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Riboni C, Selvaggi L, Cantarella F, Podda M, Bracchitta S, Mosca V, Cosenza A, Cosenza V, Selvaggi F, Nardo B, Pata F. Anal Fissure and Its Treatments: A Historical Review. J Clin Med 2024; 13:3930. [PMID: 38999495 PMCID: PMC11242537 DOI: 10.3390/jcm13133930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/25/2024] [Accepted: 06/29/2024] [Indexed: 07/14/2024] Open
Abstract
Anal fissure is one of the most common proctological pathologies. It consists of the formation of a longitudinal tear in the anoderm, causing pain and bleeding during and after defecation. When chronic, it can significantly negatively impact the quality of life of the affected patient. Currently, multiple therapeutic options are available, both medical and surgical. The objective of this article is to highlight the historical evolution in the physiopathological understanding and treatment of this disease, underlining the key moments in this history. This is the first article to summarize the milestones in the treatment of anal fissure from ancient to current times.
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Affiliation(s)
- Cristiana Riboni
- Department of Pediatric Surgery, UKBB (Universitäts-Kinderspital beider Basel), Spitalstrasse 33, 4031 Basel, Switzerland
| | - Lucio Selvaggi
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Francesco Cantarella
- CPEP (Centre for Proctology and Perineology), Ospedali Privati Forlì, 47121 Forlì, Italy
| | - Mauro Podda
- Department of Surgical Science, Università degli Studi di Cagliari, 09042 Cagliari, Italy
| | | | - Vinicio Mosca
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Angelo Cosenza
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Vincenzo Cosenza
- Plastic and Reconstructive Surgery Unit, Multidisciplinary Department of Medical-Surgical and Dental Specialties, Università degli Studi della Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Francesco Selvaggi
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Bruno Nardo
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, 87036 Rende, Italy
- A.O. Annunziata, 87100 Cosenza, Italy
| | - Francesco Pata
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, 87036 Rende, Italy
- A.O. Annunziata, 87100 Cosenza, Italy
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Ascanelli S, Rossin E, Aisoni F, Sette E, Chimisso L, Valpiani G, Costanzini A, DE Giorgio R, Feo CV. Botulinum toxin injection for chronic anal fissure: a prospective controlled study with long follow-up. Minerva Surg 2024; 79:293-302. [PMID: 38551598 DOI: 10.23736/s2724-5691.24.10228-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2024]
Abstract
BACKGROUND Botulinum toxin is an effective therapeutic option for chronic anal fissure. However, there is no evidence about treatment standardization and long-term follow-up. We aimed to evaluate the short- and long-term efficacy and safety of botulinum toxin compared to close lateral internal sphincterotomy, with a 5-year follow-up. METHODS This was a prospective, controlled, single-center study conducted at University Hospital of Ferrara, Ferrara, Italy. The primary outcome was fissure healing at 1 month. Secondary outcomes were Quality-of-Life (QoL) at 1 month and after 5 years, and fissure recurrence at 6 months and 5 years. RESULTS A total of 59 patients received botulinum toxin injection (Botox), and 32 underwent lateral internal sphincterotomy. At 1 month after treatments, postoperative pain decreased faster and significantly more in the Botox group (30 vs. 60 mm; P<0.001); fissure re-epithelization was observed in 59.4% of the surgical group compared to 25.4% of Botox (P=0.0001). Anal sphincter pressures decreased more in surgical group (P=0.044), although severe anal incontinence was present only in this subset (6.2%; P=0.041). Compared to surgery, patients who received Botox had higher satisfaction rates (P<0.001). Fissure recurrence at 6 months was more common in Botox than surgical group (16.9% vs. 3.2%, respectively; P=0.053). The overall healing rate improved in all patients and persisted at 12 months and 5 years in both groups with overall high patient satisfaction despite mild anal incontinence in 21.8% in the surgery group (P<0.05). CONCLUSIONS Botox, rather than surgery, should be considered the first-line treatment for chronic anal fissure.
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Affiliation(s)
- Simona Ascanelli
- Section of General Surgery, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Eleonora Rossin
- Section of General Surgery, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Filippo Aisoni
- Section of General Surgery, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Elisabetta Sette
- Unit of Neurology, Department of Neuroscience Rehabilitation, University Hospital Ferrara, Ferrara, Italy
| | - Laura Chimisso
- Section of General Surgery, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Giorgia Valpiani
- Accreditation Office Quality Research Innovation, University Hospital Ferrara, Ferrara, Italy
| | - Anna Costanzini
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Roberto DE Giorgio
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Carlo V Feo
- Section of General Surgery, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
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Dokcu Ş, Başçeken Sİ. Botulinum toxin injection in outpatients for chronic anal fissure. Acta Chir Belg 2024; 124:131-136. [PMID: 37440688 DOI: 10.1080/00015458.2023.2234179] [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: 07/17/2022] [Accepted: 07/04/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVES The aim of the study was to evaluate the effect of botulinum toxin (BT) injection on fissure healing in the treatment of chronic anal fissure (CAF) in outpatient conditions without any analgesia and sedation to the internal anal sphincter (IAS). The primary outcome measure was post-procedural pain. The secondary outcome measures were fissure healing and complications. METHODS Prospectively preserved data of 67 patients who received BT injections for CAF were analyzed prospectively. Demographic data, duration of symptomatic improvement, fissure location and number, parity, post-procedural pain, complications, continence status, response to treatment, and duration of follow-up were examined. Participants received bilateral (50 + 50 units) BT injections into the internal anal sphincter (IAS) in an outpatient setting. RESULTS Symptomatic improvement was observed in 58% of patients within 1 week. The complete response rate to treatment was 82% at a mean follow-up of 6 months. Patients with partial response to treatment (10%) were successfully treated with topical therapy, and patients with persisting fissures (8%) were successfully treated with partial lateral internal sphincterotomy (LIS). 14 patients (21%) reported some degree of transient incontinence at follow-up. Multiparous women experienced more symptoms of Incontinence (p = 0.00). Pre- and post-procedural Vas Score median values were 4. The 7th-week VAS score median value was 3. CONCLUSION Dysport injection under sedation-free outpatient conditions is an effective and safe alternative to LIS for the treatment of CAF, with tolerable procedural pain. All patients should be warned of transient incontinence.
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Affiliation(s)
- Şeref Dokcu
- Gazi Yaşargil Training and Research Hospital Surgical Oncology Department, Health Sciences University, Kayapınar Diyarbakır, Turkey
| | - Salim İlksen Başçeken
- Gazi Yaşargil Training and Research Hospital Surgical Oncology Department, Health Sciences University, Kayapınar Diyarbakır, Turkey
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Khan SZS, Martin S, Doh CY, Stein SL, Steinhagen E. Trends in Management of Anal Fissures. Am Surg 2024; 90:393-398. [PMID: 37658717 DOI: 10.1177/00031348231200662] [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] [Indexed: 09/03/2023]
Abstract
BACKGROUND It is unclear how patients with anal fissures are treated in real-world settings, particularly since patients may not see colorectal surgeons. This study describes trends in treatment with medical therapies (calcium-channel blockers [CCBs], nitroglycerin [NTG], and narcotics) and surgical treatments. METHODS Cohorts were created within the TriNetX database platform using codes for anal fissures and surgical interventions. Demographics were compared between patients that received surgical intervention within 1 year of diagnosis, CCB or NTG within 1 year (or preoperatively), or narcotics within 30 days or postoperatively vs those who did not. RESULTS 121,213 patients were included of which 4.0% had surgical intervention. Factors associated with surgical intervention were male sex (OR 1.40), White race (OR 1.17), and Hispanic ethnicity (OR 1.11). Male patients were more likely to undergo sphincterotomy (OR 1.49). Female (OR 1.27), non-Hispanic (OR 1.34), and White patients (OR 1.41) were more likely to have chemodenervation. Regarding nonoperatively managed patients, non-Hispanic (OR .91) and White patients (OR .89) were less likely to receive CCB/NTG. Male (OR 1.21), non-Hispanic (OR 1.08), and Black patients (OR 1.20) were more likely to receive narcotics. Male patients that required surgery were more likely to be prescribed CCB/NTG preoperatively (OR 1.27). Non-Hispanic surgical patients were more likely to receive narcotics (OR 1.84). DISCUSSION Male fissure patients were more likely to undergo surgical intervention other than chemodenervation. Differences in the rates of surgery and medical therapy (especially narcotics) between races and ethnicities require exploration to enhance the care of patients with anal fissures.
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Affiliation(s)
- Saher-Zahra S Khan
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Scott Martin
- University Hospitals Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Chang Yoon Doh
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Sharon L Stein
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Emily Steinhagen
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Cross KLR, Brown SR, Kleijnen J, Bunce J, Paul M, Pilkington S, Warren O, Jones O, Lund J, Goss HJ, Stanton M, Marunda T, Gilani A, Ngu LWS, Tozer P. The Association of Coloproctology of Great Britain and Ireland guideline on the management of anal fissure. Colorectal Dis 2023; 25:2423-2457. [PMID: 37926920 DOI: 10.1111/codi.16762] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 07/24/2023] [Accepted: 08/03/2023] [Indexed: 11/07/2023]
Abstract
AIM The management of anal fissure: ACPGBI position statement was written 15 years ago. [KLR Cross et al., Colorectal Dis, 2008]. Our aim was to update the guideline and provide recommendations on the most effective treatment for patients with anal fissures utilising a multidisciplinary, rigorous guideline methodology. METHODS The development process consisted of six phases. In phase 1 we defined the scope of the guideline. The patient population included patients with acute and chronic anal fissure. The target group was all practitioners (primary and secondary care) treating patients with fissures and, in addition, healthcare workers and patients who desired information regarding fissure management. In phase 2 we formed a guideline development group (GDG) including a methodologist. In phase 3 review questions were formulated, using a reversed PICO process, starting with possible recommendations based on the GDG's knowledge. In phase 4 a comprehensive literature search focused on existing systematic reviews addressing each review question, supplemented by more recent studies if appropriate. In phase 5 data were extracted from the included papers and checked by the GDG. If indicated, meta-analysis of systematic review data was updated by the GDG. During phase 6 the GDG members decided what recommendations could be made based on the evidence in the literature and strength of the recommendation was assessed using 'grade'. RESULTS This guideline is divided into two sections: Primary care which includes (i) diagnosis; (ii) basic treatment; (iii) topical treatment; and secondary care which includes (iv) botulinum toxin therapy; (v) surgical intervention and (vi) special situations (including pregnancy and breast-feeding patients, children, receptive anal intercourse and low-pressure fissures). A total of 23 recommendations were formulated. A new term clinically healed was described by the GDG. CONCLUSION This guideline provides an up-to-date evidence-based summary of the current knowledge of the management of anal fissure and may serve as a useful guide for clinicians as well as a potential reference for patients.
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Affiliation(s)
- Katie L R Cross
- Department of General Surgery, Royal Devon Healthcare Trust, Barnstaple, UK
| | - Steven R Brown
- Department of Surgery, Sheffield Teaching Hospitals, Sheffield, UK
| | | | - James Bunce
- Royal Derby Hospital, The University of Nottingham, Nottingham, UK
| | - Melanie Paul
- Department of Surgery, Royal Derby Hospital, Derby, UK
| | | | - Oliver Warren
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Cancer and Surgery, Imperial College London, London, UK
| | - Oliver Jones
- Department of Colorectal Surgery, Churchill Hospital, Oxford, UK
| | - Jon Lund
- Department of Surgery, Royal Derby Hospital, Derby, UK
| | - Henry J Goss
- Pharmacy Department, Royal Devon Healthcare Trust, Southampton, UK
| | - Michael Stanton
- Department of Paediatric Surgery, University Hospital, Southampton, UK
| | - Tatenda Marunda
- St Mark's Hospital, London North West University Healthcare Trust, Harrow, UK
| | - Artaza Gilani
- UCL Research Department of Primary Care and Population Health, University College London Medical School (Royal Free Hospital Campus), London, UK
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Rezvani Habibabadi M, Safaee M, Rezaei A. The Assessment of Marcaine Versus Meperidine for Spinal Anesthesia in Anorectal Surgery: A Randomized Clinical Trial. Anesth Pain Med 2023; 13:e136871. [PMID: 38476991 PMCID: PMC10928446 DOI: 10.5812/aapm-136871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 07/24/2023] [Accepted: 08/05/2023] [Indexed: 03/14/2024] Open
Abstract
Background Spinal anesthesia (SA) for the surgical management of chronic anal fissures is favored by surgeons as it provides an early return to daily activities; however, the agents applied for SA to achieve the best outcomes with minimized adverse effects are a matter of debate. Objectives This study aimed to assess the utility of Marcaine versus meperidine for SA induction of anoderm surgery. Methods This randomized clinical trial (RCT) was conducted on 138 patients with chronic anal fissures who were candidates for surgical management in 2020. The patients were randomly assigned to two groups of SA using 2.5 mL of hyperbaric Marcaine 0.5% (n = 69) or 1 mg/kg of meperidine (n = 69). Pain severity (measured via Numerical Rating Scale (NRS)), anal sphincter tone manometry (measured at baseline and the end of the sphincterotomy), and drug-related adverse effects were compared between the groups. Results Both agents led to significant pain relief within 24 hours after SA (P < 0.05); nevertheless, pain severity was remarkably lower in meperidine-treated patients in different measurements performed during the first 24 hours after SA (P < 0.05). The sphincteric tone significantly decreased in both groups (P < 0.001), while the postoperative tone was significantly less in the Marcaine-treated patients (65.22 ± 3.02 versus 46.04 ± 1.97, P < 0.001). The two groups did not differ regarding the adverse effects (P > 0.05). Conclusions Meperidine for SA in anal fissure surgical management was relatively superior to Marcaine, as postoperative pain control was remarkably better achieved with meperidine. However, anal sphincter tone reached a normal range in Marcaine-treated cases, and the average tone in those anesthetized with meperidine was slightly above the normal limits.
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Affiliation(s)
- Mehran Rezvani Habibabadi
- Department of Anesthesiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Kashani Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Masumeh Safaee
- Department of General Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Rezaei
- Department of General Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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van Reijn-Baggen DA, Elzevier HW, Putter H, Pelger RCM, Han-Geurts IJM. Pelvic floor physical therapy in patients with chronic anal fissure: long-term follow-up of a randomized controlled trial. Int J Colorectal Dis 2023; 38:3. [PMID: 36602613 PMCID: PMC9813900 DOI: 10.1007/s00384-022-04292-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Chronic anal fissure is a common benign anorectal disease with a high recurrence rate. Pelvic floor physical therapy has been proven effective in the short-term management in patients with chronic anal fissure and pelvic floor dysfunction (PAF-trial). The aim of this study was to determine the outcomes of the PAF-trial and fissure recurrence in patients who completed the 2 months of pelvic floor physical therapy at 1-year follow-up. METHODS Electromyographic registration of the pelvic floor, digital rectal examination, visual analog scales, patient-related outcome measurements, and quality of life were assessed at baseline and at 1-year after inclusion. The primary outcome was muscle tone at rest during electromyographic registration of the pelvic floor at baseline and at 1-year follow-up. Secondary outcomes contained fissure recurrence, pain ratings, pelvic floor dysfunction, complaint reduction measured with a proctology specific patient-reported outcome measurement, and quality of life. RESULTS The treatment protocol was followed by 137 patients. Ninety-seven patients (71%) completed the 1-year follow-up, 48 women (49.5%) and 49 men (50.5%) with a mean age of 44.4 ± 11.6 years (range 19-68). In the total group of patients, mean resting electromyographic values of the pelvic floor significantly improved from baseline to follow-up at 1 year (mean estimated difference 2.20 μV; 95% CI, 1.79 to 2.61; p < 0.001). After 1 year, the fissure recurred in 15 patients (15.5%). VAS-pain significantly decreased from baseline to follow-up (mean estimated difference 4.16; 95% CI, 3.75 to 4.58; p < 0.001). Dyssynergia was found in 72.9% at baseline and decreased to 14.4% at 1-year follow-up (p < 0.001). Complaint reduction measured with the Proctoprom significantly improved from baseline to 1-year follow-up (p < 0.001). Quality of life (RAND-36) significantly improved in eight of nine domains at 1-year follow-up. No significant improvement was found in the domain vitality. CONCLUSIONS In the PAF-trial, we demonstrated that pelvic floor physical therapy yields a significant and clinical benefit in the time course and therefore should be advocated as adjuvant conservative treatment in patients with chronic anal fissure. TRIAL REGISTRATION The trial is registered at the Dutch Trial registry (NTR7581) https://trialsearch.who.int.
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Affiliation(s)
- Daniëlle A van Reijn-Baggen
- Department of Surgery, Proctos Clinic, Bilthoven, The Netherlands.
- Department of Urology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Henk W Elzevier
- Department of Urology and Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - H Putter
- Department of Biomedical Data Science, Leiden University Medical Center, Leiden, The Netherlands
| | - Rob C M Pelger
- Department of Urology, Leiden University Medical Center, Leiden, The Netherlands
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Tomasicchio G, Dezi A, Picciariello A, Altomare DF, Giove C, Martines G, De Fazio M, Rinaldi M. Safety and efficacy of Levorag emulgel in the treatment of anal fissures using a validated scoring system. Front Surg 2023; 10:1145170. [PMID: 37035554 PMCID: PMC10073417 DOI: 10.3389/fsurg.2023.1145170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/08/2023] [Indexed: 04/11/2023] Open
Abstract
Introduction Anal fissure is one of the most common anal disease characterized by intense anal pain, and deterioration of patients quality of life. Treatment is mainly based on the topical administration of calcium antagonist or nitric oxide ointments, and in cases refractory to medical treatment patients can undergo surgery. This study aims to assess the efficacy and safety of Levorag emulgel in the treatment of acute and chronic fissures using of a validated scoring system. Material and Methods A prospective observational study was carried out on patients with anal fissures between February and May 2022. The efficacy of the treatment was evaluated using the REALISE score, a new validated scoring system that rates VAS for pain, NSAID use, pain duration, bleeding, and quality of life (QoL), recorded after 10, 20 and 30 days from the beginning of treatment. Results Forty patients (median age 46 years, IQR 29-57, 70% women) with acute (22, 55%) or chronic (18, 45%) anal fissures entered the study. The median anal pain score according to the VAS scale decreased significantly from 7 (IQR 4.7-8) at baseline to 1 (IQR 0-3.2, p = 0.05) after 20 days. At the 30-day proctological examination, 22 patients (61%) were pain free (median VAS of 0, IQR 0-1.2, p < 0.05). Pain duration after defecation measured according to the REALISE score, showed a significant decrease after 10 days, from a median value of 2 (IQR 1-4) to 1 (IQR 1-1.2) (p < 0.005). The median value of the REALISE score decreased significantly, from 15 (IQR 11-19.25) at first proctological evaluation to 4 (IQR 4-6, p = 0.139) after 30 days of treatment. At day 30, complete fissure healing was achieved in 30 patients (80%). The healing rate was 82% and 78% in patients with acute and chronic anal fissures, respectively. Conclusion The use of Levorag® Emulgel may represent a safe and effective non-invasive first line treatment in patients affected by acute or chronic anal fissure.
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Shahid MH, Javed S, Javed S, Khan AZ, Kaiser A, Mithany RH. Comparative Efficacy of Topical Metronidazole and Glyceryl Trinitrate Versus Topical Glyceryl Trinitrate Alone in the Treatment of Acute Anal Fissure: A Randomized Clinical Trial. Cureus 2022; 14:e31812. [DOI: 10.7759/cureus.31812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2022] [Indexed: 11/24/2022] Open
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Chiarello MM, Fico V, Brisinda G. A commentary on "Comparison of doses and injection sites of botulinum toxin for chronic anal fissure: A systematic review and network meta-analysis of randomized controlled trials" [Int. J. Surg. 104 (2022) 106798]. Int J Surg 2022; 106:106880. [PMID: 36113840 DOI: 10.1016/j.ijsu.2022.106880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 08/30/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Maria Michela Chiarello
- Unità Operativa di Chirurgia Generale, Azienda Sanitaria Provinciale di Cosenza, Cosenza, Italy
| | - Valeria Fico
- Chirurgia d'Urgenza e del Trauma, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy
| | - Giuseppe Brisinda
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
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GENTILE M, CESTARO G, VELOTTI N, DI MATTEO S, SCHIAVONE V, MUSELLA M. Lateral internal sphincterotomy (LIS) for chronic anal fissure by LigaSure™ Small Jaws: a comparison with traditional technique. Chirurgia (Bucur) 2022. [DOI: 10.23736/s0394-9508.22.05411-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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New Findings at the Internal Anal Sphincter on Cadaveric Dissection and Review of Sphincter-Related Surgery in a Newer Prospective. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03537-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
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Off-Label Use of Botulinum Toxin in Dermatology—Current State of the Art. Molecules 2022; 27:molecules27103143. [PMID: 35630620 PMCID: PMC9147387 DOI: 10.3390/molecules27103143] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 01/01/2023] Open
Abstract
Botulinum toxin (BoNT) is a neurotoxin produced by the Clostridium botulinum bacteria. Among seven different isoforms, only BoNT-A and BoNT-B are commercially used. Currently, botulinum toxin has been indicated by the U.S. Food and Drug Administration in several disorders, among others: chronic migraine, hyperhidrosis, urinary incontinence from detrusor overactivity, or cosmetics. However, there are numerous promising reports based on off-label BTX usage, indicating its potential effectiveness in other diseases, which remains unknown to many. Among them, dermatological conditions, such as rosacea, annal fissure, Raynaud phenomenon, hypertrophic scars and keloids, and also hidradenitis suppurativa, are currently being investigated. This article aims to provide a comprehensive update on the off-label use of botulinum toxin in dermatology, based on an analysis and summary of the published literature.
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van Reijn-Baggen DA, Elzevier HW, Putter H, Pelger RCM, Han-Geurts IJM. Pelvic floor physical therapy in patients with chronic anal fissure: a randomized controlled trial. Tech Coloproctol 2022; 26:571-582. [PMID: 35511322 PMCID: PMC9069957 DOI: 10.1007/s10151-022-02618-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 03/16/2022] [Indexed: 12/12/2022]
Abstract
Background A chronic anal fissure is a common, painful condition with great impact on daily life. The exact pathogenesis has not been fully elucidated and treatment varies. A large percentage of patients experience pelvic floor dysfunction (dyssynergia and increased pelvic floor muscle tone). The aim of our study was to investigate the effect of pelvic floor physical therapy in patients with chronic anal fissure. Methods Between December 2018 and July 2021, at the Proctos Clinic in the Netherlands, patients with chronic anal fissure and pelvic floor dysfunction were randomly assigned to an intervention group, receiving 8 weeks of pelvic floor physical therapy including electromyographic biofeedback or assigned to a control group receiving postponed pelvic floor physical therapy. The primary outcome was muscle tone at rest during electromyographic registration of the pelvic floor before and after pelvic floor physical therapy. Secondary outcomes contained healing of the fissure, pain ratings, improvement of pelvic floor function, and complaint reduction measured with a proctology-specific patient-reported outcome measurement. Endpoints were measured at 8- and 20-week follow-up. Results One hundred forty patients were included in the study, 68 men (48.6%) and 72 women (51.4%) with a mean age of 44.5 ± 11.1 (range 19–79) years. Mean resting electromyographic values of the pelvic floor in the intervention group significantly improved from pre- to post-treatment (p < 0.001) and relative to controls (mean estimated difference between groups − 1.88 µV; 95% CI, − 2.49 to − 1.27 (p < 0.001) at first follow-up and remained significant from baseline at 20-week follow-up (p < 0.001). The intervention group performed better compared to the control group on all secondary outcomes, i.e., healing of the fissure (55.7% of the patients vs 21.4% in control, pain ratings (p < 0.001), diminished dyssynergia (p < 0.001), complaint reduction (p < 0.001), and decrease of pelvic floor muscle tone (p < 0.05) at first follow-up. Conclusions The findings of this study provide strong evidence that pelvic floor physical therapy is effective in patients with chronic anal fissure and pelvic floor dysfunction and supports its recommendation as adjuvant treatment besides regular conservative treatment.
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Affiliation(s)
- Daniëlle A van Reijn-Baggen
- Department of Surgery, Proctos Clinic, Bilthoven, The Netherlands. .,Department of Urology, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Henk W Elzevier
- Department of Urology and Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
| | - H Putter
- Department of Biomedical Data Science, Leiden University Medical Centre, Leiden, The Netherlands
| | - Rob C M Pelger
- Department of Urology, Leiden University Medical Centre, Leiden, The Netherlands
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15
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Vitton V, Bouchard D, Guingand M, Higuero T. Treatment of anal fissures: Results from a national survey on French practice. Clin Res Hepatol Gastroenterol 2022; 46:101821. [PMID: 34666209 DOI: 10.1016/j.clinre.2021.101821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 09/19/2021] [Accepted: 10/08/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Treatment of an anal fissure (AF) is based on medical treatment (nonoperative therapies) and surgical procedures. However, the choice of treatment and its role in therapeutic strategy vary from one country to another, and to date, no standard French recommendation is currently available. Our aim was to assess French practices in the treatment of AFs. METHODS A national survey of members of the French National Society of Colo-Proctology (SNFCP) was carried out using an online questionnaire (1) to evaluate French practice and (2) to compare them with guidelines of other societies. RESULTS Two hundred responses were obtained among the 300 registered members, representing a participation rate of 67%. Members of the SNFCP agree with all scientific societies on the importance of first-line medical treatment, with surgery proposed as a second-line treatment in the case of the failure of well-conducted medical treatment. However, calcium channel blockers and topical nitrates as first-line treatment are rarely prescribed in France. Priority is therefore given to "simple" topical healing products and oral analgesics on demand. Similarly, surgical management differs since LIS is the "gold standard" in most guidelines, whereas in France, despite the data in the literature, fissurectomy is the first-line treatment. CONCLUSIONS Our study indicated the fissure treatment discrepancies of France with other countries concerning the usage of topical treatments and the choice of first-line surgical treatments that is currently considered a "French exception".
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Affiliation(s)
- Véronique Vitton
- Service de Gastroentérologie, Hôpital Nord, Assistance-Publique-Hôpitaux de Marseille, Aix-Marseille Université, France.
| | | | - Marine Guingand
- Service de Gastroentérologie, Hôpital Nord, Assistance-Publique-Hôpitaux de Marseille, Aix-Marseille Université, France
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16
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Brisinda G, Chiarello MM, Crocco A, Bentivoglio AR, Cariati M, Vanella S. Botulinum toxin injection for the treatment of chronic anal fissure: uni- and multivariate analysis of the factors that promote healing. Int J Colorectal Dis 2022; 37:693-700. [PMID: 35149889 PMCID: PMC8885481 DOI: 10.1007/s00384-022-04110-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 02/05/2023]
Abstract
PURPOSE Anal fissure is caused by a pathological contraction of the internal anal sphincter. Lateral internal sphincterotomy remains the gold standard for the treatment of fissure. Botulinum toxin injections have been proposed to treat this condition without any risk of permanent injury of the internal sphincter. We investigate clinical and pathological variables and the effects of different dosage regimens of botulinum toxin to induce healing in patients with idiopathic anal fissure. METHODS This is a retrospective study at a single center. The patients underwent a pre-treatment evaluation that included clinical inspection of the fissure and anorectal manometry. We collected and analyzed demographic data, pathological variables, associated pathological conditions, and treatment variables. Success was defined as healing of the fissure, and improvement of symptoms was defined as asymptomatic persistent fissure. RESULTS The findings of 1003 patients treated with botulinum toxin injections were reported. At 2 months evaluation, complete healing was evident in 780 patients (77.7%). Resting anal tone (77.1 ± 18.9 mmHg) was significantly lower from baseline (P < 0.0001) and from 1-month value (P = 0.0008). Thirty-nine not healed patients underwent lateral internal sphincterotomy, and 184 were re-treated with 50 UI of botulinum toxin. In these patients, the healing rate was 93.9% (171 patients). Dose and injection site of toxin correlates with healing rate. There were no relapses during an average of about 71 months. CONCLUSION Our data show that injection of botulinum toxin into the internal anal sphincter is a safe and effective alternative to surgery in patients with chronic anal fissure.
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Affiliation(s)
- Giuseppe Brisinda
- Università Cattolica del Sacro Cuore, Roma, Italy.
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy.
| | | | - Anna Crocco
- Unità Operativa Di Chirurgia Oncologica Della Tiroide E Della Paratiroide, Istituto Nazionale Tumori, IRCCS Fondazione Pascale, Napoli, Italy
| | - Anna Rita Bentivoglio
- Università Cattolica del Sacro Cuore, Roma, Italy
- Unità Operativa Di Neurologia, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy
| | - Maria Cariati
- Unità Operativa Di Chirurgia Generale, Ospedale San Giovanni Di Dio, Crotone, Italy
| | - Serafino Vanella
- Unità Operativa Di Chirurgia Generale E Oncologica, Azienda Ospedaliera San Giuseppe Moscati, Avellino, Italy
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Iacopo G, Tommaso C, Chiara L, Filippo C, Paolo D, Gianni R, Cinzia T, Giuseppina T, Federico B, Alessandra A, Silvia G, Antonella P, Luca G, Claudio E. Scanner-Assisted CO 2 Laser Fissurectomy: A Pilot Study. Front Surg 2022; 8:799607. [PMID: 35028310 PMCID: PMC8748255 DOI: 10.3389/fsurg.2021.799607] [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: 10/21/2021] [Accepted: 12/02/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Surgery for chronic anal fissure is challenging for every proctologist. Solving the pain by guaranteeing rapid and effective healing is the objective, but what is the price to pay today in functional terms? Though this result is nowadays partially achievable through interventions that include the execution of an internal sphincterotomy among the procedures, it is necessary to underline the high rate of patients who can present faecal incontinence. The aim of this study is to explore the effectiveness of scanner-assisted CO2 laser fissurectomy. Methods: From April 2021 to September 2021, all consecutive patients who affected by chronic anal fissure suitable for surgery, meeting the inclusion and exclusion criteria, were evaluated. All planned data were recorded before surgery, then at 24 h, 1 week, and 1 month follow-up. A scanner-assisted CO2 laser was used in this study to achieve a smooth and dried wound with a minimal tissue thermal damage, to ensure good postsurgical pain control, rapid and functional, elastic and stable healing, and to prevent potential relapses. Paracetamol 1 g every 8 h was prescribed for the first 24 h and then continued according to each patient's need. Ketorolac 15 mg was prescribed as rescue. Results: Mean pain intensity ≤3, considered as the principal endpoint, was recorded in 26 out of the 29 patients who enrolled in the study with a final success rate of 89.7% at 1-month follow-up. Pain and anal itching showed a statistically significant reduction while bleeding, burning, and maximum pain, and REALIS score showed a reduction too at the end of the follow-up period. Reepithelisation proved to be extremely fast and effective: 22 of 29 (75.9%) showed a complete healing and 5 showed a partial reepithelisation at 1-month follow-up. Discussion: Outcomes of this study showed that it is undoubtedly necessary to change the surgical approach in case of anal fissure. The internal sphincterotomy procedure must be most of all questioned, where the availability of cutting-edge technological tools must be avoided and offered only in selected cases. Scanner-assisted CO2 laser showed great results in terms of pain control and wound healing, secondary to an extremely precise ablation, vaporisation, and debridement procedures with minimal lateral thermal damage.
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Affiliation(s)
- Giani Iacopo
- SOSD Proctologia, USL Toscana Centro, Florence, Italy
| | | | - Linari Chiara
- SOSD Proctologia, USL Toscana Centro, Florence, Italy
| | | | - Dreoni Paolo
- SOSD Proctologia, USL Toscana Centro, Florence, Italy
| | - Rossi Gianni
- SOSD Proctologia, USL Toscana Centro, Florence, Italy
| | - Tanda Cinzia
- SOSD Proctologia, USL Toscana Centro, Florence, Italy
| | | | | | | | - Grassi Silvia
- SOSD Proctologia, USL Toscana Centro, Florence, Italy
| | | | - Giannoni Luca
- Department of CRP (Clinical Research and Practice), El.En. Group, Florence, Italy
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Alvarez-Downing MM, da Silva G. 'Bumps down under:' hemorrhoids, skin tags and all things perianal. Curr Opin Gastroenterol 2022; 38:61-66. [PMID: 34636364 DOI: 10.1097/mog.0000000000000795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW There continues to be a concentrated effort to improve treatment options readily available for some of the most common perianal diseases: hemorrhoids, anal fissure and anal fistula. The emphasis remains on therapies that definitively address the underlying pathology yet minimize pain and risk of incontinence, have a short recovery period, and are cost-effective. In this analysis, recent developments in the literature are reviewed. RECENT FINDINGS Treatment of early stage hemorrhoidal disease remains the same. For grades II-IV disease, hemorrhoidal vessel ligation/obliteration with laser or bipolar energy are reported. For more advanced diseases, modifying the technique for hemorrhoidectomy to improve postoperative complications and pain is described. For anal fissure, a stepwise method continues to be the mainstay of treatment (initiating with vasodilators, followed by botox, and ultimately sphincterotomy), which decreases the risk of incontinence with proper patient selection and technique. Management of anal fistula continues to be challenging, balancing cure vs. risk of harm. Recent developments include modifications to ligation of intersphincteric fistula tract procedure and use of laser to obliterate the tract. SUMMARY Advancements in managing benign anorectal disease are ongoing. Several reports are novel, whereas others involve enhancing well-established treatment options by either operative technique or patient selection.
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Affiliation(s)
- Melissa M Alvarez-Downing
- Department of Surgery, Division of Colorectal Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Giovanna da Silva
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
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van Reijn-Baggen DA, Elzevier HW, Pelger RC, Han-Geurts IJ. Pelvic floor physical therapy in the treatment of chronic anal fissure (PAF-study): Study protocol for a randomized controlled trial. Contemp Clin Trials Commun 2021; 24:100874. [PMID: 34841124 PMCID: PMC8606324 DOI: 10.1016/j.conctc.2021.100874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 10/31/2021] [Accepted: 11/13/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Chronic anal fissure (CAF) is a common cause of severe anorectal pain with a high incidence rate. Currently, a wide range of treatment options are available with recurrence rates varying between 7 and 42%. Pelvic floor physical therapy (PFPT) is a treatment option for increased pelvic floor muscle tone and dyssynergia which often accompanies CAF. However, literature on this subject is scarce. The Pelvic Floor Anal Fissure (PAF)-study aims to determine the efficacy and effectiveness of PFPT on improvement on pelvic floor muscle tone and function, pain, healing of the fissure, quality of life and complaint reduction in patients with CAF. METHODS The PAF-study is a single-centre, two armed, randomized controlled trial. Patients with CAF and pelvic floor dysfunction are eligible for inclusion. Exclusion criteria include abscess, fistula, Crohn's disease, ulcerative colitis, anorectal malignancy, prior rectal radiation, and pregnancy. A total of 140 patients will be randomized for either PFPT or postponed treatment of PFPT.The primary outcome is tone at rest during electromyographic registration of the pelvic floor before and after therapy. Secondary outcomes consist of healing of the fissure, pain ratings, improvement of pelvic floor function, complaint reduction and quality of life. Primary and secondary endpoints are measured at 8 and 20 weeks and at 1-year follow-up. DISCUSSION Currently, there is a gap in treatment modalities between conservative management and surgery. This manuscript prescribes the rationale, design, and methodology of a randomized controlled trial investigating PFPT as a treatment option for patients with CAF.
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Affiliation(s)
- Daniëlle A. van Reijn-Baggen
- Proctos Clinic, Department of Surgery, Bilthoven, the Netherlands
- Department of Urology and Medical Decision Making, Leiden University Medical Centre, Leiden, the Netherlands
| | - Henk W. Elzevier
- Department of Urology and Medical Decision Making, Leiden University Medical Centre, Leiden, the Netherlands
| | - Rob C.M. Pelger
- Department of Urology and Medical Decision Making, Leiden University Medical Centre, Leiden, the Netherlands
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Perivoliotis K, Baloyiannis I, Ragias D, Beis N, Papageorgouli D, Xydias E, Tepetes K. The role of percutaneous tibial nerve stimulation (PTNS) in the treatment of chronic anal fissure: a systematic review. Int J Colorectal Dis 2021; 36:2337-2346. [PMID: 34132862 DOI: 10.1007/s00384-021-03976-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE This study was designed to summarize the current evidence regarding the role of percutaneous tibial nerve stimulation (PTNS) in the treatment of chronic anal fissure (CAF). METHODS The present systematic review of the literature was conducted on the basis of the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The primary endpoint of our study was the CAF recurrence rate. Quality assessment was based on the RoB 2 tool and the Case Series Quality Checklist. RESULTS Overall, 5 studies and 102 patients were included. A considerably heterogeneity in the neuromodulation technique and setting was identified. The pooled recurrence rate was estimated at the level of 19% (16/84). Post-interventional pain and Wexner scores were considerably reduced. The 2-month healing rate was 72% (18/25), whereas 73.6% of patients were symptom-free at 6 months. CONCLUSIONS PTNS is an effective alternative for the non-operative management of CAF. Due to several limitations further larger and higher quality studies are required.
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Affiliation(s)
| | - Ioannis Baloyiannis
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - Dimitrios Ragias
- Faculty of Medicine, University of Thessaly, Mezourlo, 41110, Larissa, Greece
| | - Nikolaos Beis
- Faculty of Medicine, University of Thessaly, Mezourlo, 41110, Larissa, Greece
| | | | - Emmanouil Xydias
- Faculty of Medicine, University of Thessaly, Mezourlo, 41110, Larissa, Greece
| | - Konstantinos Tepetes
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
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21
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Nelson R. Question regarding the anal fissure systematic review. Int J Colorectal Dis 2021; 36:1063. [PMID: 33078203 DOI: 10.1007/s00384-020-03779-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Rick Nelson
- Epidemiology and Biostatistics Division, UIC School of Public Health, Chicago, IL, USA.
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22
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Affiliation(s)
- Yang Lu
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles
| | - Mary R Kwaan
- Division of Colorectal Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles
| | - Anne Y Lin
- Division of Colorectal Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles
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23
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Garg P. A simple novel concept to conservatively manage refractory spasm in acute fissure-in-ano: Defecation put on-hold temporarily (DePOT). J Family Med Prim Care 2020; 9:5800-5801. [PMID: 33532440 PMCID: PMC7842491 DOI: 10.4103/jfmpc.jfmpc_1175_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/08/2020] [Accepted: 09/11/2020] [Indexed: 02/07/2023] Open
Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Indus International Hospital, Mohali, Punjab, Haryana, India.,Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula, Haryana, India
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