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Balla A, Saraceno F, Shalaby M, Gallo G, Di Saverio S, De Nardi P, Perinotti R, Sileri P. Surgeons' practice and preferences for the anal fissure treatment: results from an international survey. Updates Surg 2023; 75:2279-2290. [PMID: 37805973 DOI: 10.1007/s13304-023-01661-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 09/23/2023] [Indexed: 10/10/2023]
Abstract
The best nonoperative or operative anal fissure (AF) treatment is not yet established, and several options have been proposed. Aim is to report the surgeons' practice for the AF treatment. Thirty-four multiple-choice questions were developed. Seven questions were about to participants' demographics and, 27 questions about their clinical practice. Based on the specialty (general surgeon and colorectal surgeon), obtained data were divided and compared between two groups. Five-hundred surgeons were included (321 general and 179 colorectal surgeons). For both groups, duration of symptoms for at least 6 weeks is the most important factor for AF diagnosis (30.6%). Type of AF (acute vs chronic) is the most important factor which guide the therapeutic plan (44.4%). The first treatment of choice for acute AF is ointment application for both groups (59.6%). For the treatment of chronic AF, this data is confirmed by colorectal surgeons (57%), but not by the general surgeons who prefer the lateral internal sphincterotomy (LIS) (31.8%) (p = 0.0001). Botulin toxin injection is most performed by colorectal surgeons (58.7%) in comparison to general surgeons (20.9%) (p = 0.0001). Anal flap is mostly performed by colorectal surgeons (37.4%) in comparison to general surgeons (28.3%) (p = 0.0001). Fissurectomy alone is statistically significantly most performed by general surgeons in comparison to colorectal surgeons (57.9% and 43.6%, respectively) (p = 0.0020). This analysis provides useful information about the clinical practice for the management of a debated topic such as AF treatment. Shared guidelines and consensus especially focused on operative management are required to standardize the treatment and to improve postoperative results.
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Affiliation(s)
- Andrea Balla
- Coloproctology and Inflammatory Bowel Disease Surgery Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| | - Federica Saraceno
- UOC of General and Minimally Invasive Surgery, Hospital "San Paolo", Largo Donatori del Sangue 1, 00053, Rome, Civitavecchia, Italy
| | - Mostafa Shalaby
- Department of General Surgery, Colorectal Surgery Unit, Mansoura University Hospitals, Mansoura, Egypt
| | - Gaetano Gallo
- Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Salomone Di Saverio
- ASUR Marche 5, San Benedetto del Tronto General Hospital, San Benedetto del Tronto, Italy
| | - Paola De Nardi
- Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, Milan, Italy
| | - Roberto Perinotti
- General Surgery, SS Colo-Rectal and Proctological Surgery, Biella Hospital, Ponderano, Biella, Italy
| | - Pierpaolo Sileri
- Coloproctology and Inflammatory Bowel Disease Surgery Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy
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2
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Vitton V, Bouchard D, Guingand M, Higuero T. Treatment of anal fissures: Results from a national survey on French practice. Clin Res Hepatol Gastroenterol 2022; 46:101821. [PMID: 34666209 DOI: 10.1016/j.clinre.2021.101821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 09/19/2021] [Accepted: 10/08/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Treatment of an anal fissure (AF) is based on medical treatment (nonoperative therapies) and surgical procedures. However, the choice of treatment and its role in therapeutic strategy vary from one country to another, and to date, no standard French recommendation is currently available. Our aim was to assess French practices in the treatment of AFs. METHODS A national survey of members of the French National Society of Colo-Proctology (SNFCP) was carried out using an online questionnaire (1) to evaluate French practice and (2) to compare them with guidelines of other societies. RESULTS Two hundred responses were obtained among the 300 registered members, representing a participation rate of 67%. Members of the SNFCP agree with all scientific societies on the importance of first-line medical treatment, with surgery proposed as a second-line treatment in the case of the failure of well-conducted medical treatment. However, calcium channel blockers and topical nitrates as first-line treatment are rarely prescribed in France. Priority is therefore given to "simple" topical healing products and oral analgesics on demand. Similarly, surgical management differs since LIS is the "gold standard" in most guidelines, whereas in France, despite the data in the literature, fissurectomy is the first-line treatment. CONCLUSIONS Our study indicated the fissure treatment discrepancies of France with other countries concerning the usage of topical treatments and the choice of first-line surgical treatments that is currently considered a "French exception".
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Affiliation(s)
- Véronique Vitton
- Service de Gastroentérologie, Hôpital Nord, Assistance-Publique-Hôpitaux de Marseille, Aix-Marseille Université, France.
| | | | - Marine Guingand
- Service de Gastroentérologie, Hôpital Nord, Assistance-Publique-Hôpitaux de Marseille, Aix-Marseille Université, France
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3
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Gardner IH, Siddharthan RV, Tsikitis VL. Benign anorectal disease: hemorrhoids, fissures, and fistulas. Ann Gastroenterol 2019; 33:9-18. [PMID: 31892792 PMCID: PMC6928486 DOI: 10.20524/aog.2019.0438] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 10/04/2020] [Indexed: 12/20/2022] Open
Abstract
Hemorrhoids, anal fissures, and fistulas are common benign anorectal diseases that have a significant impact on patients’ lives. They are primarily encountered by primary care providers, including internists, gastroenterologists, pediatricians, gynecologists, and emergency care providers. Most complex anorectal disease cases are referred to colorectal surgeons. Knowledge of these disease processes is essential for proper treatment and follow up. Hemorrhoids and fissures frequently benefit from non-operative treatment; they may, however, require surgical procedures. The treatment of anorectal abscess and fistulas is mainly surgical. The aim of this review is to examine the etiology, diagnosis, medical, and surgical treatment for these benign anorectal diseases.
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Affiliation(s)
- Ivy H Gardner
- Department of General Surgery, Division of Gastrointestinal and General Surgery Portland, Oregon Health and Science University, OR, USA
| | - Ragavan V Siddharthan
- Department of General Surgery, Division of Gastrointestinal and General Surgery Portland, Oregon Health and Science University, OR, USA
| | - Vassiliki Liana Tsikitis
- Department of General Surgery, Division of Gastrointestinal and General Surgery Portland, Oregon Health and Science University, OR, USA
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4
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Pilkington SA, Bhome R, Welch RE, Ku F, Warden C, Harris S, Hicks J, Richardson C, Dudding TC, Knight JS, King AT, Mirnezami AH, Beck NE, Nichols PH, Nugent KP. Bilateral versus unilateral botulinum toxin injections for chronic anal fissure: a randomised trial. Tech Coloproctol 2018; 22:545-551. [PMID: 30022331 PMCID: PMC6097731 DOI: 10.1007/s10151-018-1821-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/29/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Botulinum toxin injected into the internal anal sphincter is used in the treatment of chronic anal fissure but there is no standardised technique for its administration. This randomised single centre trial compares bilateral (either side of fissure) to unilateral injection. METHODS Participants were randomised to receive bilateral (50 + 50 units) or unilateral (100 units) Dysport® injections into the internal anal sphincter in an outpatient setting. Injection-related pain assessed by visual analogue scale was the primary outcome measure. Secondary outcomes were healing rate, fissure pain, incontinence, and global health scores. RESULTS Between October 2008 and April 2012, 100 patients with chronic anal fissure were randomised to receive bilateral or unilateral injections. Injection-related pain was comparable in both groups. There was no difference in healing rate. Initially, there was greater improvement in fissure pain in the bilateral group but at 1 year the unilateral group showed greater improvement. Cleveland Clinic Incontinence score was lower in the unilateral group in the early post-treatment period and global health assessment (EuroQol EQ-VAS) was higher in the unilateral group at 1 year. CONCLUSIONS Injection-related pain was similar in bilateral and unilateral injection groups. Unilateral injection was as effective as bilateral injections in healing and improving fissure pain without any deterioration in continence.
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Affiliation(s)
- S A Pilkington
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - R Bhome
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
- Academic Surgical Unit, University of Southampton, Level C South Academic Block, Southampton General Hospital, Southampton, SO16 6YD, UK
| | - R E Welch
- School of Medicine, University of Southampton, Southampton, UK
| | - F Ku
- School of Medicine, University of Southampton, Southampton, UK
| | - C Warden
- Department of Colorectal Surgery, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - S Harris
- Primary Care and Population Studies Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - J Hicks
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - C Richardson
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - T C Dudding
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - J S Knight
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - A T King
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - A H Mirnezami
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
- Academic Surgical Unit, University of Southampton, Level C South Academic Block, Southampton General Hospital, Southampton, SO16 6YD, UK
| | - N E Beck
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - P H Nichols
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - K P Nugent
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK.
- Academic Surgical Unit, University of Southampton, Level C South Academic Block, Southampton General Hospital, Southampton, SO16 6YD, UK.
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5
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Parés D, Abcarian H. Management of Common Benign Anorectal Disease: What All Physicians Need to Know. Am J Med 2018; 131:745-751. [PMID: 29499172 DOI: 10.1016/j.amjmed.2018.01.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 01/18/2018] [Accepted: 01/19/2018] [Indexed: 12/15/2022]
Abstract
Benign anorectal conditions produce anal pain, rectal bleeding, or discharge from the perianal region, which are highly prevalent symptoms in the general population. Hemorrhoidal disease, anal fissure, perianal abscess, proctalgia syndromes, and pruritus anii are the most common clinical disorders. Well-trained physicians, irrespective of their specialty, can treat most of these disorders and refer them to a specialist in proctology only when necessary. The aim of this review is to provide a practical guide to the management of benign anorectal disorders in terms of their initial management and the criteria for specialist referral.
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Affiliation(s)
- David Parés
- Department of Colon and Rectal Surgery, Hospital Germans Trias i Pujol, School of Medicine, Universitat Autónoma de Barcelona, Badalona, Spain.
| | - Herand Abcarian
- Division of Colon and Rectal Surgery, University of Illinois at Chicago
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6
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Abstract
Anal fissure (fissure-in-ano) is a very common anorectal condition. The exact etiology of this condition is debated; however, there is a clear association with elevated internal anal sphincter pressures. Though hard bowel movements are implicated in fissure etiology, they are not universally present in patients with anal fissures. Half of all patients with fissures heal with nonoperative management such as high fiber diet, sitz baths, and pharmacological agents. When nonoperative management fails, surgical treatment with lateral internal sphincterotomy has a high success rate. In this chapter, we will review the symptoms, pathophysiology, and management of anal fissures.
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Affiliation(s)
- Jennifer Sam Beaty
- Department of Surgery, Creighton University, Omaha, Nebraska
- Department of Surgery, University of Nebraska Medicine, Colon and Rectal Surgery, Omaha, Nebraska
| | - M. Shashidharan
- Department of Surgery, Creighton University, Omaha, Nebraska
- Department of Surgery, University of Nebraska Medicine, Colon and Rectal Surgery, Omaha, Nebraska
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7
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Vershenya S, Klotz J, Joos A, Bussen D, Herold A. Combined approach in the treatment of chronic anal fissures. Updates Surg 2015; 67:83-9. [DOI: 10.1007/s13304-015-0290-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 03/07/2015] [Indexed: 10/23/2022]
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Abstract
Anorectal conditions are frequently encountered clinical entities but are often misunderstood and misdiagnosed. Although the most common anorectal disorders are not considered life threatening, they can negatively impact patients' activities of daily living and quality of life. Comprehensive anorectal examination, including the use of anoscopy, has become a "lost art," and graduate medical education programs should utilize more formal training in this area. This review discusses the comprehensive anorectal exam and the diagnosis and management of three common anorectal disorders: hemorrhoids, anal fissure, and pruritus ani.
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Affiliation(s)
- Phillip K Henderson
- Division of Gastroenterology, University of South Alabama, 6000 University Commons, 75 University Boulevard South, Mobile, AL, 36688, USA,
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9
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Golfam F, Golfam P, Golfam B, Pahlevani P. Comparison of topical nifedipine with oral nifedipine for treatment of anal fissure: a randomized controlled trial. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 16:e13592. [PMID: 25389477 PMCID: PMC4222003 DOI: 10.5812/ircmj.13592] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 03/04/2014] [Accepted: 04/06/2014] [Indexed: 11/16/2022]
Abstract
Background: Medical sphincterotomy has gained popularity as a treatment for anal fissure. Calcium channel blockers in topical forms could also be appropriate with low adverse effects. Objectives: This was a prospective randomized controlled trial to compare topical and oral nifedipine in the treatment of chronic anal fissure. Patients and Methods: A prospective randomized controlled trial was conducted at two centers of Shahed University. One hundred and thirty patients with chronic anal fissure aged 18 to 60 years managed in our clinics were included in this study. The patients were randomly divided into two groups. Sixty-five patients received topical nifedipine (TN) and the same number received oral nifedipine (ON). Results: Ulcer healing occurred in 43 (73.33%) of topical nifedipine group compared to 29 (49.5%) patients in oral nifedipine, which was significantly different (P < 0.05). Side effects such as headache and flushing in oral nifedipine group were more prevalent than topical nifedipine, which was statistically different. Recurrence rates were the same after six months of follow-up. Conclusions: Although oral nifedipine can reduce symptom and signs of anal fissure, topical nifedipine has a superior role for anal fissure treatment with higher healing rate and lower side effects.
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Affiliation(s)
- Farzaneh Golfam
- Department of Surgery, Mostafa Khomeini Hospital, Shahed University, Tehran, IR Iran
| | - Parisa Golfam
- Department of Anesthesiology, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, IR Iran
- Corresponding Author: Parisa Golfam, Department of Anesthesiology, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, IR Iran. Tel: +98-9181310864, Fax: +98-8317246693, E-mail:
| | - Babak Golfam
- Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
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10
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Lex J. New drugs and devices from 2011 - 2012 that might change your practice. West J Emerg Med 2013; 14:619-28. [PMID: 24381683 PMCID: PMC3876306 DOI: 10.5811/westjem.2013.2.16210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 02/22/2013] [Indexed: 11/12/2022] Open
Abstract
To be honest, I thought this would be a lost cause. Even after skipping a New Drugs and Devices essay in 2012, I figured that I would have to search long and hard to find 10 new things that emergency practitioners needed to know about. Although there were no true blockbuster medications for emergency physicians, I nonetheless found 10 medicines that we probably should know, along with a new device that may change the way we work up patients with palpitations, and a clever new delivery system for subcutaneous epinephrine.
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Affiliation(s)
- Joe Lex
- Temple University School of Medicine, Department of Emergency Medicine, Philadelphia, Pennsylvania
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11
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Bulus H, Varol N, Tas A, Coskun A. Comparison of topical isosorbide mononitrate, topical diltiazem, and their combination in the treatment of chronic anal fissure. Asian J Surg 2013; 36:165-9. [PMID: 24054756 DOI: 10.1016/j.asjsur.2013.01.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 11/05/2012] [Accepted: 01/15/2013] [Indexed: 11/29/2022] Open
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12
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Berry SM, Barish CF, Bhandari R, Clark G, Collins GV, Howell J, Pappas JE, Riff DS, Safdi M, Yellowlees A. Nitroglycerin 0.4% ointment vs placebo in the treatment of pain resulting from chronic anal fissure: a randomized, double-blind, placebo-controlled study. BMC Gastroenterol 2013; 13:106. [PMID: 23815124 PMCID: PMC3710466 DOI: 10.1186/1471-230x-13-106] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 06/05/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Complications of chronic anal fissure (CAF) treatments are prompting interest in lower-risk therapies. This study was conducted to compare nitroglycerin (NTG) 0.4% ointment with placebo for pain associated with CAF. METHODS In this randomized, double-blind, placebo-controlled trial, patients with one CAF and moderate-to-severe pain (≥50 mm on a 100 mm visual analog scale [VAS]) received 375 mg NTG 0.4% (1.5 mg active ingredient) or 375 mg placebo ointment applied anally every 12 hours for 21 days. The primary end point was change from baseline VAS score in 24-hour pain averaged over days 14-18. Review of data from patients who withdrew early was blinded to treatment. To control for the confounding effects of analgesics, all patients received 650 mg acetaminophen for headache prophylaxis before each application. RESULTS A total of 247 patients were enrolled (NTG, n = 123; placebo, n = 124). The prespecified baseline observation carried forward (BOCF) analysis found no significant difference between groups; however, a last observation carried forward (LOCF) analysis showed a significant advantage for NTG. A post hoc analysis (LOCF/BOCF hybrid) demonstrated a significant adjusted mean difference of -7.0 mm in favor of NTG 0.4% (95% CI -13.6, -0.4; P = .038). Headache was the most common adverse event in the NTG (69.9%) and placebo (47.6%) groups. CONCLUSIONS This was the first placebo-controlled study that also controlled for the confounding effects of analgesics used to treat NTG-induced headache. In patients with moderate-to-severe CAF pain, NTG 0.4% ointment effectively reduced CAF pain compared with placebo. TRIAL REGISTRATION ClinicalTrials.gov, NCT00522041.
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Affiliation(s)
- Scott M Berry
- CRC of Jackson, 501 Marshall Street #500, Jackson, MS 39202, USA
| | - Charles F Barish
- Wake Research Associates, LLC, 3100 Blue Ridge Road, Suite 300, Raleigh, NC 27612, USA
| | - Raj Bhandari
- Delta Research Partners, LLC, 608 Grammant Street, Monroe, LA 71201, USA
| | - Gemma Clark
- ProStrakan Pharmaceuticals Ltd, Galabank Business Park, Galashiels TD1 1QH, UK
| | - Gregory V Collins
- Charlotte Clinical Research, 330 Billingsley Road, Charlotte, NC 28211, USA
| | - Julian Howell
- ProStrakan Pharmaceuticals Ltd, Galabank Business Park, Galashiels TD1 1QH, UK
| | - John E Pappas
- Kentucky Medical Research Center, 354 Waller Avenue, Suite 110, Lexington, KY 40504, USA
| | - Dennis S Riff
- Advanced Clinical Research Institute, 1211 West La Palma Ave. Suite 303, Anaheim, CA 92801, USA
| | - Michael Safdi
- Consultants for Clinical Research/GCGA Physicians, 2925 Vernon Place, Suite 200, Cincinnati, OH, USA
| | - Ann Yellowlees
- Quantics Consulting, Roslin BioCentre, Edinburgh, Scotland, UK
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13
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Cigna E, Maruccia M, Fanelli B, Scuderi N. Botulinum toxin type A in the healing of chronic lesion following bilateral spasticity of gluteus muscle. Int Wound J 2012; 11:412-5. [PMID: 23078619 DOI: 10.1111/j.1742-481x.2012.01111.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Use of botulinum toxin is expanding as the clinical studies demonstrate new potential therapeutic applications. In rehabilitation, botulinum toxin is above all used as adjunct therapy for the treatment of spasticity, but it may prove useful for other atypical clinical situations. A 17-year-old man had a sub-arachnoid haemorrhage following the rupture of cerebral aneurism. The patient presented gluteus maximus and medius bilaterally spasticity that produced a chronic lesion in the intergluteal cleft, a flexed wrist and a flexed elbow. As treatment for this spasticity, a total of 100 U botulinum toxin type A were injected into the glutei muscles. This treatment allowed for application of topical medication and subsequently, chronic lesion healing. Botulinum toxin A may be an important therapeutic aid for clinicians faced with treating persistent pathological conditions caused by spasticity.
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Affiliation(s)
- Emanuele Cigna
- Department of Plastic and Reconstructive Surgery, 'Sapienza' University, Viale del Policlinico, Rome, Italy
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14
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Abstract
Anal fissure is one of the most common anorectal problems. Anal fissure is largely associated with high anal sphincter pressures and most treatment options are based on reducing anal pressures. Conservative management, using increased fiber and warm baths, results in healing of approximately half of all anal fissures. In fissures that fail conservative care, various pharmacologic and surgical options offer satisfactory cure rates. Lateral internal sphincterotomy remains the gold standard for definitive management of anal fissure. This review outlines the key points in the presentation, pathophysiology, and management of anal fissure.
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15
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Daram SR, Lahr C, Tang SJ. Anorectal bleeding: etiology, evaluation, and management (with videos). Gastrointest Endosc 2012; 76:406-17. [PMID: 22817792 DOI: 10.1016/j.gie.2012.03.178] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 03/13/2012] [Indexed: 02/07/2023]
Affiliation(s)
- Sumanth R Daram
- Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi 39216, USA
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16
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Abstract
BACKGROUND Because of the disability associated with surgery for anal fissure and the risk of incontinence, medical alternatives for surgery have been sought. Most recently, pharmacologic methods that relax the anal smooth muscle, to accomplish reversibly what occurs in surgery, have been used to obtain fissure healing. OBJECTIVES To assess the efficacy and morbidity of various medical therapies for anal fissure. SEARCH METHODS Search terms include "anal fissure randomized". Timing from 1966 to August 2010. Further details of the search below. SELECTION CRITERIA Studies in which participants were randomized to a non-surgical therapy for anal fissure. Comparison groups may include an operative procedure, an alternate medical therapy or placebo. Chronic fissure, acute fissure and fissure in children are included in the review. Atypical fissures associated with inflammatory bowel disease or cancer or anal infection are excluded. DATA COLLECTION AND ANALYSIS Data were abstracted from published reports and meeting abstracts, assessing method of randomization, blinding, "intention to treat" and drop-outs, therapies, supportive measures (applied to both groups), dosing and frequency and cross-overs. Dichotomous outcome measures included Non-healing of the fissure (a combination of persistence and recurrence), and Adverse events (including incontinence, headache, infection, anaphylaxis). Continuous outcome measures included measures of pain relief and anorectal manometry. MAIN RESULTS In this update 23 studies including 1236 participants is added to the 54 studies and 3904 participants in the 2008 publication, however 2 studies were from the last version reclassified as un included, so the final number of participants is 5031.49 different comparisons of the ability of medical therapies to heal anal fissure have been reported in 75 RCTs. Seventeen agents were used (nitroglycerin ointment (GTN), isosorbide mono & dinitrate, Botulinum toxin (Botox), diltiazem, nifedipine (Calcium channel blockers or CCBs), hydrocortisone, lignocaine, bran, minoxidil, indoramin, clove oil, L-arginine, sitz baths, sildenafil, "healer cream" and placebo) as well as Sitz baths, anal dilators and surgical sphincterotomy. GTN was found to be marginally but significantly better than placebo in healing anal fissure (48.9% vs. 35.5%, p < 0.0009), but late recurrence of fissure was common, in the range of 50% of those initially cured. Botox and CCBs were equivalent to GTN in efficacy with fewer adverse events. No medical therapy came close to the efficacy of surgical sphincterotomy, though none of the medical therapies in these RCTs were associated with the risk of incontinence. AUTHORS' CONCLUSIONS Medical therapy for chronic anal fissure, currently consisting of topical glyceryl trinitrate, botulinum toxin injection or the topical calcium channel blockers nifedipine or diltiazem in acute and chronic fissure and fissure in children may be applied with a chance of cure that is marginally better than placebo. For chronic fissure in adults all medical therapies are far less effective than surgery. A few of the newer agents investigated show promise based only upon single studies (clove oil, sildenifil and a "healer cream") but lack comparison to more established medications.
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Affiliation(s)
- Richard L Nelson
- Department of General Surgery, Northern General Hospital, Sheffield, UK.
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17
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Segmental internal sphincterotomy--a new technique for treatment of chronic anal fissure. J Gastrointest Surg 2011; 15:2271-4. [PMID: 21948181 DOI: 10.1007/s11605-011-1689-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 09/13/2011] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Lateral internal sphincterotomy is an effective treatment for fissure in ano but carries a definite risk of incontinence. In trial to avoid this complication, segmental lateral internal sphincterotomy was used to treat chronic anal fissures. DESIGN The lateral internal sphincterotomy was done in two parts and at different planes. SETTING This study was conducted in the General Surgery Department, Zagazig University Hospital, Egypt. PATIENTS This study was undertaken on 50 patients (43 men and seven women, with mean age of 37.3 years) with chronic fissure in ano from January 2009 to December 2010. INTERVENTIONS Under general or local anesthesia, lateral internal sphincterotomy was done in two segments under direct vision. Preoperative and postoperative anal manometry study was recorded. MAIN OUTCOME MEASURES Postoperative course with early and long-term results were recorded. Mean follow-up was 18.5 months (ranging from 6 to 24 months). RESULTS In 31 patients, the technique was done under general anesthesia and the remainder under local anesthesia. The fissures and anal wounds were healed within 4 weeks. Pain was significantly reduced in all patients at day 1 postoperative. Early complications included mild hematoma and urine retention in one male patient (2%). No transient or any persistent degree of incontinence occurred in these patients group. CONCLUSION Segmental lateral internal sphincterotomy is a safe, easy, and effective procedure and not associated with risk of incontinence for the treatment of chronic anal fissure.
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Kinetic and reaction pathway analysis in the application of botulinum toxin a for wound healing. J Toxicol 2011; 2012:159726. [PMID: 22174710 PMCID: PMC3235895 DOI: 10.1155/2012/159726] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 09/05/2011] [Indexed: 11/17/2022] Open
Abstract
A relatively new
approach in the treatment of specific wounds in
animal models and in patients with type A
botulinum toxin is the focus of this paper. The
indications or conditions include traumatic
wounds (experimental and clinical), surgical
(incision) wounds, and wounds such as fissures
and ulcers that are signs/symptoms of disease or
other processes. An objective was to conduct
systematic literature searches and take note of
the reactions involved in the healing process
and identify corresponding pharmacokinetic data.
From several case reports, we developed a
qualitative model of how botulinum toxin
disrupts the vicious cycle of muscle spasm,
pain, inflammation, decreased blood flow, and
ischemia. We transformed this model into a
minimal kinetic scheme for healing chronic
wounds. The model helped us to estimate the rate
of decline of this toxin's therapeutic
effect by calculating the rate of recurrence of
clinical symptoms after a wound-healing
treatment with this neurotoxin.
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Altomare DF, Binda GA, Canuti S, Landolfi V, Trompetto M, Villani RD. The management of patients with primary chronic anal fissure: a position paper. Tech Coloproctol 2011; 15:135-41. [PMID: 21538013 PMCID: PMC3099002 DOI: 10.1007/s10151-011-0683-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2010] [Accepted: 03/15/2011] [Indexed: 12/26/2022]
Abstract
Anal fissure is one of the most common and painful proctologic diseases. Its treatment has long been discussed and several different therapeutic options have been proposed. In the last decades, the understanding of its pathophysiology has led to a progressive reduction of invasive and potentially invalidating treatments in favor of conservative treatment based on anal sphincter muscle relaxation. Despite some systematic reviews and an American position statement, there is ongoing debate about the best treatment for anal fissure. This review is aimed at identifying the best treatment option drawing on evidence-based medicine and on the expert advice of 6 colorectal surgeons with extensive experience in this field in order to produce an Italian position statement for anal fissures. While there is little chance of a cure with conservative behavioral therapy, medical treatment with calcium channel blockers, diltiazem and nifepidine or glyceryl trinitrate, had a considerable success rate ranging from 50 to 90%. Use of 0.4% glyceryl trinitrate in standardized fashion seems to have the best results despite a higher percentage of headache, while the use of botulinum toxin had inconsistent results. Nonresponding patients should undergo lateral internal sphincterotomy. The risk of incontinence after this procedure seems to have been overemphasized in the past. Only a carefully selected group of patients, without anal hypertonia, could benefit from anoplasty.
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Affiliation(s)
- D F Altomare
- Department of Emergency and Organ Transplantation, University Aldo Moro, Policlinico, piazza G Cesare 11, 70124, Bari, Italy.
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Anderson KL, Dean AJ. Foreign Bodies in the Gastrointestinal Tract and Anorectal Emergencies. Emerg Med Clin North Am 2011; 29:369-400, ix. [DOI: 10.1016/j.emc.2011.01.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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21
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Madalinski MH. Identifying the best therapy for chronic anal fissure. World J Gastrointest Pharmacol Ther 2011; 2:9-16. [PMID: 21577312 PMCID: PMC3091162 DOI: 10.4292/wjgpt.v2.i2.9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2010] [Revised: 03/20/2011] [Accepted: 03/28/2011] [Indexed: 02/06/2023] Open
Abstract
Chronic anal fissure (CAF) is a painful tear or crack which occurs in the anoderm. The optimal algorithm of therapy for CAF is still debated. Lateral internal sphincterotomy (LIS) is a surgical treatment, considered as the ‘gold standard’ therapy for CAF. It relieves CAF symptoms with a high rate of healing. Chemical sphincterotomy (CS) with nitrates, calcium blockers or botulinum toxin (BTX) is safe, with the rapid relief of pain, mild side-effects and no risk of surgery or anesthesia, but is a statistically less effective therapy for CAF than LIS. This article considers if aggressive treatment should only be offered to patients who fail pharmacological sphincterotomy. Aspects of anal fissure etiology, epidemiology and pathophysiology are considered with their meaning for further management of CAF. A molecular model of chemical interdependence significant for the chemistry of CAF healing is examined. Its application may influence the development of optimal therapy for CAF. BTX is currently considered the most effective type of CS and discussion in this article scrutinizes this method specifically. Although the effectiveness of BTX vs. LIS has been discussed, the essential focus of the article concerns identifying the best therapy application for anal fissure. Elements are presented which may help us to predict CAF healing. They provide rationale for the expansion of the CAF therapy algorithm. Ethical and economic factors are also considered in brief. As long as the patient is willing to accept the potential risk of fecal incontinence, we have grounds for the ‘gold standard’ (LIS) as the first-line treatment for CAF. We conclude that, when the diagnosis of the anal fissure is established, CS should be considered for both ethical and economic reasons. The author is convinced that a greater understanding and recognition of benign anal disorders by the GP and a proactive involvement at the point of initial diagnosis would facilitate the consideration of CS at an earlier, more practical stage with improved outcomes for the patient.
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Affiliation(s)
- Mariusz H Madalinski
- Mariusz H Madalinski, NHS Lothian-University Hospitals Division, Edinburgh EH4 2XU, United Kingdom
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Appalaneni V, Fanelli RD, Sharaf RN, Anderson MA, Banerjee S, Ben-Menachem T, Decker GA, Fisher L, Fukami N, Harrison ME, Strohmeyer L, Friis C, Ikenberry SO, Jain R, Jue TL, Khan KM, Krinsky ML, Malpas PM, Maple JT, Dominitz JA. The role of endoscopy in patients with anorectal disorders. Gastrointest Endosc 2010; 72:1117-23. [PMID: 21111864 DOI: 10.1016/j.gie.2010.04.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Accepted: 04/14/2010] [Indexed: 02/08/2023]
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Abstract
The management of wounds is a specialty in its infancy. Success requires more than the use of dressings. All wounds require a diagnosis, a point well illustrated by the management of these cases which depended solely on stopping nicorandil.
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Affiliation(s)
- Girish K Patel
- Department of Dermatology and Wound Healing, School of Medicine, Cardiff University, Cardiff, UK.
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Chauhan A. Beyond Beauty: Botulinum Toxin Use in Anal Fissure. Med J Armed Forces India 2010; 66:389. [PMID: 27365751 PMCID: PMC4919823 DOI: 10.1016/s0377-1237(10)80028-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- A Chauhan
- Classified Specialist, Surgery, Army Hospital (R & R), New Delhi-10
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Mehrotra S. Beyond Beauty: Botulinum Toxin Use in Anal Fissure: Reply. Med J Armed Forces India 2010; 66:389-90. [PMID: 27365750 PMCID: PMC4919822 DOI: 10.1016/s0377-1237(10)80029-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- S Mehrotra
- Senior Advisor, Surgery & Plastic Surgery, Command Hospital (CC), Lucknow-02
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Comparative effectiveness of medical interventions in adults versus children. J Pediatr 2010; 157:322-330.e17. [PMID: 20434730 DOI: 10.1016/j.jpeds.2010.02.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Revised: 01/15/2010] [Accepted: 02/09/2010] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To estimate the comparative effectiveness of medical interventions in adults versus children. STUDY DESIGN We identified from the Cochrane Database of Systematic Reviews (Issue 1, 2007) meta-analyses with data on at least 1 adult and 1 pediatric randomized trial with binary primary efficacy outcome. For each meta-analysis, we calculated the summary odds ratio of the adult trials and the pediatric trials, respectively; the relative odds ratio (ROR) of the adult versus pediatric odds ratios per meta-analysis; and the summary ROR across all meta-analyses. ROR <1 means that the experimental intervention is more unfavorable in children than adults. RESULTS Across 128 eligible meta-analyses (1051 adult and 343 pediatric trials), the summary ROR did not show a statistically significant difference between adults and children (0.96; 95% confidence intervals, 0.86 to 1.08). However, in all meta-analyses except for 1, the individual ROR's 95% confidence intervals could not exclude a relative difference in efficacy over 20%. In two-thirds, the relative difference in observed point estimates exceeded 50%. Nine statistically significant discrepancies were identified; 4 of them were also clinically important. CONCLUSIONS Treatment effects are on average similar in adults and children, but available evidence leaves large uncertainty about their relative efficacy. Clinically important discrepancies may occur.
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Optimal treatment duration of glyceryl trinitrate for chronic anal fissure: results of a prospective randomized multicenter trial. Tech Coloproctol 2010; 14:241-8. [PMID: 20632059 PMCID: PMC2924966 DOI: 10.1007/s10151-010-0604-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2010] [Accepted: 06/20/2010] [Indexed: 11/15/2022]
Abstract
Background Chronic anal fissure (CAF) is a painful condition that is unlikely to resolve with conventional conservative management. Previous studies have reported that topical treatment of CAF with glyceryl trinitrate (GTN) reduces pain and promotes healing, but optimal treatment duration is unknown. Methods To assess the effect of different treatment durations on CAF, we designed a prospective randomized trial comparing 40 versus 80 days with twice daily topical 0.4% GTN treatment (Rectogesic®, Prostrakan Group). Chronicity was defined by the presence of both morphological (fibrosis, skin tag, exposed sphincter, hypertrophied anal papilla) and time criteria (symptoms present for more than 2 months or pain of less duration but similar episodes in the past). A gravity score (1 = no visible sphincter; 2 = visible sphincter; 3 = visible sphincter and fibrosis) was used at baseline. Fissure healing, the primary endpoint of the study, maximum pain at defecation measured with VAS and maximum anal resting pressure were assessed at baseline and at 14, 28, 40 and 80 days. Data was gathered at the end of the assigned treatment. Results Of 188 patients with chronic fissure, 96 were randomized to the 40-day group and 92 to the 80-day group. Patients were well matched for sex, age, VAS and fissure score. There were 34 (19%) patients who did not complete treatment, 18 (10%) because of side effects. Of 154 patients who completed treatment, 90 (58%) had their fissures healed and 105 (68%) were pain free. There was no difference in healing or symptoms between the 40- and the 80-day group. There was no predictor of fissure healing. A low fissure gravity score correlated with increased resolution of pain (P < 0.05) and improvement of VAS score (P < 0.05) on both univariate and multivariate analysis. A lower baseline resting pressure was associated with better pain resolution on univariate analysis (P < 0.01). VAS at defecation and fissure healing significantly improved until 40 days (P < 0.001), while the difference between 40 and 80 days was not significant. Conclusion We found no benefits in treating CAF with topical GTN for 80 days compared to 40 days. Fissure healing and VAS improvement continue until 6 weeks of treatment but are unlikely thereafter.
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28
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Conservative and surgical treatment of chronic anal fissure: prospective longer term results. J Gastrointest Surg 2010; 14:773-80. [PMID: 20195915 DOI: 10.1007/s11605-010-1154-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Accepted: 01/04/2010] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The aim of this prospective study was to assess the efficacy of different medical treatments and surgery in the treatment of chronic anal fissure (CAF). PATIENTS AND METHODS From January 2004 to March 2009, 311 patients with typical CAF completed the study. All patients were initially treated with 0.2% nitroglycerin ointment (GTN) or anal dilators (DIL) for 8 weeks. If no improvement was observed after 8 weeks, the patients were assigned to the other treatment or a combination of the two. Persisting symptoms after 12 weeks or recurrence were indications for either botulinum toxin injection into the internal sphincter and fissurectomy or lateral internal sphincterotomy (LIS). During the follow-up (29 +/- 16 months), healing rates, symptoms, incontinence scores, and therapy adverse effects were prospectively recorded. RESULTS Overall healing rates were 64.6% and 94% after GTN/DIL or BTX/LIS. Healing rate after GTN or DIL after 12 weeks course were 54.5% and 61.5%, respectively. Fifty-four patients (17.4%) responded to further medical therapy. One hundred two patients (32.8%) underwent BTX or LIS. Healing rate after BTX was 83.3% and overall healing after LIS group was 98.7% with no definitive incontinence. CONCLUSION In conclusion, although LIS is far more effective than medical treatments, BTX injection/fissurectomy as first line treatment may significantly increase the healing rate while avoiding any risk of incontinence.
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Screening for the effectiveness of conservative treatment in chronic anal fissure patients using anorectal manometry. Int J Colorectal Dis 2010; 25:649-54. [PMID: 20127340 DOI: 10.1007/s00384-010-0885-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2010] [Indexed: 02/04/2023]
Abstract
PURPOSE Chemical sphincterotomy (CS) is routinely applied in order to avoid the irreversible anal incontinence associated with the surgical treatment of chronic anal fissure (CAF). However, CS has a lower cure rate than surgery. We developed a screening test (using anal manometry) to separate those patients that are unlikely to benefit from CS and should undergo a more aggressive treatment. METHODS Changes in pressure both at rest and during voluntary contraction of the anal sphincter in 187 patients with chronic anal fissure and 25 healthy subjects (control group) of both sexes were measured. Patients were then sequentially treated (1:1:1) with botulin toxin injections (TOX) (n = 63) or ointments of either nitroglycerine (NTG) (n = 65) or diltiazem (DTZ) (n = 59) for 2 months. The cure rate (overall and for each treatment group) and its relationship with changes in anal pressure were determined. RESULTS The overall cure rate was 53% (NTG = 54%, DTZ = 53% and TOX = 51%). Healing was not related to differences in resting or voluntary contraction pressure. However, the probability of healing was associated with an increase in the percentage change between resting and squeeze pressure (PI index) higher than 150% (190 +/- 122), similar to that of the control subjects (200 +/- 115). Failure of CS was observed in patients with a lower PI (114 +/- 77). CONCLUSIONS The ratio resting/voluntary contraction pressure may be predictive of healing in CAF, thus allowing the selection of patients at high risk of failure of conservative treatment.
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Abstract
BACKGROUND Operative techniques commonly used for fissure in ano include: anal stretch, open lateral sphincterotomy, closed lateral sphincterotomy, posterior midline sphincterotomy and to a lesser extent dermal flap coverage of the fissure. Reports of direct comparisons between operative techniques for anal fissure are variable in their results. These reports are either subject to selection bias (in non-randomized studies) or observer bias (in all studies) or have inadequate numbers of patients enrolled to answer the question of efficacy. OBJECTIVES To determine the best technique for fissure surgery. SEARCH STRATEGY The Cochrane Central Register of Controlled Trials and MEDLINE (1965-2008), Medline (Pubmed) and Embase were searched July 2008. The list of cited references in all included reports and several study authors also were helpful in finding additional comparative studies.A total of five new trials were included in this version of the review. SELECTION CRITERIA All reports in which there was a direct comparison between at least two operative techniques were reviewed and when more than one report existed for any given pair, that report was included. If crude data were not presented in the report, the authors were contacted and crude data obtained. DATA COLLECTION AND ANALYSIS The two most commonly used end points in all reported studies were persistence of the fissure and post operative incontinence of flatus. These are the only two endpoints included in the meta-analysis. MAIN RESULTS Twenty-four trials encompassing 3475 patients are included in this review . Anal stretch has a higher risk of fissure persistence than internal sphincterotomy and also a significantly higher risk of minor incontinence than sphincterotomy. The combined results of open versus closed partial lateral internal sphincterotomy show little difference between the two procedures both in fissure persistence and risk of incontinence. AUTHORS' CONCLUSIONS Anal stretch and posterior midline internal sphincterotomy should probably be abandoned in the treatment of chronic anal fissure in adults. For those patients requiring surgery for anal fissure, open and closed partial lateral internal sphincterotomy appear to be equally efficacious. More data are needed to assess the effectiveness of posterior internal sphincterotomy, anterior levatorplasty, wound suture or papilla excision.
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Affiliation(s)
- Richard L Nelson
- Department of General Surgery, Northern General Hospital, Herries Road, Sheffield, Yorkshire, UK, S5 7AU
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31
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Frich L. Botulinumtoksin mot kronisk analfissur? TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2010. [DOI: 10.4045/tidsskr.10.0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Puche JJ, José García-Coret M, Villalba FL, Ali-Mahmoud I, Roig JV. Local treatment of a chronic anal fissure with diltiazem vs. nitroglycerin. A comparative study. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/s2173-5077(10)70052-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Festen S, Gisbertz SS, van Schaagen F, Gerhards MF. Blinded randomized clinical trial of botulinum toxin versus isosorbide dinitrate ointment for treatment of anal fissure. Br J Surg 2009; 96:1393-9. [PMID: 19918859 DOI: 10.1002/bjs.6747] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Nitric oxide donors such as isosorbide dinitrate (ISDN) are considered the first choice of treatment for anal fissure. After reports of the successful treatment of such fissures with botulinum toxin, this randomized blinded trial compared botulinum toxin with ISDN in the treatment of chronic anal fissure. METHODS Patients were randomized to receive an injection of botulinum in the internal anal sphincter and a placebo ointment, or a placebo injection and ISDN ointment. The primary endpoint was macroscopic fissure healing after 4 months. RESULTS After 4 months macroscopic healing of the fissures was noted in 14 of 37 patients in the botulinum group and 21 of 36 in the ISDN group. Pain scores were lower among patients who received ISDN, although the difference was not significant. Side-effects were similar in the two groups. CONCLUSION In contrast with previous reports on botulinum toxin as a therapeutic agent for anal fissure, this study found no advantage over treatment with a nitric oxide donor as regards fissure healing and fissure-related pain.
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Affiliation(s)
- S Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1091 AC Amsterdam, The Netherlands.
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Abstract
Anorectal disorders affect men and women of all ages. Their management is not limited to the evaluation and treatment of hemorrhoids. Rather, a spectrum of anorectal disorders ranges from benign and irritating (pruritus ani) to potentially life-threatening (anorectal cancer). Symptoms are nonspecific, which can make the evaluation of patients difficult. In addition, treatment can be frustrating because clinicians are hamstrung by a lack of well-designed, prospective, clinical trials. Some of the most common anorectal disorders include fecal incontinence, pelvic floor dyssynergia, anal fissures, pruritus ani, proctalgia fugax, and solitary rectal ulcer syndrome. This article provides an update on the evaluation and treatment of common anorectal disorders.
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Affiliation(s)
- Brian E Lacy
- Dartmouth-Hitchcock Medical Center, Division of Gastroenterology and Hepatology, Area 4C, Lebanon, NH 03756, USA.
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Idiopathic hypertensive anal canal: a place of internal sphincterotomy. J Gastrointest Surg 2009; 13:1607-13. [PMID: 19517198 DOI: 10.1007/s11605-009-0931-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Accepted: 05/11/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hypertensive anal canal is frequently known to be associated with the presence of anal fissure. Based on clinical experience, we hypothesized that idiopathic anal sphincter hypertonia was a condition equivalent to anal fissure, and therefore, it could be treated the same way. PATIENT AND METHODS Sixty-three patients complaining of anal pain without any anal pathology and ten healthy volunteers were examined. All patients underwent clinical evaluation, neurological examination, anorectal manometry, and measurement of pudendal nerve terminal motor latency. All patients with hypertensive anal canal were randomized into three groups. Group I (surgical group) underwent closed lateral sphincterotomy (LS), group II using nitroglycerine ointment (GTN), and group III received injection of botulinum toxin in internal sphincter. Post-procedures data were recorded at follow-up period. RESULTS The mean resting anal pressure (MRAP) was significantly higher in the patient group (114.6 +/- 7.4 mmHg) than control group (72.5 +/- 6.6 mmHg, P < 0.001). Anal pain is the main presenting symptoms aggravated by defecation and not relived by analgesics or local anesthetics. After LS, pain visual analogue scale decreased significantly at follow-up period than after chemical sphincterotomy using GTN or BTX (P = 0.001). There was a significant decrease in MRAP postoperatively from 114.6 +/- 7.4 to 70.8 +/- 5.5 mmHg than after using GTN or BTX (P = 0.03). CONCLUSION Idiopathic hypertensive anal canal is a fact and already exists presented by anal pain aggravated by defecation. It can be managed safely by closed lateral sphincterotomy, but chemical sphincterotomy had a minor role in its management.
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Giordano P, Gravante G, Grondona P, Ruggiero B, Porrett T, Lunniss PJ. Simple cutaneous advancement flap anoplasty for resistant chronic anal fissure: a prospective study. World J Surg 2009; 33:1058-63. [PMID: 19225835 DOI: 10.1007/s00268-009-9937-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND A proportion of patients with chronic anal fissure have persistent symptoms and pathology despite optimum conservative therapies. Lateral anal sphincterotomy, the standard surgical treatment, is associated with functional compromise in a minority of patients. Sphincter-sparing anoplasty has been advocated as an alternative procedure for those with "low pressure" sphincters. The aim of this study was to determine the efficacy of simple cutaneous advancement flap anoplasty (SCAFA) when applied to consecutive patients with chronic anal fissure irrespective of anal tone and the patient's gender. METHOD This was a prospective outcome study of 51 consecutive patients treated with SCAFA over a 6.5-year period. RESULTS Surgery was well tolerated. There were three (5.9%) early flap dehiscences, all of which were treated with repeat SCAFA, and one of those three patients remained symptomatic at 2 months. All fissures healed in the short term. Three other patients subsequently developed fissures at sites remote from the original pathology. Continence was unaffected by the procedure. CONCLUSIONS Simple cutaneous advancement flap anoplasty should be considered as a first-line surgical treatment of chronic anal fissure, irrespective of patient gender and anal tone.
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Affiliation(s)
- Pasquale Giordano
- Department of Surgery, Whipps Cross University Hospital, Whipps Cross Road, London E11 1NR, UK.
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Fernández García M, Albornoz López R, Pérez Rodrigo I, Abellón Ruiz J. Efectividad y seguridad de diltiazem 2 % tópico en fisura anal. FARMACIA HOSPITALARIA 2009. [DOI: 10.1016/s1130-6343(09)70992-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Apostolidis A, Dasgupta P, Denys P, Elneil S, Fowler CJ, Giannantoni A, Karsenty G, Schulte-Baukloh H, Schurch B, Wyndaele JJ. Recommendations on the Use of Botulinum Toxin in the Treatment of Lower Urinary Tract Disorders and Pelvic Floor Dysfunctions: A European Consensus Report. Eur Urol 2009; 55:100-19. [DOI: 10.1016/j.eururo.2008.09.009] [Citation(s) in RCA: 241] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Accepted: 09/08/2008] [Indexed: 01/23/2023]
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Alonso-Coello P, Marzo-Castillejo M, Mascort JJ, Hervás AJ, Viña LM, Ferrús JA, Ferrándiz J, López-Rivas L, Rigau D, Solà I, Bonfill X, Piqué JM. Guía de práctica clínica sobre el manejo de las hemorroides y la fisura anal (actualización 2007). GASTROENTEROLOGIA Y HEPATOLOGIA 2008; 31:668-81. [PMID: 19174084 DOI: 10.1016/s0210-5705(08)75815-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Pablo Alonso-Coello
- Centro Cochrane Iberoamericano, Servicio de Epidemiología Clínica y Salud Pública (Universidad Autónoma de Barcelona), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Abstract
Hemorrhoids and anal fissures are common benign anorectal conditions that form a significant part of a colorectal surgeon's workload. This review summarizes and evaluates the current techniques available in their management.
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Affiliation(s)
- Peter S Chong
- Department of Colorectal Surgery, Western General Hospital, Edinburgh EH4 2XU, UK.
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Soll C, Dindo D, Hahnloser D. Combined fissurectomy and botulinum toxin injection. A new therapeutic approach for chronic anal fissures. ACTA ACUST UNITED AC 2008; 32:667-70. [PMID: 18468825 DOI: 10.1016/j.gcb.2008.03.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- C Soll
- Department of Visceral and Transplantation Surgery, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
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Baraza W, Boereboom C, Shorthouse A, Brown S. The long-term efficacy of fissurectomy and botulinum toxin injection for chronic anal fissure in females. Dis Colon Rectum 2008; 51:239-43. [PMID: 18175186 DOI: 10.1007/s10350-007-9161-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Revised: 05/29/2007] [Accepted: 08/25/2007] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Healing rates for botulinum toxin injection for anal fissure may be improved if combined with fissurectomy. This procedure has a decreased risk of incontinence, which is particularly important in females. We investigated the long-term efficacy of fissurectomy and botulinum toxin injection for chronic resistant fissures in females. METHODS Female patients who consented underwent excision of the fissure edges and injection of 25-100 units of botulinum into the intersphincteric space. Patients were followed up 2 months after the procedure and over a period of up to 39 months. RESULTS Forty-six patients (mean age, 42 years) were recruited. No patient had incontinence symptoms preoperatively. At a median follow-up period of 11 months, there was a cure rate of 85 percent in 44 patients. After a median follow-up of 22 months, 12 more patients were lost to follow-up. Of the remaining patients, 16 (50 percent) suffered recurrence during the follow-up period. Five patients required further surgical intervention. Three patients suffered chronic perianal infection requiring antibiotic treatment or surgery. There was one case of incontinence at final assessment: the patient complained of urge incontinence, which has persisted for more than 18 months. CONCLUSIONS Fissurectomy and botulinum toxin injection for the treatment of chronic anal fissure in females seems to be effective in the medium-term but there is a high rate of late recurrence. However, only a minority of patients proceed to more invasive surgical intervention, which may make it a useful option in patients not suitable for lateral sphincterotomy.
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Affiliation(s)
- Wal Baraza
- The Northern General Hospital, Sheffield, United Kingdom.
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43
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Sileri P, Mele A, Stolfi VM, Grande M, Sica G, Gentileschi P, Di Carlo S, Gaspari AL. Medical and surgical treatment of chronic anal fissure: a prospective study. J Gastrointest Surg 2007; 11:1541-8. [PMID: 17763918 DOI: 10.1007/s11605-007-0255-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Accepted: 07/19/2007] [Indexed: 01/31/2023]
Abstract
The aim of this prospective study was to assess the efficacy of different medical treatments and surgery in the treatment of chronic anal fissure (CAF). From 1/04 to 09/06, 156 patients with typical CAF completed the study. All patients were treated with 0.2% nitroglycerin ointment (GTN) or anal dilators (DIL) for 8 weeks. If no improvement was observed after 8 weeks, patient was assigned to the other treatment or a combination of the two. Persisting symptoms after 12 weeks or recurrence were indications for either botulinum toxin injection into the internal sphincter and fissurectomy or lateral internal sphincterotomy (LIS). During the follow-up (19 +/- 8 months), healing rates, symptoms, incontinence scores, and therapy adverse effects were prospectively recorded. Overall healing rates were 65.3 and 96.3% after GTN/DIL or BTX/LIS. Healing rate after GTN or DIL were 39.8 and 46%, respectively. Thirty-six patients (23.1%) responded to further medical therapy. Fifty-four patients (34.6%) underwent BTX or LIS. Healing rate after BTX was 81.8%. LIS group showed a 100% healing rate with no morbidity and postoperative incontinence. In conclusion, although LIS is far more effective than medical treatments, BTX injection/fissurectomy as first line treatment may significantly increase the healing rate while avoiding any risk of incontinence.
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Affiliation(s)
- Pierpaolo Sileri
- Department of Surgery, University of Rome Tor Vergata, Policlinico Tor Vergata, Rome, Italy.
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Affiliation(s)
- Vincent de Parades
- Service de proctologie médico-interventionnelle, Goupe hospitalier Diaconesses-Croix Saint-Simon, Paris.
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45
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Collins EE, Lund JN. A review of chronic anal fissure management. Tech Coloproctol 2007; 11:209-23. [PMID: 17676270 DOI: 10.1007/s10151-007-0355-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2007] [Accepted: 06/26/2007] [Indexed: 12/14/2022]
Abstract
Anal fissure management has rapidly progressed in the last 15 years as our understanding of fissure pathophysiology has developed. All methods of treatment aim to reduce the anal sphincter spasm associated with chronic anal fissures. Surgical techniques have been used for over 100 years with success. Lateral internal sphincterotomy remains the surgical treatment of choice for many practitioners. Postoperative impairment of continence remains controversial. Recently, less invasive methods of treatment have been explored. Topical nitrates, calcium channel blockers and botulinum toxin are established treatments. These and other non-surgical treatments are described in this review. Various guidelines and treatment algorithms for anal fissure are also discussed.
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Affiliation(s)
- E E Collins
- Department of Surgery, University of Nottingham Medical School, Derby, Derby City General Hospital, Uttoxeter Road, Derby, DE22 3DT, UK.
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Ahmad J, Andrabi SIH, Rathore MA. Comparison of topical glyceryl trinitrate with lignocaine ointment for treatment of anal fissure: a randomised controlled trial. Int J Surg 2007; 5:429-32. [PMID: 17869598 DOI: 10.1016/j.ijsu.2007.07.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Revised: 07/21/2007] [Accepted: 07/26/2007] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Topical glyceryl trinitrate (GTN) has gained popularity as a treatment for anal fissure in the West. In our country, lignocaine is still the current treatment for the entity. This study was done to compare the effect of GTN with lignocaine in terms of healing rate and recurrence in South Asian population. METHODS A prospective, double blinded, randomised controlled trial was conducted on 50 patients (both treatment arms included) of all ages and either gender with a clinical diagnosis of anal fissure. Group A was given 0.2% GTN ointment and Group B was given lignocaine ointment. Both subjective and objective signs of healing were assessed and adverse effects of the treatment were sought. RESULTS Symptomatic relief was earlier with GTN as compared with lignocaine. Pain relief was steady and sustained in those treated with GTN but returned to pre-treatment status within 5 weeks in patients with lignocaine. After 8 weeks of treatment, 80% of patients in Group A showed clinical signs of healing compared to 32% in Group B (p=0.001). Headache was the main side effect of GTN. At 6-month follow-up, recurrence was seen in 3/8 patients in Group B compared to 8/20 in the GTN Group (p=1). CONCLUSION Topical GTN has earlier and a higher rate of clinical healing of anal fissure with acceptable side effects. The recurrence rate is high and comparable to lignocaine ointment. It is a safe and an effective treatment of anal fissure in a South Asian population.
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Affiliation(s)
- J Ahmad
- Department of Surgery, Jinnah Hospital Lahore, Pakistan.
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47
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Abstract
BACKGROUND Operative techniques commonly used for fissure in ano include: anal stretch, open lateral sphincterotomy, closed lateral sphincterotomy, posterior midline sphincterotomy and to a lesser extent dermal flap coverage of the fissure. Reports of direct comparisons between operative techniques for anal fissure are variable in their results. These reports are either subject to selection bias (in non-randomized studies) or observer bias (in all studies) or have inadequate numbers of patients enrolled to answer the question of efficacy. OBJECTIVES To determine the best technique for fissure surgery. SEARCH STRATEGY The Cochrane Central Register of Controlled Trials and MEDLINE (1965-2005) were searched. The list of cited references in all included reports and several study authors also were helpful in finding additional comparative studies. SELECTION CRITERIA All reports in which there was a direct comparison between at least two operative techniques were reviewed and when more than one report existed for any given pair, that report was included. If crude data were not presented in the report, the authors were contacted and crude data obtained. DATA COLLECTION AND ANALYSIS The two most commonly used end points in all reported studies were persistence of the fissure and post operative incontinence of flatus. These are the only two endpoints included in the meta-analysis. MAIN RESULTS Twenty-four trials encompassing 3475 patients are included in this review . Anal stretch has a higher risk of fissure persistence than internal sphincterotomy and also a significantly higher risk of minor incontinence than sphincterotomy. The combined results of open versus closed partial lateral internal sphincterotomy show little difference between the two procedures both in fissure persistence and risk of incontinence. AUTHORS' CONCLUSIONS Anal stretch and posterior midline internal sphincterotomy should probably be abandoned in the treatment of chronic anal fissure in adults. For those patients requiring surgery for anal fissure, open and closed partial lateral internal sphincterotomy appear to be equally efficacious. More data are needed to assess the effectiveness of posterior internal sphincterotomy, anterior levatorplasty, wound suture or papilla excision.
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Affiliation(s)
- R Nelson
- Surgery, University of Illinois, 1740 West Taylor, Room 2204 m/c 957, Chicago, Illinois 60612, USA.
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