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Roelandt P, Bislenghi G, Coremans G, De Looze D, Denis MA, De Schepper H, Dewint P, Geldof J, Gijsen I, Komen N, Ruymbeke H, Stijns J, Surmont M, Van de Putte D, Van den Broeck S, Van Geluwe B, Wyndaele J. Belgian consensus guideline on the management of anal fissures. Acta Gastroenterol Belg 2024; 87:304-321. [PMID: 39210763 DOI: 10.51821/87.2.11787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Introduction Acute and chronic anal fissures are common proctological problems that lead to relatively high morbidity and frequent contacts with health care professionals. Multiple treatment options, both topical and surgical, are available, therefore evidence-based guidance is preferred. Methods A Delphi consensus process was used to review the literature and create relevant statements on the treatment of anal fissures. These statements were discussed and modulated until sufficient agreement was reached. These guidelines were based on the published literature up to January 2023. Results Anal fissures occur equally in both sexes, mostly between the second and fourth decades of life. Diagnosis can be made based on cardinal symptoms and clinical examination. In case of insufficient relief with conservative treatment options, pharmacological sphincter relaxation is preferred. After 6-8 weeks of topical treatment, surgical options can be explored. Both lateral internal sphincterotomy as well as fissurectomy are well-established surgical techniques, both with specific benefits and risks. Conclusions The current guidelines for the management of anal fissures include recommendations for the clinical evaluation of anal fissures, and their conservative, topical and surgical management.
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Affiliation(s)
- P Roelandt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Diseases (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - G Bislenghi
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - G Coremans
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - D De Looze
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Ghent, Belgium
| | - M A Denis
- Department of Gastroenterology and Hepatology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - H De Schepper
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium
| | - P Dewint
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium
- Department of Gastroenterology and Hepatology, Maria Middelares Hospital, Ghent, Belgium
| | - J Geldof
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Ghent, Belgium
| | - I Gijsen
- Department of Gastroenterology and Hepatology, Noorderhart Hospital, Pelt, Belgium
| | - N Komen
- Department of Abdominal Surgery, Antwerp University Hospital, Edegem, Belgium
- Antwerp RESURG Group, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - H Ruymbeke
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Ghent, Belgium
- Department of Gastroenterology, VITAZ, Sint-Niklaas, Belgium
| | - J Stijns
- Department of Abdominal Surgery, University Hospital Brussels, Brussels, Belgium
| | - M Surmont
- Department of Gastroenterology and Hepatology, University Hospital Brussels, Brussels, Belgium
| | - D Van de Putte
- Department of Gastro-intestinal Surgery, University Hospital Ghent, Ghent, Belgium
| | - S Van den Broeck
- Department of Abdominal Surgery, Antwerp University Hospital, Edegem, Belgium
| | - B Van Geluwe
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Abdominal Surgery, General Hospital Groeninge, Kortrijk, Belgium
| | - J Wyndaele
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
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Brillantino A, Renzi A, Talento P, Iacobellis F, Brusciano L, Monaco L, Izzo D, Giordano A, Pinto M, Fantini C, Gasparrini M, Schiano Di Visconte M, Milazzo F, Ferreri G, Braini A, Cocozza U, Pezzatini M, Gianfreda V, Di Leo A, Landolfi V, Favetta U, Agradi S, Marino G, Varriale M, Mongardini M, Pagano CEFA, Contul RB, Gallese N, Ucchino G, D'Ambra M, Rizzato R, Sarzo G, Masci B, Da Pozzo F, Ascanelli S, Foroni F, Palumbo A, Liguori P, Pezzolla A, Marano L, Capomagi A, Cudazzo E, Babic F, Geremia C, Bussotti A, Cicconi M, Di Sarno A, Mongardini FM, Brescia A, Lenisa L, Mistrangelo M, Sotelo MLS, Vicenzo L, Longo A, Docimo L. The Italian Unitary Society of Colon-proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of anal fissure. BMC Surg 2023; 23:311. [PMID: 37833715 PMCID: PMC10576345 DOI: 10.1186/s12893-023-02223-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 10/06/2023] [Indexed: 10/15/2023] Open
Abstract
INTRODUCTION The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colon-Proctologia) on the diagnosis and management of anal fissure, with the purpose to guide every physician in the choice of the best treatment option, according with the available literature. METHODS A panel of experts was designed and charged by the Board of the SIUCP to develop key-questions on the main topics covering the management of anal fissure and to performe an accurate search on each topic in different databanks, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in different rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to the PICO criteria, and the statements developed adopting the GRADE methodology. CONCLUSIONS In patients with acute anal fissure the medical therapy with dietary and behavioral norms is indicated. In the chronic phase of disease, the conservative treatment with topical 0.3% nifedipine plus 1.5% lidocaine or nitrates may represent the first-line therapy, eventually associated with ointments with film-forming, anti-inflammatory and healing properties such as Propionibacterium extract gel. In case of first-line treatment failure, the surgical strategy (internal sphincterotomy or fissurectomy with flap), may be guided by the clinical findings, eventually supported by endoanal ultrasound and anal manometry.
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Affiliation(s)
- Antonio Brillantino
- Deparment of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, Naples, 80131, Italy.
| | - Adolfo Renzi
- "Buonconsiglio-Fatebenefratelli" Hospital, Naples, Italy
| | - Pasquale Talento
- Department of Surgery, Pelvic Floor Center, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Francesca Iacobellis
- Department of General and Emergency Radiology, "A. Cardarelli" Hospital, Naples, Italy
| | - Luigi Brusciano
- Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Luigi Monaco
- "Pineta Grande" Hospital, "Villa Esther" Clinic, Avellino, Italy
| | - Domenico Izzo
- Department of General and Emergency Surgery, AORN dei Colli Monaldi-Cotugno-CTO, CTO Hospital, Naples, Italy
| | - Alfredo Giordano
- Department of General and Emergency Surgery, University of Salerno, Hospital of Mercato San Severino, Salerno, Italy
| | | | - Corrado Fantini
- Department of Surgery, "Dei Pellegrini" Hospital, ASL Napoli 1, Naples, Italy
| | | | - Michele Schiano Di Visconte
- Department of General Surgery, Colorectal and Pelvic Floor Diseases Center, "Santa Maria Dei Battuti" Hospital, Conegliano, TV, Italy
| | - Francesca Milazzo
- Department of Surgery, Pelvic Floor Center, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Giovanni Ferreri
- Department of Surgery, Pelvic Floor Center, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Andrea Braini
- Department of General Surgery, Azienda Sanitaria Friuli Occidentale (ASFO), Pordenone, Italy
| | - Umberto Cocozza
- Department of General Surgery, "S. Maria Degli Angeli" Hospital, Putignano (Bari), Italy
| | | | - Valeria Gianfreda
- Unit of Colonproctologic and Pelvic Surgery, "M.G. Vannini" Hospital, Rome, Italy
| | - Alberto Di Leo
- Department of General and Minivasive Surgery, "San Camillo" Hospital, Trento, Italy
| | - Vincenzo Landolfi
- Department of General and Specalist Surgery, AORN "S.G. Moscati", Avellino, Italy
| | - Umberto Favetta
- Unit of Proctology and Pelvic Surgery, "Città di Pavia" Clinic, Pavia, Italy
| | - Sergio Agradi
- Humanitas Gavazzeni/Castelli Bergamo, Bergamo, Italy
| | - Giovanni Marino
- Department of General Surgery, "Santa Marta e Santa Venera" Hospital of Acireale, Catania, Italy
| | - Massimilano Varriale
- Department of General and Emergency Surgery, "Sandro Pertini" Hospital, Asl Roma 2, Rome, Italy
| | | | | | | | - Nando Gallese
- Unit of Proctologic Surgery, "Sant'Antonio" Clinic, Cagliari, Italy
| | | | - Michele D'Ambra
- Department of General and Oncologic-Minivasive Surgery, "Federico II" University, Naples, Italy
| | - Roberto Rizzato
- Department of General Surgery, Hospital of Conegliano AULSS 2, Marca Trevigiana, Treviso, Italy
| | - Giacomo Sarzo
- Department of General Surgery, University of Padova, "Sant'Antonio" Hospital, Padova, Italy
| | | | - Francesca Da Pozzo
- Department of Surgery, "Santa Maria dei battuti" Hospital, San Vito al Tagliamento, Pordenone, Italy
| | - Simona Ascanelli
- Department of Surgery, University Hospital of Ferrara, Ferrara, Italy
| | - Fabrizio Foroni
- Deparment of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, Naples, 80131, Italy
| | - Alessio Palumbo
- Deparment of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, Naples, 80131, Italy
| | | | | | - Luigi Marano
- Academy of Applied Medical and Social Sciences - AMiSNS: Akademia Medycznych i Spolecznych Nauk Stosowanych, Elbląg, Poland
| | | | - Eugenio Cudazzo
- Department of Surgery, Pelvic Floor Center, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Francesca Babic
- Department of Surgery, Hospital of Cattinara, ASUGI Trieste, Trieste, Italy
| | - Carmelo Geremia
- Unit of Proctology and Pelvic Surgery, "Città di Pavia" Clinic, Pavia, Italy
| | | | - Mario Cicconi
- Department of General Surgery, "Sant'Omero-Val Vibrata" Hospital, Teramo, Italy
| | | | - Federico Maria Mongardini
- Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Antonio Brescia
- Department of Oncologic Colorectal Surgery, University Hospital S. Andrea, "La Sapienza" University, Rome, Italy
| | - Leonardo Lenisa
- Department of Surgery, Humanitas San Pio X, Surgery Unit, Pelvic Floor Centre, Milano, Italy
| | | | | | - Luciano Vicenzo
- Deparment of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, Naples, 80131, Italy
| | | | - Ludovico Docimo
- Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
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D'Orazio B, Geraci G, Famà F, Terranova G, Di Vita G. Botulinum toxin associated with fissurectomy and anoplasty for hypertonic chronic anal fissure: A case-control study. World J Clin Cases 2021; 9:9722-9730. [PMID: 34877311 PMCID: PMC8610929 DOI: 10.12998/wjcc.v9.i32.9722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/07/2021] [Accepted: 08/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Lateral internal sphincterotomy is still the approach of choice for the treatment of chronic anal fissure (CAF) with internal anal sphincter (IAS) hypertonia, but it is burdened by high-risk postoperative faecal incontinence (FI). Sphincter saving procedures have recently been reconsidered as treatments to overcome this risk. The most employed procedure is fissurectomy with anoplasty, eventually associated with pharmacological sphincterotomy.
AIM To evaluate whether fissurectomy and anoplasty with botulinum toxin injection improves the results of fissurectomy and anoplasty alone.
METHODS We conducted a case-control study involving 30 male patients affected by CAF with hypertonic IAS who underwent fissurectomy and anoplasty with V-Y cutaneous flap advancement. The patients were divided into two groups: Those in group I underwent surgery alone, and those in group II underwent surgery and a botulinum toxin injection directly into the IAS. They were followed up for at least 2 years. The goals were to achieve complete healing of the patient and to assess the FI and recurrence rate along with manometry parameters.
RESULTS The intensity and duration of post-defecatory pain decreased significantly in both groups of patients starting with the first defecation, and this reduction was higher in group II. Forty days after surgery, we achieved complete wound healing in all the patients in group II but only in 80% of the patients in group I (P < 0.032). We recorded 2 cases of recurrence, one in each group, and both healed with conservative therapy. We recorded one temporary and low-grade postoperative case of “de novo” FI. Manometry parameters reverted to the normal range earlier for group II patients.
CONCLUSION The injection of botulinum toxin A in association with fissurectomy and anoplasty with a V-Y advancement flap improves the results of surgery alone in patients affected by CAF with IAS hypertonia.
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Affiliation(s)
- Beatrice D'Orazio
- Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo 90100, Sicily, Italy
| | - Girolamo Geraci
- Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo 90100, Sicily, Italy
| | - Fausto Famà
- Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital of Messina, Messina 98121, Sicily, Italy
| | - Gloria Terranova
- Department of Surgical, Oncological and Stomatological Sciences, Postgraduate Medical School in General Surgery, University of Palermo, Palermo 90100, Sicily, Italy
| | - Gaetano Di Vita
- Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo 90100, Sicily, Italy
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Winter KA, Savolt T, Quinn KR, Helmer SD, Porter MG, Sanchez NC. Does Adding a Fissurectomy to Botox Sphincterotomy Increase Success Rate or Just Cost? Am Surg 2021:31348211050830. [PMID: 34732061 DOI: 10.1177/00031348211050830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND While Botox sphincterotomy with or without fissurectomy has been proven effective in healing anal fissures, they have not been directly compared. We evaluated cost-effectiveness and outcomes between Botox sphincterotomies with and without fissurectomy. METHODS A 5-year retrospective review was conducted comparing all patients undergoing Botox sphincterotomy for anal fissure with or without fissurectomy. Outcomes including recurrence/persistence, additional treatments, complications, and total charges were compared between study groups. RESULTS Patients treated without fissurectomy (n = 53) had recurrent/persistent fissure more often (56.6 vs 31.0%, P = .001), and required more Botox treatments. Those treated with fissurectomy (n = 154) had more complications (13.5 vs 0%, P = .003). Patients initially treated without fissurectomy had a median total charge of $2 973, while median total charge for those initially treated with fissurectomy was $17 925 (P < .001). CONCLUSIONS Botox sphincterotomy in an office without fissurectomy is a viable option. It may result in longer healing times but is associated with reduced cost, lower complication rates, and no need for anesthesia or operative intervention in most cases. But the choice of treatment route must be individualized.
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Affiliation(s)
- Kelly A Winter
- Department of Surgery, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Todd Savolt
- Department of Surgery, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Karson R Quinn
- Department of Surgery, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Stephen D Helmer
- Department of Surgery, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Michael G Porter
- Department of Surgery, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Noel C Sanchez
- Department of Surgery, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
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Anaraki F, Foroughifar T, Laleh SH, Etemad O. Evaluation of outcomes in fissurectomy and V–Y advancement flap for the treatment of chronic anal fissure. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2018.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AbstractChronic anal fissure is difficult to treat. Surgery is usually recommended in the case of drug therapeutic failure. Fecal incontinence in patients with weaker sphincters (multipara older patients with a history of pelvic surgery etc.) is a major reason for rejecting surgery. Such these patients should be underwent fissurectomy and V–Y advancement flap in which sphincterotomy is not required. In this prospective study, we determined the outcomes and complications of fissurectomy and V–Y advancement flap in both groups of patients with low and high anal sphincter tones.
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Affiliation(s)
- Fakhrosadat Anaraki
- Shahid Beheshti University of Medical Sciences, Taleghani Hospital Research Development Unit, Colorectal Division of Surgical Ward, Tehran, Iran
| | - Tahereh Foroughifar
- Tehran University of Medical Sciences, Baharloo Hospital, Department of Pelvic Floor Surgery, Tehran, Iran
| | - Seyed Hossein Laleh
- Shahid Beheshti University of Medical Sciences, Taleghani Hospital Research Development Unit, Colorectal Division of Surgical Ward, Tehran, Iran
| | - Omid Etemad
- Tehran University of Medical Sciences, Imam Khomeini Hospital Complex, Plastic & Reconstructive Surgery Ward, Tehran, Iran
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D'Orazio B, Geraci G, Martorana G, Sciumé C, Corbo G, Di Vita G. Fisurectomy and anoplasty with botulinum toxin injection in patients with chronic anal posterior fissure with hypertonia: a long-term evaluation. Updates Surg 2020; 73:1575-1581. [PMID: 32666478 PMCID: PMC8397652 DOI: 10.1007/s13304-020-00846-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/01/2020] [Indexed: 12/14/2022]
Abstract
Chronic anal fissure’s (CAF) etiopathogenesis remain unclear. CAF of the posterior commissure (CAPF) are often characterized by internal anal sphincter (IAS) hypertonia. The treatment of this disease aimed to reduce IAS hypertonia. Due to the high rate of anal incontinence after LIS, the employment of sphincter preserving surgical techniques associated to pharmacological sphincterotomy appears more sensible. The aim of our study is to evaluate the long-term results of fissurectomy and anoplasty with V–Y cutaneous flap advancement associated to 30 UI of botulinum toxin injection for CAPF with IAS hypertonia. We enrolled 45 patients undergone to fissurectomy and anoplasty with V–Y cutaneous flap advancement and 30 UI botulinum toxin injection. All patients were followed up for at least 5 years after the surgical procedure, with evaluation of anal continence, recurrence rate and MRP (Maximum resting pressure), MSP (Maximum restricting pressure), USWA (Ultrasound wave activity). All patients healed within 40 days after surgery. We observed 3 “de novo” post-operative anal incontinence cases, temporary and minor; the pre-operative ones have only temporary worsened after surgery. We reported 3 cases of recurrences, within 2 years from surgery, all healed after conservative medical therapy. At 5 year follow-up post-operative manometric findings were similar to those of healthy subjects. At 5 years after the surgical procedure, we achieved good results, and these evidences show that surgical section of the IAS is not at all necessary for the healing process of the CAPF.
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Affiliation(s)
- Beatrice D'Orazio
- General Surgery Unit, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Via Liborio Giuffrè, 5, 90127, Palermo, Italy.,Postgraduate Medical School in General Surgery, University of Palermo, Palermo, Italy
| | - Girolamo Geraci
- General Surgery Unit, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Via Liborio Giuffrè, 5, 90127, Palermo, Italy
| | - Guido Martorana
- General and Oncological Surgery Unit, Fondazione Istituto G. Giglio, Cefalù, Italy
| | - Carmelo Sciumé
- General Surgery Unit, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Via Liborio Giuffrè, 5, 90127, Palermo, Italy
| | - Giovanni Corbo
- General Surgery Unit, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Via Liborio Giuffrè, 5, 90127, Palermo, Italy.,Postgraduate Medical School in General Surgery, University of Palermo, Palermo, Italy
| | - Gaetano Di Vita
- General Surgery Unit, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Via Liborio Giuffrè, 5, 90127, Palermo, Italy.
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Abstract
ZusammenfassungDie Analfissur ist eine der häufigsten Pathologien, welche sich dem Proktologen präsentiert. Entsprechend ist es wichtig, verlässliche Leitlinien dazu zu entwickeln. Die aktuelle Leitlinie wurde anhand eines systematischen Literaturreview von einem interdisziplinären Expertengremium diskutiert und verabschiedet.Die akute Analfissur, soll auf Grund ihrer hohen Selbstheilungstendenz konservativ behandelt werden. Die Heilung wird am besten durch die Einnahme von Ballaststoff reicher Ernährung und einer medikamentösen Relaxation durch Kalziumkanal-Antagonisten (CCA) unterstützt. Zur Behandlung der chronischen Analfissur (CAF), soll den Patienten eine medikamentöse Behandlung zur „chemischen Sphinkterotomie“ mittels topischer CCA oder Nitraten angeboten werden. Bei Versagen dieser Therapie, kann zur Relaxation des inneren Analsphinkters Botulinumtoxin injiziert werden. Es ist belegt, dass die operativen Therapien effektiver sind. Deshalb kann eine Operation schon als primäre Therapie oder nach erfolgloser medikamentöser Therapie erfolgen. Die Fissurektomie, evtl. mit zusätzlicher Botulinumtoxin Injektion oder Lappendeckung, ist die Operation der Wahl. Obwohl die laterale Internus Sphinkterotomie die CAF effektiver heilt, bleibt diese wegen dem höheren Risiko für eine postoperative Stuhlinkontinenz eine Option für Einzelfälle.
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Cariati M, Chiarello MM, Cannistra' M, Lerose MA, Brisinda G. Gastrointestinal Uses of Botulinum Toxin. Handb Exp Pharmacol 2020; 263:185-226. [PMID: 32072269 DOI: 10.1007/164_2019_326] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Botulinum toxin (BT), one of the most powerful inhibitors that prevents the release of acetylcholine from nerve endings, represents an alternative therapeutic approach for "spastic" disorders of the gastrointestinal tract such as achalasia, gastroparesis, sphincter of Oddi dysfunction, chronic anal fissures, and pelvic floor dyssynergia.BT has proven to be safe and this allows it to be a valid alternative in patients at high risk of invasive procedures but long-term efficacy in many disorders has not been observed, primarily due to its relatively short duration of action. Administration of BT has a low rate of adverse reactions and complications. However, not all patients respond to BT therapy, and large randomized controlled trials are lacking for many conditions commonly treated with BT.The local injection of BT in some conditions becomes a useful tool to decide to switch to more invasive therapies. Since 1980, the toxin has rapidly transformed from lethal poison to a safe therapeutic agent, with a significant impact on the quality of life.
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Affiliation(s)
- Maria Cariati
- Department of Surgery, "San Giovanni di Dio" Hospital, Crotone, Italy
| | | | - Marco Cannistra'
- Department of Surgery, "San Giovanni di Dio" Hospital, Crotone, Italy
| | | | - Giuseppe Brisinda
- Department of Surgery, "San Giovanni di Dio" Hospital, Crotone, Italy. .,Department of Surgery, "Agostino Gemelli" Hospital, Catholic School of Medicine, Rome, Italy.
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Andicoechea Agorría A, Del Casar Lizcano JM, Barbón Remis E, Jara Quezada JH, Fernández Fernández JC, Sánchez Sánchez MDR, Quintela Baizán I, Vivoso Piñero F. Treatment of a chronic anal fissure with a botulin toxin A injection and fissurectomy. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 111:672-676. [PMID: 31333035 DOI: 10.17235/reed.2019.6202/2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION pharmacological treatment of a chronic anal fissure (CAF) achieves healing in half of cases and lateral internal sphincterotomy (LIS) is the definite treatment. The objective of this study was to assess the combination of fissurectomy and botulin toxin A (BTA) injection. METHODS this was a retrospective study of 54 patients with anal sphincter hypertonia and CAF treated with an injection of BAT and fissurectomy, after an unsuccessful management with topical nitroglycerin (NGT) for eight weeks. Fissurectomy and an injection of BTA (33 or 50 units) in the internal anal sphincter was performed during the same session. The main outcome measure was the healing rate, with incontinence and the need of LIS as secondary outcomes. RESULTS two patients were excluded from the study, one due to Crohn's disease and the other was lost to follow-up. Of the 52 patients included in the study, there were 36 females (70%) and 16 (30%) males, with a mean age of 49 years (range 22-75). Fissure healing was initially achieved in 49 patients (94.2%) and LIS was required in the remaining three patients (5.8%). After initial healing, 18 patients (34.7%) developed 23 recurrences at a mean time of 27 months (5-83 months). Of these patients, healing with conservative sphincter measures was obtained in eleven cases (NGT in eight and repeat fissurectomy and BAT in three); two patients are currently under treatment with NGT and five underwent LIS. CONCLUSIONS BTA injection associated with fissurectomy is a safe and effective procedure in patients with CAF, avoiding the need of LIS in a high percentage of patients.
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High-dose versus low-dose botulinum toxin in anal fissure disease. Tech Coloproctol 2017; 21:803-808. [DOI: 10.1007/s10151-017-1700-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 09/25/2017] [Indexed: 11/27/2022]
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Barbeiro S, Atalaia-Martins C, Marcos P, Gonçalves C, Canhoto M, Arroja B, Silva F, Cotrim I, Eliseu L, Santos A, Vasconcelos H. Long-term outcomes of Botulinum toxin in the treatment of chronic anal fissure: 5 years of follow-up. United European Gastroenterol J 2016; 5:293-297. [PMID: 28344798 DOI: 10.1177/2050640616656708] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 06/01/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Chronic anal fissure is a frequent and disabling disease, often affecting young adults. Botulinum toxin and lateral internal sphincterotomy are the main therapeutic options for refractory cases. Botulinum toxin is minimally invasive and safer compared with surgery, which carries a difficult post-operative recovery and fecal incontinence risk. The long-term efficacy of Botulinum toxin is not well known. OBJECTIVE The aim of this study was to evaluate the long-term efficacy and safety of Botulinum toxin in the treatment of chronic anal fissure. METHODS This was a retrospective study at a single center, including patients treated with Botulinum toxin from 2005 to 2010, followed over at least a period of 5 years. All patients were treated with injection of 25U of Botulinum toxin in the intersphincteric groove. The response was registered as complete, partial, refractory and relapse. RESULTS Botulinum toxin was administered to 126 patients, 69.8% (n = 88) were followed over a period of 5 years. After 3 months, 46.6% (n = 41) had complete response, 23.9% (n = 21) had partial response and 29.5% (n = 26) were refractory. Relapse was observed in 1.2% (n = 1) at 6 months, 11.4% (n = 10) at 1 year, 2.3% (n = 2) at 3 years; no relapse at 5 years. The overall success rate was 64.8% at 5 years of follow-up. Botulinum toxin was well tolerated by all patients and there were no complications. CONCLUSION The use of Botulinum toxin to treat patients with chronic anal fissure was safe and effective in long-term follow-up.
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Affiliation(s)
- Sandra Barbeiro
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | | | - Pedro Marcos
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Cláudia Gonçalves
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Manuela Canhoto
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Bruno Arroja
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Filipe Silva
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Isabel Cotrim
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Liliana Eliseu
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Antonieta Santos
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Helena Vasconcelos
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
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Fissurectomy Combined with High-Dose Botulinum Toxin Is a Safe and Effective Treatment for Chronic Anal Fissure and a Promising Alternative to Surgical Sphincterotomy. Dis Colon Rectum 2015; 58:967-73. [PMID: 26347969 DOI: 10.1097/dcr.0000000000000434] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is paucity of data on the long-term outcome of the combination of fissurectomy and botulinum toxin A injection for the management of chronic anal fissure. OBJECTIVES The aim of this study is to assess the safety, efficacy, and long-term outcome of the combination of fissurectomy and botulinum toxin A injection. DESIGN This is a nonrandomized prospective cohort study. SETTINGS This study was conducted at a district general hospital in the United Kingdom. PATIENTS The cohort included all patients treated with fissurectomy and botulinum toxin A for chronic anal fissure between September 2008 and March 2012. INTERVENTION The patients were treated with a combination of fissurectomy and botulinum toxin A injection. MAIN OUTCOME MEASURES Symptomatic relief, fissure healing, complications, recurrence, and the need for further surgical intervention. RESULTS One hundred and two patients received fissurectomy and botulinum toxin A injection for chronic anal fissure. At 12-week follow-up, 68 patients had resolution of symptoms and complete healing of chronic anal fissure, 29 patients had improvement of symptoms but incomplete healing and had further topical or botulinum toxin A treatment with subsequent complete healing. Ninety-five patients (93%) reported no postoperative complications. Seven patients reported a degree of incontinence in the immediate postoperative period. All reported normal continence at12-week follow-up. No local complications were observed or reported. At the mean follow-up of 33 months, there was no evidence of recurrence. Twelve-month follow-up was conducted via telephone interview only. LIMITATIONS This study is nonrandomized and did not examine the dose response of Botulinum Toxin A. CONCLUSIONS Fissurectomy combined with high-dose botulinum toxin A is a safe, effective, and durable option for the management of chronic anal fissure and a promising alternative to surgical sphincterotomy.
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Brisinda G, Sivestrini N, Bianco G, Maria G. Treatment of gastrointestinal sphincters spasms with botulinum toxin A. Toxins (Basel) 2015; 7:1882-916. [PMID: 26035487 PMCID: PMC4488680 DOI: 10.3390/toxins7061882] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 05/10/2015] [Accepted: 05/21/2015] [Indexed: 02/05/2023] Open
Abstract
Botulinum toxin A inhibits neuromuscular transmission. It has become a drug with many indications. The range of clinical applications has grown to encompass several neurological and non-neurological conditions. One of the most recent achievements in the field is the observation that botulinum toxin A provides benefit in diseases of the gastrointestinal tract. Although toxin blocks cholinergic nerve endings in the autonomic nervous system, it has also been shown that it does not block non-adrenergic non-cholinergic responses mediated by nitric oxide. This has promoted further interest in using botulinum toxin A as a treatment for overactive smooth muscles and sphincters. The introduction of this therapy has made the treatment of several clinical conditions easier, in the outpatient setting, at a lower cost and without permanent complications. This review presents current data on the use of botulinum toxin A in the treatment of pathological conditions of the gastrointestinal tract.
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Affiliation(s)
- Giuseppe Brisinda
- Department of Surgery, University Hospital "Agostino Gemelli", Largo Agostino Gemelli 8, 00168 Rome, Italy.
| | - Nicola Sivestrini
- Department of Surgery, University Hospital "Agostino Gemelli", Largo Agostino Gemelli 8, 00168 Rome, Italy.
| | - Giuseppe Bianco
- Department of Surgery, University Hospital "Agostino Gemelli", Largo Agostino Gemelli 8, 00168 Rome, Italy.
| | - Giorgio Maria
- Department of Surgery, University Hospital "Agostino Gemelli", Largo Agostino Gemelli 8, 00168 Rome, Italy.
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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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Brisinda G, Bianco G, Silvestrini N, Maria G. Cost considerations in the treatment of anal fissures. Expert Rev Pharmacoecon Outcomes Res 2014; 14:511-25. [PMID: 24867398 DOI: 10.1586/14737167.2014.924398] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Anal fissure is a split in the lining of the distal anal canal. Lateral internal sphincterotomy remains the gold standard for treatment of anal fissure. Although technique is simple and effective, a drawback of this surgical procedure is its potential to cause minor but some times permanent alteration in rectal continence. Conservative approaches (such as topical application of ointment or botulinum toxin injections) have been proposed in order to treat this condition without any risk of permanent injury of the internal anal sphincter. These treatments are effective in a large number of patients. Furthermore, with the ready availability of medical therapies to induce healing of anal fissure, the risk of a first-line surgical approach is difficult to justify. The conservative treatments have a lower cost than surgery. Moreover, evaluation of the actual costs of each therapeutic option is important especially in times of economic crisis and downsizing of health spending.
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Affiliation(s)
- Giuseppe Brisinda
- Department of Surgery, Catholic School of Medicine, University Hospital "Agostino Gemelli", Largo Agostino Gemelli 8, 00168, Rome, Italy
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Farouk R. Sphincter-Preserving Therapy for Treating a Chronic Anal Fissure: Long-term Outcomes. Ann Coloproctol 2014; 30:132-4. [PMID: 24999464 PMCID: PMC4079811 DOI: 10.3393/ac.2014.30.3.132] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 11/24/2013] [Indexed: 01/20/2023] Open
Abstract
Purpose To estimate the risk of recurrent fissure in ano after sphincter preserving treatments. Methods A retrospective case note review, combined with a telephone survey was conducted for all patients treated for a chronic anal fissure between 1998 and 2008. Results Six hundred and twelve patients (303 women: mean age, 39 years; range, 16-86 years) were treated for chronic anal fissure between 1998 and 2008. Topical diltiazem 2% was initially prescribed for 8 weeks. The fissure did not heal in 141 patients. These patients (61 women: mean age, 30 years; range, 15-86 years) were treated with 100 IU botulinum A toxin (Botox) injection combined with a fissurectomy under general anaesthesia. Thirty eight patients suffered a recurrence of their fissure within two years. Thirty-four healed with further medical or sphincter conserving surgical therapy while four required a lateral internal sphincterotomy. Conclusion The vast majority of patients with chronic anal fissure can be treated with sphincter conserving treatments. This may require several interventions before healing can be achieved. Assessment for recurrence after 'conservative' treatments requires a minimum of two-year follow-up.
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Affiliation(s)
- Ridzuan Farouk
- Department of Surgery, National University Hospital, Singapore
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19
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Garg P, Garg M, Menon GR. Long-term continence disturbance after lateral internal sphincterotomy for chronic anal fissure: a systematic review and meta-analysis. Colorectal Dis 2013; 15:e104-17. [PMID: 23320551 DOI: 10.1111/codi.12108] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Accepted: 09/13/2012] [Indexed: 02/08/2023]
Abstract
AIM A systematic review was carried out to analyse continence at 2 years or more after lateral internal sphincterotomy (LIS) for chronic anal fissure (CAF). METHOD PubMed, MEDLINE, Scopus, Embase, Ovid, SCI, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar were used to search the literature from 1969-2012 for studies reporting a follow-up of more than 2 years after LIS for CAF. The primary outcome parameter analysed was continence. The secondary outcome parameters included success rate, recurrence, incidence of postoperative abscess and fistula formation and patient satisfaction. RESULTS Of 324 studies screened, 22 (n = 4512) were included. The mean follow-up period ranged from 24-124 months. The overall continence disturbance rate was 14% (95% CI 0.09-0.2). Weighted analysis showed flatus incontinence in 9% (95% CI 0.04-0.16), soilage/seepage in 6% (95% CI 0.03-0.1), accidental defaecation in 0.91% (95% CI 0.003-0.02), incontinence to liquid stool in 0.67% (95% CI 0.001-0.02) and incontinence to solid stool in 0.83% (95% CI 0.003-0.02) of patients. CONCLUSION The long-term risk of continence disturbance after lateral internal sphincterotomy is significant. Randomized controlled trials with a long follow-up are needed to substantiate these findings and to redefine its role in the treatment of chronic anal fissure.
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Affiliation(s)
- P Garg
- Fortis Super Specialty Hospital, Mohali, India.
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Abramowitz L, Bouchard D, Souffran M, Devulder F, Ganansia R, Castinel A, Suduca JM, Soudan D, Varastet M, Staumont G. Sphincter-sparing anal-fissure surgery: a 1-year prospective, observational, multicentre study of fissurectomy with anoplasty. Colorectal Dis 2013; 15:359-67. [PMID: 22776322 DOI: 10.1111/j.1463-1318.2012.03176.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
AIM Internal sphincterotomy is the standard surgical treatment for chronic anal fissure, but is frequently complicated by anal incontinence. Fissurectomy is proposed as an alternative technique to avoid sphincter injury. We describe 1-year outcomes of fissurectomy. METHOD This was a prospective, multicentre, observational study. All patients with planned surgery for chronic anal fissure were included and had fissurectomy. Data were collected before surgery, at healing, and 1 year after fissurectomy. Patient self-assessed anal symptoms and quality of life (using the 36-item short-form health survey [SF-36] questionnaire). Presurgical and postsurgical variables were compared using the Wilcoxon signed-rank test for paired samples. RESULTS Two-hundred and sixty-four patients were included (median age, 45 years; 52% women). Anoplasty was associated with fissurectomy in 83% of the 257 documented cases. The main complications were urinary retention (n = 3), local infection (n = 4) and faecal impaction (n = 1). Healing was achieved in all patients at a median of 7.5 weeks after surgery. No recurrence occurred. At 1 year, 210 (79%) questionnaires were returned. Median anal pain had dropped from 7.3/10 to 0.1/10 (P < 0.001), anal discomfort had decreased from 5.0/10 to 0.1/10 (P < 0.001) and the Knowles-Eckersley-Scott Symptom constipation score had decreased from 9/45 to 5/45 (P < 0.001). There was a nonsignificant increase in the Wexner anal incontinence score, from 1/20 to 2/20. De-novo clinically significant anal incontinence (Wexner score > 5) affected 7% of patients at 1 year, but presurgical incontinence had disappeared in 15% of patients. All SF-36 domains significantly improved. Anoplasty did not impact any result. CONCLUSION Given its high rate of healing and low rate of de-novo anal incontinence, fissurectomy with anoplasty is a valuable sphincter-sparing surgical treatment for chronic anal fissure.
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Affiliation(s)
- L Abramowitz
- Unité de Proctologie Médico-Chirurgicale, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France.
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Schornagel IL, Witvliet M, Engel AF. Five-year results of fissurectomy for chronic anal fissure: low recurrence rate and minimal effect on continence. Colorectal Dis 2012; 14:997-1000. [PMID: 21955514 DOI: 10.1111/j.1463-1318.2011.02840.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AIM The aim of the study was to determine the long-term outcome, recurrence rate and faecal incontinence score after fissurectomy for chronic anal fissure (CAF) not responding to conservative treatment. METHOD Fifty-three consecutive patients (29 women) who underwent fissurectomy for a medically resistant CAF between 1998 and 2005 were included in the study. At a minimum follow-up of 5 years a standardized questionnaire was sent to all patients, assessing recurrence, satisfaction with the operation (on a scale of 0-10) and faecal continence (Vaizey score, 0-24). The patients were compared with a control group of 50 healthy volunteers, matched for sex and age, who had never undergone anal surgery. RESULTS Forty-three (81%) patients (25 women) returned the questionnaire. The mean age was 40 (SD 12.1) years and median follow up was 8.2 (5.5-12.2) years. Five patients had a recurrent CAF (11.6%). Ninety per cent of patients would have consented to the operation again if necessary. The mean Vaizey score at follow-up was 2.5 (SD ± 4.2). The mean Vaizey score of the four patients who had had a previous lateral sphincterotomy was 3.8 and for the eight patients who had reported a continence disturbance before fissurectomy it was 8.3. The mean Vaizey score of the 31 patients who were continent before fissurectomy was 0.8 compared with 0.4 in the control group (P = 0.9). CONCLUSION At 5 years or more fissurectomy for medically resistant CAF is effective with a low recurrence rate and minimal influence on continence.
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Affiliation(s)
- I L Schornagel
- Department of Colorectal Surgery, Zaans Medical Centre, Zaandam, The Netherlands
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Patti R, Territo V, Aiello P, Angelo GL, Di Vita G. Manometric Evaluation of Internal Anal Sphincter after Fissurectomy and Anoplasty for Chronic Anal Fissure: A Prospective Study. Am Surg 2012. [DOI: 10.1177/000313481207800531] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Chronic anal fissure (CAF) is a common painful clinical disease and its pathogenesis remains poorly understood. After failure of pharmacological therapy, that is the first-line treatment, surgical sphincterotomy remains the treatment of choice although it is followed by a high rate of anal incontinence resulting from the sphincter damage; therefore, the research of a sphincter-saving surgical option has become an important goal. The aim of this study was to evaluate the manometric modifications and the incidence of anal incontinence after fissurectomy and anoplasty with advancement skin flap in patients affected by CAF with hypertonia of the internal anal sphincter (IAS). Fifteen patients affected by CAF with hypertonia of IAS, unresponsive to medical therapy, were enrolled. All subjects underwent fissurectomy and anoplasty with advancement skin flap. Anorectal manometry was performed preoperatively and after 6 and 12 months from surgery. Maximum resting pressure (MRP), maximum squeeze pressure (MSP), ultraslow wave activity (USWA), fissure healing, anal continence, and postoperative complications were recorded. All patients healed within 30 days from surgery. No intra- or postoperative complications were recorded except for a case of partial donor site break. No significant modifications of MSP were detected. Six months after surgery, MRP was higher with respect to healthy subjects but significantly reduced in comparison to baseline levels. At 12 months, it was higher have versus 6-month values but significantly lower versus preoperative values. USWA was significantly represented in patients with CAF versus healthy subject. Both at 6 and 12 months, they decreased significantly with respect to preoperative values without significant differences versus healthy subjects. Both at 6 and 12 months, anal continence did not differ with respect to preoperative time. The fissurectomy with anoplasty resulted in a high healing rate without surgical sequelae or anal incontinence. Also, it was able to reduce IAS pressure in the same manner as surgical sphincterotomy or forceful dilatation.
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Affiliation(s)
- Rosalia Patti
- General Surgery Unit, Department of Surgical and Oncological Sciences, University of Palermo, Palermo, Italy
| | - Valentina Territo
- General Surgery Unit, Department of Surgical and Oncological Sciences, University of Palermo, Palermo, Italy
| | - Paolo Aiello
- General Surgery Unit, Department of Surgical and Oncological Sciences, University of Palermo, Palermo, Italy
| | - Giuseppe Livio Angelo
- General Surgery Unit, Department of Surgical and Oncological Sciences, University of Palermo, Palermo, Italy
| | - Gaetano Di Vita
- General Surgery Unit, Department of Surgical and Oncological Sciences, University of Palermo, Palermo, Italy
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Patti R, Guercio G, Territo V, Aiello P, Angelo GL, Di Vita G. Advancement flap in the management of chronic anal fissure: a prospective study. Updates Surg 2012; 64:101-6. [DOI: 10.1007/s13304-012-0147-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2011] [Accepted: 03/14/2012] [Indexed: 01/14/2023]
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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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Wollina U. Pharmacological sphincterotomy for chronic anal fissures by botulinum toxin a. J Cutan Aesthet Surg 2011; 1:58-63. [PMID: 20300345 PMCID: PMC2840903 DOI: 10.4103/0974-2077.44160] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Chronic anal fissure is a common proctologic disease. Botulinum toxin (BTX) can be used for temporary chemical denervation to treat this painful disorder. Its application is by intramuscular injections into either the external or internal anal sphincter muscle. The mode of action, application techniques, and possible complications or adverse effects of BTX therapy are discussed in this report. The healing rate is dependent on the BTX dosage. The short-term healing rate (</= 6 months) is 60-90%, whereas about 50% of the patients show a complete response in long-term follow-up studies (> 1 year). Adverse effects are generally mild, but relapses occur more often than with surgery. Conservative therapy is currently considered as a first-line treatment. With increasing evidence for its efficacy, BTX can now be considered among the first-line nonsurgical treatements. Although, surgical management by lateral sphincterotomy is the most effective treatment, it shows a higher incidence of incontinence and greater general morbidity rate than BTX. BTX is a useful alternative to surgery and in many cases, surgery can be avoided with the use of BTX.
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Affiliation(s)
- Uwe Wollina
- Department of Dermatology and Allergology, Hospital Dresden-Friedrichstadt, Academic Teaching Hospital of the University of Dresden, Friedrichstrasse 41, Dresden, Germany
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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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Fissurectomy combined with anoplasty and injection of botulinum toxin in treatment of anterior chronic anal fissure with hypertonia of internal anal sphincter: a pilot study. Tech Coloproctol 2010; 14:31-6. [PMID: 20127381 DOI: 10.1007/s10151-009-0562-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Accepted: 12/21/2009] [Indexed: 12/17/2022]
Abstract
BACKGROUND In patients affected by anterior chronic anal fissure (CAAF) with hypertonia of the internal anal sphincter (IAS), the role of IAS hypertonia remains unclear. The aim of this study was to evaluate the efficacy of fissurectomy combined with advancement flap and IAS injection of botulinum toxin in healing the CAAF with hypertonia of IAS resistant to medical therapy. METHODS Ten consecutive patients were enrolled. Anorectal manometry was performed preoperatively and at 6 months. CAAF with hypertonia was defined as those associated with maximum resting pressure (MRP) values higher than 85 mmHg. All patients underwent fissurectomy and anoplasty with advancement skin flap combined with the intrasphincter injection of 30 UI of botulinum toxin. Complete healing, MRP changes, relief of symptoms and immediate and long-term complications were recorded. RESULTS Complete healing was observed in all patients within 30 days of the operation. The intensity and duration of pain post-defecation was reduced significantly starting from the first defecation. In all subjects, the preoperative MRP values were significantly reduced at 6 months. One month after surgery, three patients reported anal incontinence, two of them had complained preoperatively. The only postoperative complications were minor. CONCLUSIONS Fissurectomy combined with advancement flap and intrasphincter injection of botulinum toxin results in complete healing, significant MRP reduction and full relief of symptom in all patients, thus it represents a valid procedure in preventing the occurrence of anal incontinence.
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Aivaz O, Rayhanabad J, Nguyen V, Haigh PI, Abbas M. Botulinum Toxin A with Fissurectomy is a Viable Alternative to Lateral Internal Sphincterotomy for Chronic Anal Fissure. Am Surg 2009. [DOI: 10.1177/000313480907501013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Lateral internal sphincterotomy (LIS) is the gold standard surgical treatment for anal fissure. However, it carries potential complications, including fecal incontinence. The goal of this retrospective study was to compare the outcome of botulinum toxin A injection coupled with fissurectomy ([BTX + FIS) versus LIS. There were 59 patients who underwent BTX + FIS or LIS over a 5-year period. LIS was performed in the standard fashion without fissurectomy. BTX + FIS entailed internal sphincter injection with 80 units of botulinum toxin A coupled with fissurectomy. Forty patients underwent LIS and 19 had BTX + FIS. The choice of operation was based on the patient's preference. Primary healing rate was 90 and 74 per cent in the LIS and BTX + FIS groups, respectively ( P = 0.13). The complication rate was 10 per cent in the LIS vs 0 per cent in the BTX + FIS groups ( P = 0.29). Complications of LIS included anal sepsis in one patient and flatal and/or fecal incontinence in three patients. During a mean follow up of 19 months; recurrence rate was 0 and 5 per cent in the LIS and BTX+FIS groups, respectively ( P = 0.32). The results of this study demonstrate that BTX + FIS is a viable alternative to LIS for patients with chronic anal fissure and should be considered as an alternative first-line surgical therapy.
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Affiliation(s)
- Ohara Aivaz
- From Department of Surgery, Kaiser Permanente, Los Angeles, California
| | | | - Vincent Nguyen
- From Department of Surgery, Kaiser Permanente, Los Angeles, California
| | - Philip I. Haigh
- From Department of Surgery, Kaiser Permanente, Los Angeles, California
| | - Maher Abbas
- From Department of Surgery, Kaiser Permanente, Los Angeles, California
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Abstract
BACKGROUND AND AIMS The lack of consensus on how to define and grade adverse postoperative events has greatly hampered the evaluation of surgical procedures. A new classification of complications, initiated in 1992, was updated 5 years ago. It is based on the type of therapy needed to correct the complication. The principle of the classification was to be simple, reproducible, flexible, and applicable irrespective of the cultural background. The aim of the current study was to critically evaluate this classification from the perspective of its use in the literature, by assessing interobserver variability in grading complex complication scenarios and to correlate the classification grades with patients', nurses', and doctors' perception. MATERIAL AND METHODS Reports from the literature using the classification system were systematically analyzed. Next, 11 scenarios illustrating difficult cases were prepared to develop a consensus on how to rank the various complications. Third, 7 centers from different continents, having routinely used the classification, independently assessed the 11 scenarios. An agreement analysis was performed to test the accuracy and reliability of the classification. Finally, the perception of the severity was tested in patients, nurses, and physicians by presenting 30 scenarios, each illustrating a specific grade of complication. RESULTS We noted a dramatic increase in the use of the classification in many fields of surgery. About half of the studies used the contracted form, whereas the rest used the full range of grading. Two-thirds of the publications avoided subjective terms such as minor or major complications. The study of 11 difficult cases among various centers revealed a high degree of agreement in identifying and ranking complications (89% agreement), and enabled a better definition of unclear situations. Each grade of complications significantly correlated with the perception by patients, nurses, and physicians (P < 0.05, Kruskal-Wallis test). CONCLUSIONS This 5-year evaluation provides strong evidence that the classification is valid and applicable worldwide in many fields of surgery. No modification in the general principle of classification is warranted in view of the use in ongoing publications and trials. Subjective, inaccurate, or confusing terms such as "minor or major" should be removed from the surgical literature.
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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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31
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Sinha D, Thomson AJ. Botulinum toxin for pelvic pain in women. WOMEN'S HEALTH (LONDON, ENGLAND) 2008; 4:173-81. [PMID: 19072519 DOI: 10.2217/17455057.4.2.173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Pelvic pain is a common disorder in women, causing significant morbidity. Often the etiology is not clear as it results from a complex interaction between neurologic, musculoskeletal and endocrine systems that is further influenced by behavioral and psychological factors. A comprehensive approach to the problem requires recognition of the multiple organ systems that may be involved. A thorough history and physical examination, followed by selected laboratory and imaging studies, is essential in evaluation of these patients. Medical and surgical management improves or controls the symptoms in the majority of cases, but there remains a group of women who are difficult to treat. Botulinum toxin is a presynaptic neuromuscular blocking agent inducing selective and reversible muscle weakness that lasts several months when injected intramuscularly. It has been shown to be effective in treating pain caused by muscular spasm in conditions other than pelvic pain caused by muscular hypertonicity. Evidence or literature related to treatment of pelvic pain with botulinum toxin is discussed in this review.
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Affiliation(s)
- Deepali Sinha
- Worcestershire Royal Hospital, Charles Hastings Way, Worcester WR51DD, UK.
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32
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Lestár B. [New trends in coloproctology]. Magy Seb 2008; 61:352-358. [PMID: 19073491 DOI: 10.1556/maseb.61.2008.6.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Béla Lestár
- Ceglédi Városi Kórház Sebészeti Osztály Cegléd
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33
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A pilot comparative study of fissurectomy/diltiazem and fissurectomy/botulinum toxin in the treatment of chronic anal fissure. Tech Coloproctol 2008; 12:331-6; discussion 336. [PMID: 19018466 DOI: 10.1007/s10151-008-0444-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2008] [Accepted: 09/15/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND Treatment of chronic anal fissure (CAF) by fissurectomy with botulinum toxin A (BTA) injection results in a healing rate of greater than 90%. BTA injection, however, can cause incontinence and perianal sepsis. The decrease in sphincter pressure following topical treatment with 2% diltiazem cream (DTC) is comparable to that following BTA injection but with potentially fewer complications and at less cost. We report the shortterm results of a pilot study comparing fissurectomy with BTA and fissurectomy followed by DTC for the treatment of CAF. METHODS The recorded outcomes of CAF following treatment with the two methods were analysed retrospectively. Patients underwent either fissurectomy followed by injection of 40 U BTA into the internal sphincter (group A) or fissurectomy followed by the perianal application of DTC twice daily for 8 weeks (group B). Symptom resolution and treatment side effects at the initial follow-up were compared. RESULTS Demographics, fissure characteristics and the number of multiparous women between the two groups were comparable. At a median follow-up of 12 weeks (range 8-20 weeks), the two groups had similar rates of complete symptom resolution (group A, 25/28, 89.3%; group B, 19/23, 82.6%; p=0.7739), with minor side effects. CONCLUSIONS In this small pilot study fissurectomy combined with chemical sphincterotomy resulted in high short-term fissure healing rates. The study also suggested that fissurectomy followed by 8 weeks of topical DTC may be as good as fissurectomy with BTA injection in the treatment of CAF. A prospective study, adequately powered to determine the significance of differences is needed.
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Ommer A, Wenger FA, Rolfs T, Walz MK. Continence disorders after anal surgery--a relevant problem? Int J Colorectal Dis 2008; 23:1023-31. [PMID: 18629515 DOI: 10.1007/s00384-008-0524-y] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2008] [Indexed: 02/04/2023]
Abstract
SUBJECT Anal incontinence is a well-known and feared complication following surgery involving the anal sphincter, particularly if partial transection of the sphincter is part of the surgical procedure. METHODS The literature was reviewed to evaluate the risk of postoperative incontinence following anal dilatation, lateral sphincterotomy, surgery for haemorrhoidal disease and anal fistula. RESULTS Various degrees of anal incontinence are reported with frequencies as follows: anal dilatation 0-50%, lateral sphincterotomy 0-45%, haemorrhoidal surgery 0-28%, lay open technique of anal fistula 0-64% and plastic repair of fistula 0-43%. Results vary considerably depending on what definition of "incontinence" was applied. The most important risk factors for postoperative incontinence are female sex, advanced age, previous anorectal interventions, childbirth and type of anal surgery (sphincter division). Sphincter lesions have been reported following procedures as minimal as exploration of the anal canal via speculum. CONCLUSIONS Continence disorders after anal surgery are not uncommon and the result of the additive effect of various factors. Certain risk factors should be considered before choosing the operative procedure. Since options for surgical repair of postoperative incontinence disorders are limited, careful indications and minimal trauma to the anal sphincter are mandatory in anal surgery.
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Affiliation(s)
- A Ommer
- Kliniken Essen-Mitte, Clinic of Surgery and Center of Minimal Invasive Surgery, Henricistrasse 92, 45136 Essen, Germany.
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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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36
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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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