The aim of the present study is to describe the effects of phototherapy in the treatment of chronic anal fissure in the pre-surgical period.

This is a preliminary analysis of an interventionist study in progress. The eligible population consisted of individuals with anal fissure awaiting surgical intervention. Individuals aged 18 years or older were included, diagnosed with anal fissure and who voluntarily agreed to participate in the research. Those who had some pelvic inflammation, who had already undergone a surgical procedure and had recurrence were excluded from the study. The selected individuals underwent a standardized anamnesis of the service, answered questionnaires on symptoms of intestinal constipation (Rome IV Criteria and the Bristol Scale), underwent a physical evaluation by a trained professional, and then began the application of the research protocol. The Laser device Antares (IBRAMED, São Paulo, Brazil) was used for three sessions with an interval of 24 hours. The Laser protocolo was red light, 3J, 100mW, six points with 30 seconds in each point per session.  The Visual Analogue Scale (VAS) was used before starting treatment, after the first and second sessions, and 1 week after the third session. In addition, at the end of the treatment, the closure, or not, of the lesion was verified, and the questionnaires performed prior to phototherapy were reapplied. The visual analogue scale (VAS) was used to assess the patient's level of pain, which can be divided into mild pain (1-2), moderate pain (3-7), and severe pain (8-10). The Bristol Scale is based on the identification of the patient's consistency of stools, while types 1-2 correspond to constipation, 3-4 indicate normal intestinal rhythm, 5 indicate lack of fiber, and 6-7 correspond to diarrhea.

The study consisted of a sample of 10 patients, who were between 29 and 59 years of age (35 +/- 14). Of these, nine were female, half were self-reported black and had completed high school, six were single, the predominant religion was Catholic, and the most prevalent income was one minimum wage. As for comorbidities, five patients had other clinical diagnoses, being four with Systemic Arterial Hypertension and one with Diabetes Mellitus. Only two individuals had psychiatric comorbidities, one being diagnosed with panic disorder  and the other with Depressive Mood Disorder. (Table 1)
The VAS was applied in four moments of the study. Before undergoing treatment with laser phototherapy, 70% of the patients had severe pain (5 patients reported grade 10), and 30% of them had moderate pain. After the first phototherapy session, 60% of the patients had moderate pain and 40% had severe pain, with none reporting grade 10 again. After the second session, 90% of the patients reported moderate pain and 10% of them already had mild pain. In the final VAS, one week after the last session, 50% of the people reported mild pain (mostly grade 1), 40% moderate pain and 10% no longer had any pain, demonstrating significant improvement among patients. (Table 2)
Regarding the questionnaires carried out before the treatment, referring to the symptoms of constipation, satisfactory results were also obtained. In the pre-treatment stage, according to the Bristol scale, only 30% of the sample did not have dry-looking stools, while, among the remaining 70%, all of them already showed signs of severe constipation, with Bristol 1. In addition, all the participants needed to strain during the evacuation act, they presented bleeding and also had tenesmus. In addition, 20% of the patients had a sensation of obstruction or performed manual maneuvers to decompaction the stool. As for the weekly evacuation frequency, most participants (70%) evacuated on average 1 or 2 times a week, with 20% reported 3 times, and 10% reported 7 times. (Table 2)
In the post-treatment stage, only 1 of the patients (10%) had dry-looking stools (type 2), which were interspersed with normal-looking stools (type 3). The other participants (90%) started to present Bristol between 3 and 4. In addition, only 30% of the patients still needed to strain to evacuate or had tenesmus after the act. Only 1 patient (10%) had bleeding or a sensation of obstruction. None of the participants needed to perform a manual maneuver for stool decompaction. As for the weekly evacuation frequency, no one reported less than 3 times a week, while groups of 20% of the patients reported 3, 4, 5 or 7 times each, 10% reported 4-5 times, and another 10%, 3- 4. (Table 2)

Part of patients with anal fissure, especially in chronic cases, may possibly need some invasive therapies. However, in the long term, such interventions can lead to fecal incontinence, a symptom that significantly interferes with the patient's quality of life.[1] In this sense, despite this study is initializing with few patients, phototherapy using Laser probably appears as a viable alternative, since it seems to be safe and it is showing effective in resolving anal fissure, without causing unwanted effects. 
There was a significant improvement in the final VAS scale when compared to the initial one, since all patients achieved improvement in pain, while none fell into the severe pain group (previously composed of 70% of patients). In addition, most of the group claimed mild pain or even complete eradication of pain. Comparing the pre- and post-treatment stages, typical symptoms of constipation were eradicated in most cases. Furthermore, anorectal bleeding was stopped in 90% of patients.
Laser application improves local circulation and aids healing, while these properties improve anal fissure and, consequently, the associated symptoms. Due to the presence of pain during evacuation in the presence of the lesion, many patients delay the evacuation act, a fact that ends up causing the drying of the fecal cake and consequent tissue damage, with greater discomfort during the expulsion of the stool.[2] Once the lesion heals, pain is minimized, bowel movements become more frequent, also reducing the chances of trauma to the anal canal, responsible for the emergence of fissures or worsening of existing ones. Also, the properties already mentioned reduce muscle exposure in the region, also avoiding the presence of spasms, improving local blood flow.

Laser phototherapy may represent a potential therapeutic alternative for patients with anal fissure, as it resulted in significant symptomatic improvement in patients in the preliminary data from this study.

Salati SA. Anal Fissure - an extensive update. Pol Przegl Chir. 202Mar 12;93(4):46-5doi: 10.5604/01.3001.0014.787PMID: 34515649.
MOREIRA H; MOREIRA JPT; MOREIRA JUNIOR H; LOUSA LR; OLIVEIRA EC. Tratamento Clínico Conservador e Cirúrgico da Fissura Anal. Rev bras Coloproct, 2003;23(2):89-99