Management of chronic anal fissure: effectiveness of a personalized target-to-treat treatment algorithm

Chronic anal fissure (CAF) is a common condition with a complex pathogenesis, the main element of which is a persistent increase in the tone of the internal anal sphincter. This forms a «pain — spasm — ischemia» cycle, leading to chronicity and resistance to standard approaches. In real clinical practice, the lack of a clear algorithm for selecting and escalating therapy often leads to premature surgical intervention or excessively long use of ineffective conservative methods. Objective: to evaluate the efficacy and safety of a personalized target-to-treat algorithm for the management of chroni­c anal fissure compared to standard tactics in a Ukrainian proctology center. Materials and methods. A single-center prospective comparative study was conducted. The main group (n=83) included patients who received treatment according to a personalized algorithm developed based on ASCRS and ACPGBI recommendations, with an individual choice of the first-line therapy (conservative therapy, botulinum toxin therapy, tailored lateral internal sphincterotomy, fissurectomy). The comparison group (n=72) consisted of patients treated according to the center’s standard protocol. The frequency of clinical healing, dynamics of pain syndrome (Visual Analogue Scale), quality of life indicators (SF-36), duration of disability, and the frequency of recurrences over 6 months were evaluated. Results. In the target-to-treat group, clinical healing was achieved in 92.1% (76/83) of patients, which was significantly higher than in the standard treatment group (71.8%, 52/72; p=0.015). The algorithm provided faster pain relief: the average time to reduce pain intensity by ≥50% on the Visual Analogue Scale was 5.8±2.1 days compared to 10.6±3.0 days in the control group (p<0.001). Quality of life indicators on the SF-36 scale improved significantly more in the main group across all domains (p<0.05). The duration of disability was lower (8.1±2.9 days vs. 14.7±4.1 days; p<0.001), and the recurrence rate after 6 months was significantly lower (7.23% vs. 22.22%; p=0.012). Conclusions. The personalized target-to-treat algorithm for the management of chronic anal fissure is a highly effective and safe approach. It provides a significantly higher rate of clinical healing, accelerates the regression of pain syndrome, improves quality of life, shortens the period of disability, and reduces the risk of recurrence compared to standard tactics. The algorithm can be recommended for widespread implementation in proctological practice.