At six weeks postoperative , 96 percent of fissures had healed . There were no significant differences in pain scores between closed and open internal sphincterotomy at Day 1 or Day 3 postoperative . New incontinence of any grade was seen in 6.8 percent of patients at 52-week follow-up . Three patients ( 4.1 percent , 1 closed , 2 open ) suffered major incontinence at 52 weeks . There were no significant differences in continence at 1 , 6 , or 52 weeks , although more open patients experienced minor imperfections at 1 week . CONCLUSIONS : Incontinence after internal sphincterotomy is not insignificant . The technique ( closed vs. open ) does not seem to influence incontinence rates Twenty patients with chronic anal fissure were r and omized into two groups . Ten patients were treated with lateral subcutaneous sphincterotomy and 10 with anal dilatation . Anal dilatation was carried out preoperatively , and at 1 and 3 months after the operation in all patients . Preoperatively there was a significantly increased maximal resting pressure in the 20 fissure patients ( 80 mmHg median ) compared with 20 control subjects ( 50 mmHg median ) . Postoperatively a significant decrease in pressure occurred in the dilated group ( 49 mmHg medianp<0.05 ) , whereas the pressure was not significantly reduced in the group that underwent sphincterotomy ( 65 mmHg medianp<0.05 ) . At 1 year three patients complained of recurrent symptoms of anal fissure in the dilated group compared with one in the sphincterotomy group . Minor continence disturbance was noted in two patients in both groups Abstract . Mean maximum anal resting pressure is directly related to the activity of the smooth muscles of the internal and external sphincters and has been found to be increased in the patients of anal fissure . It has been shown that blood flow at the posterior midline of anoderm is inversely related to the mean maximum anal resting pressure , and topical application of glyceryl trinitrate ( GTN ) ointments is a very successful treatment . This r and omized study was design ed to evaluate the relative value of a nitroglycerin patch applied at a distance from the fissure site in healing anal fissure compared to GTN ointment and compared to surgical treatment .  Forty-two consecutive patients with chronic anal fissure of more than 4 months ' duration were r and omized into two equally sized groups : those in group A received 0.2 % GTN ointment while those in group B received a 10-mg nitroglycerin patch for 8 weeks . Patients were also asked to rate their pain intensity on a scale of 0–10 . Five patients were excluded for various reasons ; results were analyzed for the remaining 37 patients ( group A , n=18 ; group B , n=19 ) . A control group C consisted of 12 patients who underwent surgical treatment . Fissures healed completely in 12 of 18 ( 66.7 % ) patients in group A , 12 of 19 ( 63.2 % ) in group B and 11/12 ( 91.7 % ) in group C. The healing rates in groups A and B did not differ significantly ( P=0.7 ) , nor was there a difference between these and surgical group C ( P=0.13 ) . The local application of GTN ointment and the nitroglycerin patch are both effective , economical , and alternative treatment options for most patients with anal fissures Background : Parikartika resembles fissure-in-ano which is very common among all ano-rectal disorders . In Ayurvedic texts , Parikartika is described as a complication of Vamana and Virechana as well as complication of Atisara . Ksharasutra was proved successful in the management of fistula-in-ano , piles , and there is a need to try its efficacy in fissure-in-ano . Aim : To evaluate the role of Ksharasutra suturing ( KSS ) in fissure bed in chronic fissure-in-ano . Material s and Methods : Total 100 patients of chronic fissure-in-ano were selected and r and omly divided into two groups ( 50 in each group ) . In group-A , patients were undergone by KSS ; while in patients of Group-B Lord′s anal dilatation followed by KSS was done under spinal anesthesia . The KSS was done once and after slough out of Ksharasutra , the wound was treated for 4 weeks and assessment of the result was done on the basis of gradation adopted . Results : The pain relief on 14 th day in Group-A was 86 % while in Group-B 100 % was observed . As on 7 th day in Group-A , oozing was stopped in 68 % patients , while in Group-B , oozing was stopped in 82 % patients . On 21 st day , Group-B showed more healing ( 85 % ) as compared to Group-A ( 69 % ) . In this study 68 % of patients were cured . Conclusion : In Group-B ( KSS with Lord′s anal dilatation ) patients were cured early as compared to patients of Group-A ( KSS alone ) Aim The present study aims to evaluate and compare the efficacy of two nitrate gels , containing isosorbide-5-mononitrate ( ISMN ) or glyceryl trinitrate ( GTN ) , in the therapy of chronic anal fissure . Material s and methods The patients were r and omly assigned to three groups : 0.1 % ISMN gel ( 21 patients ) , 0.1 % GTN gel ( 21 patients ) and a placebo group ( ten patients ) . The ethic committee of our hospital approved the protocol and informed consent was obtained from all participants . All patients underwent clinical examination , visual inspection of the fissure and anal manometry prior to and after therapy . Results The chronic anal fissure was completely healed in 71 % of the patients treated with ISMN , 67 % with GTN and in 30 % from the placebo group . One patient in the ISMN group reported mild headache . Three patients in the GTN group had anal burning . Conclusion Both topical nitrate treatments ( ISMN and GTN ) were effective for chronic anal fissures . The reduction of the anal pressure was slightly higher after ISMN treatment ( 28 % ) than the treatment with GTN ( 23 % ) . However , the statistical difference was not significant ( p > 0.05 ) Abstract . Background The surgical approach in chronic anal fissures ( CAF ) may , occasionally result in anal incontinence . The aim of this investigation was to study feasibility , effectiveness , and safety of hydropneumatic anal dilation ( HAD ) in conservative treatment of CAF and to compare it with local nitroglycerin ( GTN ) treatment . Methods Efficacy of HAD was evaluated in 109 patients ( 65 male , 44 female ; mean age , 53.3 years ) , following anal dilation using Microvasive Rigif 
    Output:
    
Conclusions LIS is superior to non-surgical therapies in achieving sustained cure of fissure .
Calcium channel blockers were more effective than GTN and with less risk of headache , but with only a low quality of evidence .
Among the surgical studies , manual anal stretch performed worse than LIS in the treatment of  chronic anal fissure in adults .
For those patients requiring surgery for anal fissure , open LIS and closed LIS appear to be equally efficacious , with a moderate GRADE quality of evidence .