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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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Skoufou M, Lefèvre JH, Fels A, Fathallah N, Benfredj P, de Parades V. Fissurectomy with mucosal advancement flap anoplasty: The end of a dogma? J Visc Surg 2023; 160:330-336. [PMID: 36973105 DOI: 10.1016/j.jviscsurg.2023.03.003] [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: 03/29/2023]
Abstract
INTRODUCTION The goal was to compare fissurectomy with mucosal advancement flap anoplasty to fissurectomy alone in the surgical treatment of anal fissure. PATIENTS AND METHODS This study included patients who underwent surgery in 2019 for solitary, idiopathic, non-infected, posterior anal fissure, after failure of medical treatment. The choice to perform advancement flap anoplasty was based on surgeon preference and did not depend on the fissure itself. The main endpoint was the time to relief of pain. RESULTS Of 599 fissurectomies performed during the study period, 226 patients (37.6% women, mean age 41.7±12.0 years old) underwent fissurectomy alone (n=182) or associated with advancement flap anoplasty (n=44). The two groups differed as to their sex ratio (33.5 vs. 54.5% women, P=0.01), body mass index (25.3±4.0 vs. 23.6±3.9, P=0.013) and Bristol score (3.2 vs. 3.4, P=0.038). Time to relief of pain, time to disappearance of bleeding and time to healing were 1.1 (0.5-2.3), 1.0 (0.5-2.1) and 2.0 (1.1-3.6) months, respectively. The rate of healing was 93.8% and the complication rate was 6.2%. The differences between the two groups for these outcomes were not statistically significant. The risk factors associated with absence of healing were age ≥ 40 years (Odds ratio (OR): 3.84; 95% CI, 1.12-17.68) and pre-surgical duration of fissure<35.6 weeks (OR: 6.54; 95% CI: 1.69-43.21). CONCLUSION Mucosal advancement flap anoplasty does not provide any added value to fissurectomy alone.
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Affiliation(s)
- M Skoufou
- Medical and Surgical Proctology Department, Saint-Joseph Hospital Group, 75014 Paris, France.
| | - J H Lefèvre
- Department of Digestive Surgery, Sorbonne University, Saint-Antoine Hospital, AP-HP, 75012 Paris, France
| | - A Fels
- Clinical Research Department, Saint-Joseph Hospital Group, 75014 Paris, France
| | - N Fathallah
- Medical and Surgical Proctology Department, Saint-Joseph Hospital Group, 75014 Paris, France
| | - P Benfredj
- Medical and Surgical Proctology Department, Saint-Joseph Hospital Group, 75014 Paris, France
| | - V de Parades
- Medical and Surgical Proctology Department, Saint-Joseph Hospital Group, 75014 Paris, France
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Najafi MS, Kazemeini A, Meshkati Yazd SM, Dashtkuhi M, Ahmadi Tafti SM, Behboudi B, Fazeli MS, Keshvari A, Keramati MR. Mucosal vs. cutaneous advancement flaps for the treatment of chronic anal fissures: a randomized clinical trial. Tech Coloproctol 2023; 27:891-896. [PMID: 37154993 DOI: 10.1007/s10151-023-02810-5] [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] [Received: 12/30/2022] [Accepted: 04/24/2023] [Indexed: 05/10/2023]
Abstract
PURPOSE The aim of this study was to compare two surgical treatment methods for chronic anal fissures (CAF), mucosal advancement flap anoplasty (MAFA) and cutaneous advancement flap anoplasty (CAFA). METHODS A randomized, blinded clinical trial was conducted on patients with CAF refractory to medical treatment referred to a tertiary-level hospital between January 2021 and December 2022. The patients were assigned to two groups by block randomization and were compared in terms of outcome, pain reduction, and complications. RESULTS There were 30 patients (male to female ratio 2:3, median age 42 years [range 25-59 years]). Both techniques reduced anal pain significantly (p = 0.001); however, there were no significant differences between MAFA and CAFA groups in recurrence, duration of healing, postoperative pain, and postoperative bleeding. No patient suffered from fecal incontinence (Wexner score = 0) or flap necrosis postoperatively. Only two patients in the MAFA group (1 and 3 months after surgery) and one patient in the CAFA group (2 months after surgery) had recurrence (total recurrence rate = 10%, healing rate = 90%). All of the patients were satisfied with their surgical results. CONCLUSION Mucosal and cutaneous anal advancement flap techniques are effective and comparable surgical procedures for the treatment of chronic anal fissures with minimal complications, fast healing process, and minimal postoperative pain and complications. CLINICAL TRIAL ID IRCT20120129008861N4 ( www.irct.ir ).
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Affiliation(s)
- M S Najafi
- Division of Colorectal Surgery, Department of Surgery, Imam-Khomeini Hospital Complex, Tehran University of Medical Sciences, Keshavarz Blvd, Tehran, 1419733141, Iran
- Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - A Kazemeini
- Division of Colorectal Surgery, Department of Surgery, Imam-Khomeini Hospital Complex, Tehran University of Medical Sciences, Keshavarz Blvd, Tehran, 1419733141, Iran
- Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - S M Meshkati Yazd
- Division of Colorectal Surgery, Department of Surgery, Imam-Khomeini Hospital Complex, Tehran University of Medical Sciences, Keshavarz Blvd, Tehran, 1419733141, Iran
- Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - M Dashtkuhi
- Division of Colorectal Surgery, Department of Surgery, Imam-Khomeini Hospital Complex, Tehran University of Medical Sciences, Keshavarz Blvd, Tehran, 1419733141, Iran
- Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - S M Ahmadi Tafti
- Division of Colorectal Surgery, Department of Surgery, Imam-Khomeini Hospital Complex, Tehran University of Medical Sciences, Keshavarz Blvd, Tehran, 1419733141, Iran
- Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - B Behboudi
- Division of Colorectal Surgery, Department of Surgery, Imam-Khomeini Hospital Complex, Tehran University of Medical Sciences, Keshavarz Blvd, Tehran, 1419733141, Iran
- Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - M S Fazeli
- Division of Colorectal Surgery, Department of Surgery, Imam-Khomeini Hospital Complex, Tehran University of Medical Sciences, Keshavarz Blvd, Tehran, 1419733141, Iran
- Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - A Keshvari
- Division of Colorectal Surgery, Department of Surgery, Imam-Khomeini Hospital Complex, Tehran University of Medical Sciences, Keshavarz Blvd, Tehran, 1419733141, Iran
- Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - M R Keramati
- Division of Colorectal Surgery, Department of Surgery, Imam-Khomeini Hospital Complex, Tehran University of Medical Sciences, Keshavarz Blvd, Tehran, 1419733141, Iran.
- Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran.
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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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D'Orazio B, Geraci G, Bonventre S, Calì D, Di Vita G. Safety and effectiveness of saving sphincter procedure in the treatment of chronic anal fissure in female patients. BMC Surg 2021; 21:350. [PMID: 34560857 PMCID: PMC8461903 DOI: 10.1186/s12893-021-01346-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 09/13/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Lateral internal sphincterotomy (LIS) is still the approach of choice for the treatment of chronic anal fissure (CAF) regardless to the internal anal sphincter tone but it is burdened by high risk post-operative faecal incontinence (FI). In female patient there are some anatomical and functional differences of the sphinteric system which make them more at risk of FI and vaginal birth could cause sphinteric lesions affecting the anal continence function. The aim of our study is to evaluate the results of saving sphincter procedure as treatment for female patients affected by CAF. METHODS We studied 110 female patients affected by CAF undergone fissurectomy and anoplasty with V-Y cutaneous flap advancement associating pharmacological sphincterotomy in patients with hypertonic IAS. The follow up was at least for 2 years. The goals were patient's complete healing, the evaluation of FI, recurrence rate and manometry parameters. RESULTS All wounds healed within 40 days after surgery. We recorded 8 cases of recurrences 6 healed with medical therapy and 2 with dilatation. We recorded 2 "de novo" temporary and low grade post-operative cases of FI. Post-operative value of MRP were unmodified in patient with normotonic IAS but significantly lower at 12 months follow up as compared with the pre-operative ones in patients with hypertonic IAS; after 24 months from surgery MRP values were within the normal range. CONCLUSION The fissurectomy and anoplasty with V-Y cutaneous flap alone or in association with a pharmacological sphincterotomy in patients with hypertonic IAS may represent an effective approach for the treatment of CAF in female patients.
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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
| | - Girolamo Geraci
- General Surgery Unit, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Via Liborio Giuffrè, 5, 90127, Palermo, Italy
| | - Sebastiano Bonventre
- General Surgery Unit, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Via Liborio Giuffrè, 5, 90127, Palermo, Italy
| | - Dario Calì
- 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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6
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Hancke E, Suchan K, Voelke K. Anocutaneous advancement flap provides a quicker cure than fissurectomy in surgical treatment for chronic anal fissure-a retrospective, observational study. Langenbecks Arch Surg 2021; 406:2861-2867. [PMID: 34159437 PMCID: PMC8803790 DOI: 10.1007/s00423-021-02227-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 06/01/2021] [Indexed: 11/27/2022]
Abstract
Purpose Anocutaneous advancement flap is a surgical procedure for the treatment of chronic anal fissures. This study aimed to assess the results of anocutaneous advancement flap in a consecutive cohort of patients. Methods This is a retrospective, observational study. From 2000 to 2011, 481 patients had been operated for a single chronic anal fissure at the Maingau Clinic of the German Red Cross in Frankfurt am Main. The intention was to excise the fissure by fissurectomy (FIS) and then to cover the wound primarily with an anocutaneous advancement flap (AAF). The primary outcomes were resolution of symptoms and healing rates 1 month postoperatively. Secondary outcomes included incidences of early and late complications, postoperative incontinence, and recurrent fissure. Results Anocutaneous advancement flap was performed in 455 (94.6%). In 26 (5.4%) patients, AAF failed due to lacking skin and the wound left open after FIS. One month postoperatively, half of the patients with AAF were free of symptoms (53.2%) with complete wound healing (47.9%). The incidence of early complications within 1 month postoperatively was 0.9% after AAF. From 1 month to 5 years after operation anal abscesses and fistula occurred in 2.9%. Mild symptoms of anal incontinence were recorded in 0.2% and recurrent chronic anal fissure in 3.3% of patients. Subgroup analysis revealed improved wound healing 1 month postoperatively in patients with AAF compared to FIS. Conclusion Anocutaneous advancement flap is a very safe sphincter-sparing surgical option for CAF, provides a quicker cure than fissurectomy, and may be considered a good first-line surgical treatment option for chronic anal fissures if medical treatment failed.
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Affiliation(s)
- Edgar Hancke
- Sektion Proktologie, Klinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Ketteler Krankenhaus Offenbach, Lichtenplattenweg 85, D-63071, Offenbach am Main, Germany. .,Centrum Coloproctologie, Klinik Maingau Vom Roten Kreuz, Eschenheimer Anlage 7, 60316, Frankfurt am Main, Germany.
| | - Katrin Suchan
- Centrum Coloproctologie, Klinik Maingau Vom Roten Kreuz, Eschenheimer Anlage 7, 60316, Frankfurt am Main, Germany
| | - Knut Voelke
- Centrum Coloproctologie, Klinik Maingau Vom Roten Kreuz, Eschenheimer Anlage 7, 60316, Frankfurt am Main, Germany
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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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8
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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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Hancke E. Sphinkterschonende operative Therapie der chronischen Analfissur durch primäre plastische Deckung. COLOPROCTOLOGY 2020. [DOI: 10.1007/s00053-020-00459-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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10
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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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Hancke E, Suchan K, Völke K. Anokutaner Advancement-Flap zur sphinkterschonenden chirurgischen Therapie der chronischen Analfissur. COLOPROCTOLOGY 2020. [DOI: 10.1007/s00053-020-00449-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Ulyanov AA, Solomka AY, Achkasov EE, Antipova EV, Kuznetsova EV. [Chronic anal fissure: etiopathogenesis, diagnosis, treatment]. Khirurgiia (Mosk) 2018:89-95. [PMID: 30531762 DOI: 10.17116/hirurgia201811189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Etiology, epidemiology and pathophysiology of anal fissure are examined in the article in order to determine the most optimal treatment strategy. The authors concluded that the most effective treatment is combined approach using both minimally invasive surgery and various medicines for anal spasm reduction.
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Affiliation(s)
- A A Ulyanov
- Central Literary Fund Clinic, Moscow, Russia
| | - A Ya Solomka
- Municipal Clinical Hospital #24 of Moscow Healthcare Department, Moscow, Russia
| | - E E Achkasov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - E V Antipova
- Municipal Clinical Hospital #24 of Moscow Healthcare Department, Moscow, Russia
| | - E V Kuznetsova
- Municipal Clinical Hospital #24 of Moscow Healthcare Department, Moscow, Russia
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13
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Arroyo A, Montes E, Calderón T, Blesa I, Elía M, Salgado G, García-Armengol J, de-la-Portilla F. Treatment algorithm for anal fissure. Consensus document of the Spanish Association of Coloproctology and the Coloproctology Division of the Spanish Association of Surgeons. Cir Esp 2018. [PMID: 29525120 DOI: 10.1016/j.ciresp.2018.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The Spanish Association of Coloproctology and the Coloproctology Division of the Spanish Association of Surgeons propose this consensus document with a treatment algorithm for anal fissure that could be used for decision making. Non-surgical therapy and surgical treatment of anal fissure are explained, and the recommended algorithm is provided. The methodology used was: creation of a group of experts; search in PubMed, MEDLINE and the Cochrane Library for publications from the last 10 years about anal fissure; presentation at the 21st National Meeting of the Spanish Association of Coloproctology Foundation 2017 with voting for/against each conclusion by the attendees and review by the scientific committee of the Spanish Association of Coloproctology.
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Affiliation(s)
- Antonio Arroyo
- Servicio de Cirugía General y Aparato Digestivo, Hospital General Universitario, Elche, Alicante, España.
| | - Elisa Montes
- Servicio de Cirugía General y Aparato Digestivo, Hospital de Jerez, Jerez de la Frontera, Cádiz, España
| | - Teresa Calderón
- Servicio de Cirugía General y Aparato Digestivo, Hospital Nuestra Señora del Prado, Talavera de la Reina, Toledo, España
| | - Isabel Blesa
- Servicio de Cirugía General y Aparato Digestivo, Complejo Hospitalario Torrecárdenas, Almería, España
| | - Manuela Elía
- Servicio de Cirugía General y Digestiva, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - Gervasio Salgado
- Sección de Cirugía Colorrectal, Hospital Santa Elena, Málaga, España
| | - Juan García-Armengol
- Servicio de Cirugía General y Aparato Digestivo, Hospital Nisa 9 de Octubre, Valencia, España
| | - Fernando de-la-Portilla
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Virgen del Rocío, Sevilla, España
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Sahebally SM, Walsh SR, Mahmood W, Aherne TM, Joyce MR. Anal advancement flap versus lateral internal sphincterotomy for chronic anal fissure- a systematic review and meta-analysis. Int J Surg 2017; 49:16-21. [PMID: 29233787 DOI: 10.1016/j.ijsu.2017.12.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/17/2017] [Accepted: 12/01/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Chronic anal fissures (CAF) are common and associated with reduced quality of life. Lateral internal sphincterotomy (LIS) is frequently carried out but carries a significant risk of anal incontinence. Anal advancement flap (AAF) has been advocated as an alternative, 'sphincter-preserving' procedure. We aimed to perform a systematic review and meta-analysis to compare the efficacy of both techniques in the treatment of CAF. METHODS The online databases of PubMed/Medline, CINAHL, EMBASE and Cochrane Central Register of Controlled Trials were searched from inception to January 2017. All studies that investigated and reported outcomes of LIS and AAF for treatment of CAF were included. The primary outcome measure was anal incontinence while secondary outcomes included unhealed fissure and wound complication rates. Random effects models were used to calculate pooled effect size estimates. RESULTS Four studies (2 randomized controlled trials and 2 retrospective studies) describing 300 patients (150 LIS, 150 AAF) fulfilled our inclusion criteria. There was significant clinical heterogeneity among the trials. On random effects analysis, AAF was associated with a significantly lower rate of anal incontinence compared to LIS (OR = 0.06, 95% CI = 0.01 to 0.36, p = .002). However, there were no statistically significant differences in unhealed fissure (OR = 2.21, 95% CI = 0.25 to 19.33, p = .47) or wound complication rates (OR = 1.41, 95% CI = 0.50 to 4.99 p = .51) between AAF and LIS. CONCLUSIONS AAF is associated with less incontinence, but similar wound complications as well as a similar rate of unhealed fissures compared to LIS. However, further well-executed, multi-centre randomized trials are required to provide stronger evidence.
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Affiliation(s)
- Shaheel Mohammad Sahebally
- Discipline of Surgery, Lambe Institute, National University of Ireland, Galway, Ireland; Department of Colorectal Surgery, University Hospital Galway, Galway, Ireland.
| | - Stewart Redmond Walsh
- Discipline of Surgery, Lambe Institute, National University of Ireland, Galway, Ireland
| | - Waqas Mahmood
- Discipline of Surgery, Lambe Institute, National University of Ireland, Galway, Ireland
| | - Thomas Michael Aherne
- Discipline of Surgery, Lambe Institute, National University of Ireland, Galway, Ireland
| | - Myles Richard Joyce
- Department of Colorectal Surgery, University Hospital Galway, Galway, Ireland
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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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Theodoropoulos GE, Spiropoulos V, Bramis K, Plastiras A, Zografos G. Dermal Flap Advancement Combined with Conservative Sphincterotomy in the Treatment of Chronic Anal Fissure. Am Surg 2015. [DOI: 10.1177/000313481508100224] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Lateral internal sphincterotomy (LIS) is considered the surgical treatment of choice for chronic anal fissure (CAF). Flap techniques for fissure coverage have the advantage of primary wound healing, potentially providing better functional results and faster pain relief. The standard surgical strategy for CAF consisting of conventional LIS (CLIS) up tothe dentate line was modified by “tailoring” the LIS to the apex of the CAF, but never greater than 1 cm, and by advancing a dermal flap for coverage of the CAF (LIS + flap) after fissurectomy. Thirty consecutive patients who underwent “LIS + flap” were compared with 32 patients who had been previously treated by CLIS. A modified, trapezoidlike Y-V flap from perianal skin was advanced into the CAF base. Pain at the first postoperative day, pain at defecation during the first week, postoperative use of analgesics, and time for patients’ pain relief were significantly less at the “LIS + flap” group ( P < 0.01). Objective healing was achieved faster ( P < 0.01) and soiling episodes were less ( P < 0.05) after “LIS + flap.” The addition of a dermal flap after “conservative” LIS resulted in better healing and significantly less postoperative discomfort than the isolated application of CLIS.
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Affiliation(s)
- George E. Theodoropoulos
- Colorectal and Inflammatory Bowel Diseases Unit, First Department of Propaedeutic Surgery of Athens Medical School, Athens, Greece
| | - Vasileios Spiropoulos
- Colorectal and Inflammatory Bowel Diseases Unit, First Department of Propaedeutic Surgery of Athens Medical School, Athens, Greece
| | - Konstantinos Bramis
- Colorectal and Inflammatory Bowel Diseases Unit, First Department of Propaedeutic Surgery of Athens Medical School, Athens, Greece
| | - Aris Plastiras
- Colorectal and Inflammatory Bowel Diseases Unit, First Department of Propaedeutic Surgery of Athens Medical School, Athens, Greece
| | - George Zografos
- Colorectal and Inflammatory Bowel Diseases Unit, First Department of Propaedeutic Surgery of Athens Medical School, Athens, Greece
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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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Magdy A, El Nakeeb A, Fouda EY, Youssef M, Farid M. Comparative study of conventional lateral internal sphincterotomy, V-Y anoplasty, and tailored lateral internal sphincterotomy with V-Y anoplasty in the treatment of chronic anal fissure. J Gastrointest Surg 2012; 16:1955-62. [PMID: 22869534 DOI: 10.1007/s11605-012-1984-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 07/24/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Lateral internal sphincterotomy has been proven highly effective in curing anal fissure but with a high incidence of postoperative incontinence. OBJECTIVE We compared conventional lateral internal sphincterotomy, V-Y advancement flap, and combined tailored lateral internal sphincterotomy with V-Y advancement flap in treating anal fissure. PATIENTS Consecutive patients treated for anal fissure at our colorectal unit were evaluated for inclusion. Participants were randomly allocated to receive conventional sphincterotomy (GI), V-Y advancement flap (GII), or combined tailored lateral sphincterotomy with V-Y advancement l flap (GIII). MAIN OUTCOME MEASURES The primary outcome measure was the incontinence rate; secondary outcomes included healing rate, operative time, anal manometery, and recurrence rate. RESULTS One hundred fifty patients with chronic anal fissure were randomized. Healing rate after 1 year was 84% in GI, 48% in GII, and 94% in GIII, respectively (P = 0.001). The recurrence rate was 4% in G1, 22% in GII, and 2% in GIII (P = 0.01). Incontinence rate was 14% in GI, 0% in GII, and 2% in GIII (P = 0.03). CONCLUSION Although all three procedures are simple and easy to perform, tailored lateral internal sphincterotomy with V-YF appears to produce the greatest healing rate, with the fewest complications and less rate of recurrence.
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Affiliation(s)
- Alaa Magdy
- Mansoura University Hospital, Mansoura, Egypt
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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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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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Pescatori M. Anal Fissure. PREVENTION AND TREATMENT OF COMPLICATIONS IN PROCTOLOGICAL SURGERY 2012:1-14. [DOI: 10.1007/978-88-470-2077-1_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Medium-term results of anal advancement flap compared with lateral sphincterotomy for the treatment of anal fissure. Int J Colorectal Dis 2011; 26:1211-4. [PMID: 21562745 DOI: 10.1007/s00384-011-1234-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2011] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Anal fissure is associated with anal pain and bleeding. Lateral internal sphincterotomy (LIS) has been a common form of surgical management. This can however cause incontinence and hence an equally effective alternative without this risk would be ideal. Anal fissurectomy and an anal advancement flap (AAF) have been used as an alternative to LIS. METHODS We carried out a retrospective analysis of the results of AAF and LIS for the treatment of anal fissure. Fifty patients underwent AAF and a further 50 cases were chosen who had undergone LIS over the same time period. Patient and procedural data were collected including post-operative course. RESULTS Presenting symptoms included anal pain (94%), rectal bleeding (77%) and constipation (15%). Mean (±SD) follow-up was 20 ± 12 months in the AAF group vs 22 ± 12.5 months in the LIS group. Healing of fissure was achieved in 96% of patients after AAF and 88% after LIS (p = 0.27). Resolution of symptoms was achieved in 90% after AAF and 72% of patients after LIS (p = 0.04). LIS was associated with an increased incidence of readmission with infection and pain (8% vs 4%, p = 0.35). Seven patients whom had undergone successful AAF with complete resolution of symptoms had previously had LIS with failure of symptom relief. There was no incidence of faecal incontinence in either group. CONCLUSION AAF is associated with a higher incidence of symptomatic relief and fissure healing and lower incidence of complications when compared with LIS. AAF is effective at healing fissures which are refractory to LIS.
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Mucosal Advancement Flap Anoplasty for Chronic Anal Fissure Resistant to Conservative Therapy. World J Surg 2011; 35:900-4. [DOI: 10.1007/s00268-011-0959-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pescatori M. Ragade anale. PREVENZIONE E TRATTAMENTO DELLE COMPLICANZE IN CHIRURGIA PROCTOLOGICA 2011:1-14. [DOI: 10.1007/978-88-470-2062-7_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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