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Brillantino A, Renzi A, Talento P, Iacobellis F, Brusciano L, Monaco L, Izzo D, Giordano A, Pinto M, Fantini C, Gasparrini M, Schiano Di Visconte M, Milazzo F, Ferreri G, Braini A, Cocozza U, Pezzatini M, Gianfreda V, Di Leo A, Landolfi V, Favetta U, Agradi S, Marino G, Varriale M, Mongardini M, Pagano CEFA, Contul RB, Gallese N, Ucchino G, D'Ambra M, Rizzato R, Sarzo G, Masci B, Da Pozzo F, Ascanelli S, Foroni F, Palumbo A, Liguori P, Pezzolla A, Marano L, Capomagi A, Cudazzo E, Babic F, Geremia C, Bussotti A, Cicconi M, Di Sarno A, Mongardini FM, Brescia A, Lenisa L, Mistrangelo M, Sotelo MLS, Vicenzo L, Longo A, Docimo L. The Italian Unitary Society of Colon-proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of anal fissure. BMC Surg 2023; 23:311. [PMID: 37833715 PMCID: PMC10576345 DOI: 10.1186/s12893-023-02223-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 10/06/2023] [Indexed: 10/15/2023] Open
Abstract
INTRODUCTION The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colon-Proctologia) on the diagnosis and management of anal fissure, with the purpose to guide every physician in the choice of the best treatment option, according with the available literature. METHODS A panel of experts was designed and charged by the Board of the SIUCP to develop key-questions on the main topics covering the management of anal fissure and to performe an accurate search on each topic in different databanks, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in different rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to the PICO criteria, and the statements developed adopting the GRADE methodology. CONCLUSIONS In patients with acute anal fissure the medical therapy with dietary and behavioral norms is indicated. In the chronic phase of disease, the conservative treatment with topical 0.3% nifedipine plus 1.5% lidocaine or nitrates may represent the first-line therapy, eventually associated with ointments with film-forming, anti-inflammatory and healing properties such as Propionibacterium extract gel. In case of first-line treatment failure, the surgical strategy (internal sphincterotomy or fissurectomy with flap), may be guided by the clinical findings, eventually supported by endoanal ultrasound and anal manometry.
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Affiliation(s)
- Antonio Brillantino
- Deparment of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, Naples, 80131, Italy.
| | - Adolfo Renzi
- "Buonconsiglio-Fatebenefratelli" Hospital, Naples, Italy
| | - Pasquale Talento
- Department of Surgery, Pelvic Floor Center, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Francesca Iacobellis
- Department of General and Emergency Radiology, "A. Cardarelli" Hospital, Naples, Italy
| | - Luigi Brusciano
- Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Luigi Monaco
- "Pineta Grande" Hospital, "Villa Esther" Clinic, Avellino, Italy
| | - Domenico Izzo
- Department of General and Emergency Surgery, AORN dei Colli Monaldi-Cotugno-CTO, CTO Hospital, Naples, Italy
| | - Alfredo Giordano
- Department of General and Emergency Surgery, University of Salerno, Hospital of Mercato San Severino, Salerno, Italy
| | | | - Corrado Fantini
- Department of Surgery, "Dei Pellegrini" Hospital, ASL Napoli 1, Naples, Italy
| | | | - Michele Schiano Di Visconte
- Department of General Surgery, Colorectal and Pelvic Floor Diseases Center, "Santa Maria Dei Battuti" Hospital, Conegliano, TV, Italy
| | - Francesca Milazzo
- Department of Surgery, Pelvic Floor Center, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Giovanni Ferreri
- Department of Surgery, Pelvic Floor Center, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Andrea Braini
- Department of General Surgery, Azienda Sanitaria Friuli Occidentale (ASFO), Pordenone, Italy
| | - Umberto Cocozza
- Department of General Surgery, "S. Maria Degli Angeli" Hospital, Putignano (Bari), Italy
| | | | - Valeria Gianfreda
- Unit of Colonproctologic and Pelvic Surgery, "M.G. Vannini" Hospital, Rome, Italy
| | - Alberto Di Leo
- Department of General and Minivasive Surgery, "San Camillo" Hospital, Trento, Italy
| | - Vincenzo Landolfi
- Department of General and Specalist Surgery, AORN "S.G. Moscati", Avellino, Italy
| | - Umberto Favetta
- Unit of Proctology and Pelvic Surgery, "Città di Pavia" Clinic, Pavia, Italy
| | - Sergio Agradi
- Humanitas Gavazzeni/Castelli Bergamo, Bergamo, Italy
| | - Giovanni Marino
- Department of General Surgery, "Santa Marta e Santa Venera" Hospital of Acireale, Catania, Italy
| | - Massimilano Varriale
- Department of General and Emergency Surgery, "Sandro Pertini" Hospital, Asl Roma 2, Rome, Italy
| | | | | | | | - Nando Gallese
- Unit of Proctologic Surgery, "Sant'Antonio" Clinic, Cagliari, Italy
| | | | - Michele D'Ambra
- Department of General and Oncologic-Minivasive Surgery, "Federico II" University, Naples, Italy
| | - Roberto Rizzato
- Department of General Surgery, Hospital of Conegliano AULSS 2, Marca Trevigiana, Treviso, Italy
| | - Giacomo Sarzo
- Department of General Surgery, University of Padova, "Sant'Antonio" Hospital, Padova, Italy
| | | | - Francesca Da Pozzo
- Department of Surgery, "Santa Maria dei battuti" Hospital, San Vito al Tagliamento, Pordenone, Italy
| | - Simona Ascanelli
- Department of Surgery, University Hospital of Ferrara, Ferrara, Italy
| | - Fabrizio Foroni
- Deparment of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, Naples, 80131, Italy
| | - Alessio Palumbo
- Deparment of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, Naples, 80131, Italy
| | | | | | - Luigi Marano
- Academy of Applied Medical and Social Sciences - AMiSNS: Akademia Medycznych i Spolecznych Nauk Stosowanych, Elbląg, Poland
| | | | - Eugenio Cudazzo
- Department of Surgery, Pelvic Floor Center, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Francesca Babic
- Department of Surgery, Hospital of Cattinara, ASUGI Trieste, Trieste, Italy
| | - Carmelo Geremia
- Unit of Proctology and Pelvic Surgery, "Città di Pavia" Clinic, Pavia, Italy
| | | | - Mario Cicconi
- Department of General Surgery, "Sant'Omero-Val Vibrata" Hospital, Teramo, Italy
| | | | - Federico Maria Mongardini
- Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Antonio Brescia
- Department of Oncologic Colorectal Surgery, University Hospital S. Andrea, "La Sapienza" University, Rome, Italy
| | - Leonardo Lenisa
- Department of Surgery, Humanitas San Pio X, Surgery Unit, Pelvic Floor Centre, Milano, Italy
| | | | | | - Luciano Vicenzo
- Deparment of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, Naples, 80131, Italy
| | | | - Ludovico Docimo
- Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
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Davids JS, Hawkins AT, Bhama AR, Feinberg AE, Grieco MJ, Lightner AL, Feingold DL, Paquette IM. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anal Fissures. Dis Colon Rectum 2023; 66:190-199. [PMID: 36321851 DOI: 10.1097/dcr.0000000000002664] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Jennifer S Davids
- Division of Colon and Rectal Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Alexander T Hawkins
- Division of General Surgery, Section of Colon and Rectal Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anuradha R Bhama
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Adina E Feinberg
- Division of General Surgery, Joseph Brant Hospital, Burlington, Ontario, Canada
| | - Michael J Grieco
- Division of Colon and Rectal Surgery, New York University, New York, New York
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Daniel L Feingold
- Division of Colon and Rectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati, Cincinnati, Ohio
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Roelandt P, Coremans G, Wyndaele J. Injection of botulinum toxin significantly increases efficiency of fissurectomy in the treatment of chronic anal fissures. Int J Colorectal Dis 2022; 37:309-312. [PMID: 34727216 DOI: 10.1007/s00384-021-04057-8] [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] [Accepted: 10/25/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE While acute anal fissures can be treated with topical therapy to reduce sphincter hypertonia (e.g., isosorbide dinitrate, glyceryl trinitrate, diltiazem), chronic fissures may require more invasive instrumental therapy. Currently, the golden standard remains lateral internal sphincterotomy; however, this carries the long-term risk of faecal incontinence. Fissurectomy can be a valuable alternative, but is less efficient because of absence of correction of underlying hypertonia. In this study, we aim to evaluate the additional effect of injection of botulinum toxin during fissurectomy in the treatment of chronic anal fissures. METHODS A single-centre retrospective analysis of 293 isolated superficial fissurectomies with or without injection of botulinum toxin was performed, with pain relief as primary endpoint. RESULTS The majority of patients undergoing fissurectomy were women (65%, mean age 45.0 years vs. 35% men, mean age 48.3 years), often because of ventral fissures (30% in women vs. 8% in men). Fissurectomy resulted in resolution of complaints in 81.1%, while additional injection of botulinum toxin resulted in resolution in 90.1% (p < 0.05). Complication rate was identical between the two groups, mainly (flatus) incontinence (4.5% vs 4.9% with botulinum toxin) and post-operative bleeding (1.8% vs 2.5% with botulinum toxin). CONCLUSION Injection of botulinum toxin significantly increases the efficiency of fissurectomy in the treatment of chronic anal fissures without additional complications.
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Affiliation(s)
- Philip Roelandt
- Department of Gastroenterology and Hepatology, UZ Leuven, Leuven, Belgium. .,Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Translational Research in Gastrointestinal Diseases (TARGID), KU Leuven, Leuven, Belgium.
| | - Georges Coremans
- Department of Gastroenterology and Hepatology, UZ Leuven, Leuven, Belgium
| | - Jan Wyndaele
- Department of Gastroenterology and Hepatology, UZ Leuven, Leuven, Belgium
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Botulinum Toxin Injection Plus Topical Diltiazem for Chronic Anal Fissure: A Randomized Double-Blind Clinical Trial and Long-term Outcome. Dis Colon Rectum 2021; 64:1521-1530. [PMID: 34747917 DOI: 10.1097/dcr.0000000000001983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Chemical sphincterotomy avoids the risk of permanent incontinence in the treatment of chronic anal fissure, but it does not reach the efficacy of surgery and recurrence is high. Drug combination has been proposed to overcome these drawbacks. OBJECTIVE This study aimed to compare the clinical, morphological, and functional effects of combined therapy with botulinum toxin injection and topical diltiazem in chronic anal fissure and to assess the long-term outcome after healing. DESIGN This is a randomized, controlled, double-blind, 2-arm, parallel-group trial with a long-term follow-up. SETTINGS This study was conducted at a tertiary care center. PATIENTS A total of 70 consecutive patients were referred to the gastroenterology department of a hospital in Valencia, Spain. INTERVENTION After botulinum toxin injection (20 IU), patients were randomly assigned to local diltiazem (diltiazem group) or placebo gel (placebo group) for 12 weeks. MAIN OUTCOME MEASURES The primary outcome was fissure healing (evaluated by video register by 3 independent physicians). Secondary outcomes included symptomatic relief (30-day diary), effect on anal sphincters (manometry), safety, and long-term recurrence (24 months and 10 years). RESULTS Healing was achieved per protocol in 13 of 25 (52%) patients of the diltiazem group and 11 of 30 (36.7%) patients of the placebo group (p = 0.25); on an intention-to-treat basis in 37.1% and 31.4% (p = 0.61). Both groups displayed significant reduction of anal pressures. Thirty percent reported minor and transitory incontinence, without differences between groups. Nine (69.2%) of the diltiazem group and 6 (54.5%) of the placebo group experienced a relapse at 24 months (p = 0.67). The overall recurrence rate at 10 years was 83.3% (20/24 patients). LIMITATIONS This study was limited by the loss of patients during the trial. The low healing rate led to a small cohort to assess recurrence. CONCLUSIONS Combined botulinum toxin injection and topical diltiazem is not superior to botulinum toxin injection in the treatment of chronic anal fissure. Both options offer suboptimal healing rates. Long-term recurrence is high (>80% at 10 years) and might appear at any time after healing. See Video Abstract at http://links.lww.com/DCR/B527. INYECCIN DE TOXINA BOTULNICA MS DILTIAZEM TPICO EN FISURA ANAL CRNICA UN ENSAYO CLNICO ALEATORIZADO DOBLE CIEGO Y RESULTADOS A LARGO PLAZO ANTECEDENTES:La esfinterotomía química evita el riesgo de incontinencia permanente en el tratamiento de la fisura anal crónica, pero no alcanza la eficacia de la cirugía y la recurrencia es alta. Se ha propuesto la combinación de fármacos para superar estos inconvenientes.OBJETIVO:Comparar los efectos clínicos, morfológicos y funcionales de la terapia combinada con inyección de toxina botulínica y diltiazem tópico en fisura anal crónica y evaluar el resultado a largo plazo después de la cicatrización.DISEÑO:Ensayo aleatorizado, controlado, doble ciego, de dos brazos, de grupos paralelos con un seguimiento a largo plazo.ESCENARIO:Estudio realizado en un centro de atención terciaria.PACIENTES:Un total de 70 pacientes consecutivos referidos al servicio de gastroenterología de un hospital de Valencia, España.INTERVENCIÓN:Después de la inyección de toxina botulínica (20UI), los pacientes fueron asignados al azar a diltiazem local (grupo de diltiazem) o gel de placebo (grupo de placebo) durante 12 semanas.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la cicatrización de la fisura (evaluado por registro de video por tres médicos independientes). Los resultados secundarios incluyeron alivio sintomático (diario de 30 días), efecto sobre los esfínteres anales (manometría), seguridad y recurrencia a largo plazo (24 meses y 10 años).RESULTADOS:La curación se logró por protocolo en 13/25 (52%) en el grupo de Diltiazem y 11/30 (36,7%) en el grupo de Placebo (p = 0.25); por intención de tratar en el 37.1% y el 31.4%, respectivamente (p = 0.61). Ambos grupos mostraron una reducción significativa de las presiones anales. El 30% refirió incontinencia leve y transitoria, sin diferencias entre grupos. 9 (69.2%) del grupo de Diltiazem y 6 (54.5%) del grupo de placebo recurrieron a los 24 meses (p = 0.67). La tasa global de recurrencia a los 10 años fue del 83.3% (20/24 pacientes).LIMITACIONES:La pérdida de pacientes a lo largo del ensayo. La baja tasa de curación llevó a una pequeña cohorte para evaluar la recurrencia.CONCLUSIONES:La inyección combinada de toxina botulínica y diltiazem tópico no es superior a la inyección de TB en el tratamiento de la fisura anal crónica. Ambas opciones ofrecen tasas de curación subóptimas. La recurrencia a largo plazo es alta (> 80% a los 10 años) y puede aparecer en cualquier momento después de la curación. Consulte Video Resumen en http://links.lww.com/DCR/B527.
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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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Alshehri A, Barghouthi R, Albanyan S, Alayed M, Alsubaie H, Alhayyan R, Alzahem A, Altokhais T, Albassam A, Aljazaeri A. A prospective, double-blind, randomized, placebo-controlled trial comparing the efficacy of polyethylene glycol versus polyethylene glycol combined with topical diltiazem for treating anal fissure in children. J Pediatr Surg 2020; 55:2017-2021. [PMID: 32057442 DOI: 10.1016/j.jpedsurg.2020.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 12/24/2019] [Accepted: 01/14/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Anal fissure (AF) in children is usually treated with laxatives and/or topical agents such as calcium channel blockers. We hypothesize that owing to the superior efficacy of Polyethylene glycol (PEG) in treating constipation in children, adding diltiazem (DTZ) might not improve healing of AF. METHODS Children ≤14 years with anal fissure presented to the pediatric surgery clinic between November 2014 and March 2016 were recruited. Randomization was performed to either PEG with DTZ or PEG with placebo. Study personnel, patients, and their families were blinded. Primary outcome was resolution of symptoms. Secondary outcomes were constipation and treatment complications at 12-week follow up. RESULTS 48 patients were randomized: 24 to PEG + DTZ and 24 to PEG + placebo. Both groups were similar in their baseline characteristics. At week 12, majority of patients' symptoms have improved without significant difference between groups; painful defecation at week 12: 20.8% and 8.3% (p-value 0.41), blood per rectum at week 12: 4.2% and 8.3% (p value 0.58) in the DTZ and placebo groups, respectively. Additionally, there was similar improvement in constipation in both groups. CONCLUSION PEG alone was associated with similar improvement in anal fissure symptoms in children compared to PEG and topical diltiazem combined. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Abdullah Alshehri
- Pediatric Surgery Division, Department of Surgery, King Saud University Medical City, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
| | - Rakan Barghouthi
- Pediatric Surgery Division, Department of Surgery, King Saud University Medical City, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Saleh Albanyan
- Pediatric Surgery Division, Department of Surgery, King Saud University Medical City, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Maria Alayed
- Pediatric Surgery Division, Department of Surgery, King Saud University Medical City, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Hadeel Alsubaie
- Pediatric Surgery Division, Department of Surgery, King Saud University Medical City, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Rawan Alhayyan
- Pediatric Surgery Division, Department of Surgery, King Saud University Medical City, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulrahman Alzahem
- Pediatric Surgery Division, Department of Surgery, King Saud University Medical City, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Tariq Altokhais
- Pediatric Surgery Division, Department of Surgery, King Saud University Medical City, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulrahman Albassam
- Pediatric Surgery Division, Department of Surgery, King Saud University Medical City, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ayman Aljazaeri
- Pediatric Surgery Division, Department of Surgery, King Saud University Medical City, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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D'Orazio B, Geraci G, Martorana G, Sciumé C, Corbo G, Di Vita G. Fisurectomy and anoplasty with botulinum toxin injection in patients with chronic anal posterior fissure with hypertonia: a long-term evaluation. Updates Surg 2020; 73:1575-1581. [PMID: 32666478 PMCID: PMC8397652 DOI: 10.1007/s13304-020-00846-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/01/2020] [Indexed: 12/14/2022]
Abstract
Chronic anal fissure’s (CAF) etiopathogenesis remain unclear. CAF of the posterior commissure (CAPF) are often characterized by internal anal sphincter (IAS) hypertonia. The treatment of this disease aimed to reduce IAS hypertonia. Due to the high rate of anal incontinence after LIS, the employment of sphincter preserving surgical techniques associated to pharmacological sphincterotomy appears more sensible. The aim of our study is to evaluate the long-term results of fissurectomy and anoplasty with V–Y cutaneous flap advancement associated to 30 UI of botulinum toxin injection for CAPF with IAS hypertonia. We enrolled 45 patients undergone to fissurectomy and anoplasty with V–Y cutaneous flap advancement and 30 UI botulinum toxin injection. All patients were followed up for at least 5 years after the surgical procedure, with evaluation of anal continence, recurrence rate and MRP (Maximum resting pressure), MSP (Maximum restricting pressure), USWA (Ultrasound wave activity). All patients healed within 40 days after surgery. We observed 3 “de novo” post-operative anal incontinence cases, temporary and minor; the pre-operative ones have only temporary worsened after surgery. We reported 3 cases of recurrences, within 2 years from surgery, all healed after conservative medical therapy. At 5 year follow-up post-operative manometric findings were similar to those of healthy subjects. At 5 years after the surgical procedure, we achieved good results, and these evidences show that surgical section of the IAS is not at all necessary for the healing process of the CAPF.
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Affiliation(s)
- Beatrice D'Orazio
- General Surgery Unit, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Via Liborio Giuffrè, 5, 90127, Palermo, Italy.,Postgraduate Medical School in General Surgery, University of Palermo, Palermo, Italy
| | - Girolamo Geraci
- General Surgery Unit, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Via Liborio Giuffrè, 5, 90127, Palermo, Italy
| | - Guido Martorana
- General and Oncological Surgery Unit, Fondazione Istituto G. Giglio, Cefalù, Italy
| | - Carmelo Sciumé
- General Surgery Unit, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Via Liborio Giuffrè, 5, 90127, Palermo, Italy
| | - Giovanni Corbo
- General Surgery Unit, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Via Liborio Giuffrè, 5, 90127, Palermo, Italy.,Postgraduate Medical School in General Surgery, University of Palermo, Palermo, Italy
| | - Gaetano Di Vita
- General Surgery Unit, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Via Liborio Giuffrè, 5, 90127, Palermo, Italy.
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Abstract
ZusammenfassungDie Analfissur ist eine der häufigsten Pathologien, welche sich dem Proktologen präsentiert. Entsprechend ist es wichtig, verlässliche Leitlinien dazu zu entwickeln. Die aktuelle Leitlinie wurde anhand eines systematischen Literaturreview von einem interdisziplinären Expertengremium diskutiert und verabschiedet.Die akute Analfissur, soll auf Grund ihrer hohen Selbstheilungstendenz konservativ behandelt werden. Die Heilung wird am besten durch die Einnahme von Ballaststoff reicher Ernährung und einer medikamentösen Relaxation durch Kalziumkanal-Antagonisten (CCA) unterstützt. Zur Behandlung der chronischen Analfissur (CAF), soll den Patienten eine medikamentöse Behandlung zur „chemischen Sphinkterotomie“ mittels topischer CCA oder Nitraten angeboten werden. Bei Versagen dieser Therapie, kann zur Relaxation des inneren Analsphinkters Botulinumtoxin injiziert werden. Es ist belegt, dass die operativen Therapien effektiver sind. Deshalb kann eine Operation schon als primäre Therapie oder nach erfolgloser medikamentöser Therapie erfolgen. Die Fissurektomie, evtl. mit zusätzlicher Botulinumtoxin Injektion oder Lappendeckung, ist die Operation der Wahl. Obwohl die laterale Internus Sphinkterotomie die CAF effektiver heilt, bleibt diese wegen dem höheren Risiko für eine postoperative Stuhlinkontinenz eine Option für Einzelfälle.
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Soltany S, Hemmati HR, Toussy JA, Salehi D, Toosi PA. Therapeutic properties of botulinum toxin on chronic anal fissure treatment and the patient factors role. J Family Med Prim Care 2020; 9:1562-1566. [PMID: 32509650 PMCID: PMC7266196 DOI: 10.4103/jfmpc.jfmpc_944_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 02/21/2020] [Accepted: 03/03/2020] [Indexed: 12/28/2022] Open
Abstract
Background: One of the most frequent distressing diseases which causes anal pain and bleeding after defecation is anal fissure. Despite a poorly understood pathogenesis, the internal anal sphincter spasm has been identified to play a central role in pathogenesis. Recently, botulinum toxin is being used increasingly for the treatment of chronic anal fissure to achieve chemical sphincterotomy and reduce internal sphincter tonicity. Based on the heterogeneity among the published studies, we aimed this study to evaluate its healing rate and for recognizing the factors of patients which may affect the outcome. Subjects and Methods: In a prospective case series medical research, 106 patients who suffer from chronic anal fissure were treated by botulinum toxin injections. All patients received 30 units of botulinum toxin and were physically examined every week for 2 months. They were evaluated for bleeding, pain, hematoma, thrombosis, infection, incontinence, and healing of the fissure. At the end of the follow-up period, the fissure healing rate and its relation to age, gender, prior topical therapy, duration of symptoms, and the position of the fissure were assessed. Results: At the end of the study (8 weeks), the healing rate was 84.9% (90 patients responded to injections). Healing rate was higher in females and in patients who experienced a shorter duration of symptoms before injection. The mean healing time was 4.68 weeks. In addition, patients with one fissure (anterior or posterior) demonstrated higher healing rate and shorter healing time compared to patients with two fissures (anterior and posterior). Conclusion: This study demonstrated that botulinum toxin injection is safe and effective for the treatment of chronic anal fissures, with a low complication rate. In addition, the healing rate was higher in females, patients with shorter duration of symptoms, and those with one fissure.
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Affiliation(s)
- Setareh Soltany
- Cancer Research Center, Kowsar Hospital, Semnan University of Medical Sciences, Semnan, Iran
| | - Hamid Reza Hemmati
- Department of Surgery, Kowsar Hospital, Semnan University of Medical Sciences, Semnan, Iran
| | - Jafar Alavy Toussy
- Department of Pathology, Semnan University of Medical Sciences, Semnan, Iran
| | - Dina Salehi
- Department of Medicine, School of Medicine, Semnan University of Medical Sciences, Semnan, Iran
| | - Parisa Alavi Toosi
- Department of Medicine, School of Medicine, Semnan University of Medical Sciences, Semnan, Iran
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Andicoechea Agorría A, Del Casar Lizcano JM, Barbón Remis E, Jara Quezada JH, Fernández Fernández JC, Sánchez Sánchez MDR, Quintela Baizán I, Vivoso Piñero F. Treatment of a chronic anal fissure with a botulin toxin A injection and fissurectomy. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 111:672-676. [PMID: 31333035 DOI: 10.17235/reed.2019.6202/2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION pharmacological treatment of a chronic anal fissure (CAF) achieves healing in half of cases and lateral internal sphincterotomy (LIS) is the definite treatment. The objective of this study was to assess the combination of fissurectomy and botulin toxin A (BTA) injection. METHODS this was a retrospective study of 54 patients with anal sphincter hypertonia and CAF treated with an injection of BAT and fissurectomy, after an unsuccessful management with topical nitroglycerin (NGT) for eight weeks. Fissurectomy and an injection of BTA (33 or 50 units) in the internal anal sphincter was performed during the same session. The main outcome measure was the healing rate, with incontinence and the need of LIS as secondary outcomes. RESULTS two patients were excluded from the study, one due to Crohn's disease and the other was lost to follow-up. Of the 52 patients included in the study, there were 36 females (70%) and 16 (30%) males, with a mean age of 49 years (range 22-75). Fissure healing was initially achieved in 49 patients (94.2%) and LIS was required in the remaining three patients (5.8%). After initial healing, 18 patients (34.7%) developed 23 recurrences at a mean time of 27 months (5-83 months). Of these patients, healing with conservative sphincter measures was obtained in eleven cases (NGT in eight and repeat fissurectomy and BAT in three); two patients are currently under treatment with NGT and five underwent LIS. CONCLUSIONS BTA injection associated with fissurectomy is a safe and effective procedure in patients with CAF, avoiding the need of LIS in a high percentage of patients.
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Barbeiro S, Atalaia-Martins C, Marcos P, Gonçalves C, Canhoto M, Arroja B, Silva F, Cotrim I, Eliseu L, Santos A, Vasconcelos H. Long-term outcomes of Botulinum toxin in the treatment of chronic anal fissure: 5 years of follow-up. United European Gastroenterol J 2016; 5:293-297. [PMID: 28344798 DOI: 10.1177/2050640616656708] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 06/01/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Chronic anal fissure is a frequent and disabling disease, often affecting young adults. Botulinum toxin and lateral internal sphincterotomy are the main therapeutic options for refractory cases. Botulinum toxin is minimally invasive and safer compared with surgery, which carries a difficult post-operative recovery and fecal incontinence risk. The long-term efficacy of Botulinum toxin is not well known. OBJECTIVE The aim of this study was to evaluate the long-term efficacy and safety of Botulinum toxin in the treatment of chronic anal fissure. METHODS This was a retrospective study at a single center, including patients treated with Botulinum toxin from 2005 to 2010, followed over at least a period of 5 years. All patients were treated with injection of 25U of Botulinum toxin in the intersphincteric groove. The response was registered as complete, partial, refractory and relapse. RESULTS Botulinum toxin was administered to 126 patients, 69.8% (n = 88) were followed over a period of 5 years. After 3 months, 46.6% (n = 41) had complete response, 23.9% (n = 21) had partial response and 29.5% (n = 26) were refractory. Relapse was observed in 1.2% (n = 1) at 6 months, 11.4% (n = 10) at 1 year, 2.3% (n = 2) at 3 years; no relapse at 5 years. The overall success rate was 64.8% at 5 years of follow-up. Botulinum toxin was well tolerated by all patients and there were no complications. CONCLUSION The use of Botulinum toxin to treat patients with chronic anal fissure was safe and effective in long-term follow-up.
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Affiliation(s)
- Sandra Barbeiro
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | | | - Pedro Marcos
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Cláudia Gonçalves
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Manuela Canhoto
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Bruno Arroja
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Filipe Silva
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Isabel Cotrim
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Liliana Eliseu
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Antonieta Santos
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Helena Vasconcelos
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
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Whatley JZ, Tang SJ, Glover PH, Davis ED, Jex KT, Wu R, Lahr CJ. Management of complicated chronic anal fissures with high-dose circumferential chemodenervation (HDCC) of the internal anal sphincter. Int J Surg 2015; 24:24-6. [DOI: 10.1016/j.ijsu.2015.10.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 10/01/2015] [Accepted: 10/12/2015] [Indexed: 11/28/2022]
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Fissurectomy Combined with High-Dose Botulinum Toxin Is a Safe and Effective Treatment for Chronic Anal Fissure and a Promising Alternative to Surgical Sphincterotomy. Dis Colon Rectum 2015; 58:967-73. [PMID: 26347969 DOI: 10.1097/dcr.0000000000000434] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is paucity of data on the long-term outcome of the combination of fissurectomy and botulinum toxin A injection for the management of chronic anal fissure. OBJECTIVES The aim of this study is to assess the safety, efficacy, and long-term outcome of the combination of fissurectomy and botulinum toxin A injection. DESIGN This is a nonrandomized prospective cohort study. SETTINGS This study was conducted at a district general hospital in the United Kingdom. PATIENTS The cohort included all patients treated with fissurectomy and botulinum toxin A for chronic anal fissure between September 2008 and March 2012. INTERVENTION The patients were treated with a combination of fissurectomy and botulinum toxin A injection. MAIN OUTCOME MEASURES Symptomatic relief, fissure healing, complications, recurrence, and the need for further surgical intervention. RESULTS One hundred and two patients received fissurectomy and botulinum toxin A injection for chronic anal fissure. At 12-week follow-up, 68 patients had resolution of symptoms and complete healing of chronic anal fissure, 29 patients had improvement of symptoms but incomplete healing and had further topical or botulinum toxin A treatment with subsequent complete healing. Ninety-five patients (93%) reported no postoperative complications. Seven patients reported a degree of incontinence in the immediate postoperative period. All reported normal continence at12-week follow-up. No local complications were observed or reported. At the mean follow-up of 33 months, there was no evidence of recurrence. Twelve-month follow-up was conducted via telephone interview only. LIMITATIONS This study is nonrandomized and did not examine the dose response of Botulinum Toxin A. CONCLUSIONS Fissurectomy combined with high-dose botulinum toxin A is a safe, effective, and durable option for the management of chronic anal fissure and a promising alternative to surgical sphincterotomy.
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Dat A, Chin M, Skinner S, Farmer C, Wale R, Carne P, Bell S, Warrier SK. Botulinum toxin therapy for chronic anal fissures: where are we at currently? ANZ J Surg 2015; 87:E70-E73. [PMID: 26423046 DOI: 10.1111/ans.13329] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Botulinum toxin (Botox) injection for chronic anal fissure (CAF) is commonly performed, yet there remains no consensus on optimal dosage or frequency of injections required to achieve complete resolution of anal fissure. The aim of this study was to determine the effectiveness of Botox and side-effect profile in the management of CAF. METHODS A retrospective clinical study of patients between 2010 and 2014 who underwent a Botox injection for CAF at a tertiary centre was performed. The effectiveness of Botox was measured using standardized outcomes including overall healing rate, presence of anal pain, recurrence and need for repeat botulinum injection. Binary outcomes were assessed using logistic regression model. The analysis was performed using Stata version 13 (StataCorp, College Station, TX, USA). RESULTS One hundred and one patients underwent 126 Botox injections within the study period. The mean first post-operative visit was at 1 month. The overall recurrence rate was 32%. The majority of patients were given 33 U. No statistically significant relationship between dose and recurrence was identified. The presence of pain at the first post-operative visit was a predictor of future recurrence (odds ratio 3.92, confidence interval 1.58-9.74, P = 0.003). CONCLUSION Botox is an effective strategy for CAF. Low doses can be given with good efficacy as highlighted by our audit and has the potential for great cost saving. The best predictor of recurrence is the presence of pain at the first post-procedure visit.
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Affiliation(s)
- Anthony Dat
- Department of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Martin Chin
- Department of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Stewart Skinner
- Department of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Chip Farmer
- Department of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Roger Wale
- Department of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Peter Carne
- Department of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Stephen Bell
- Department of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Department of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia
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Glover PH, Tang SJ, Whatley JZ, Davis ED, Jex KT, Wu R, Lahr CJ. High-dose circumferential chemodenervation of the internal anal sphincter: A new treatment modality for uncomplicated chronic anal fissure: A retrospective cohort study (with video). Int J Surg 2015; 23:1-4. [PMID: 26365430 DOI: 10.1016/j.ijsu.2015.08.076] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 08/10/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND Botulinum toxin injection into the internal anal sphincter is gaining popularity as a second line therapy for chronic anal fissures if medical therapy fails. The dosage of botulinum toxin reported ranged from 20 to 50 IU with no more than 3 injection sites and results in a healing rate of 41%-88% at 3 months. We propose a new injection method of high-dose circumferential chemodenervation of 100 IU in treating chronic anal fissure. METHODS This was a retrospective review at a single academic center. 75 patients (50 women and 25 men) with uncomplicated chronic anal fissures underwent high-dose circumferential chemodenervation-internal anal sphincter (100 IU). We measured fissure healing, complication, and recurrence rates at 3 and 6 months post injection. RESULTS Of the 75 patients, healing rate was 90.7% at 3 months follow up with the first injection and 81.3% with the second injection. The recurrence rates were 20.6% and 12.5% at 6 months after the 1st and 2nd injections respectively. Excluding 5 patients who lost follow up, the total healing rate of the study cohort was 100%. At 2 weeks and 3 months, there were no major complications including hematoma, infection, flatus, fecal, and urinary incontinence. CONCLUSIONS High-dose circumferential chemodenervation-internal anal sphincter (100 IU) is a safe and effective method for uncomplicated chronic anal fissure.
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Affiliation(s)
- Porter H Glover
- Division of Gastroenterology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA
| | - Shou-jiang Tang
- Division of Gastroenterology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA.
| | - James Z Whatley
- Division of Gastroenterology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA
| | - Eric D Davis
- Division of Gastroenterology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA
| | - Kellen T Jex
- Division of Gastroenterology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA
| | - Ruonan Wu
- Division of Gastroenterology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA
| | - Christopher J Lahr
- Department of Surgery, University of Mississippi Medical Center, 2500 North State Street Jackson, MS 39216, USA
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Grekova NM, Maleva EA, Lebedeva Y, Bordunovsky VN, Telesheva LF, Bychkovskikh VA. The effects of topical application of metronidazole for treatment of chronic anal fissure: A randomized, controlled pilot study. Indian J Gastroenterol 2015; 34:152-7. [PMID: 25925729 DOI: 10.1007/s12664-015-0559-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 04/01/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Chronic anal fissures (CAFs) rarely heal with conservative management. Because they are associated with strong anal sphincter tone, most treatment aim to reduce anal pressure. Although infections can cause fissures, as can traumatic injury to the anal canal, antimicrobial treatment is not recommended. In a previous study, we reported identifying a wide spectrum of pathogenic microorganisms in the bases of CAFs, anaerobic bacteria being present in half the cases. We postulated that microbial colonization delays healing of CAF and aimed to determine whether decreasing the bacterial load with topical antibacterial treatment accelerates fissure healing. METHODS We cultured fecal samples and swabs from the bases of CAFs in 103 patients. Patients in whose samples anaerobic bacteria were identified (47 patients) were then invited to participate in a prospective randomized clinical trial comparing topical metronidazole with conventional treatment. The primary endpoint was fissure healing confirmed on anoscopy. Secondary endpoints of maximum pain on defecation assessed by visual analog scale, maximum anal resting pressure, and rectal pH were recorded on entry and at 10, 21, and 28 days. RESULTS The CAFs were colonized by mixtures of gram-positive/gram-negative anaerobic bacteria or gram-negative aerobic monocultures. Patients with anaerobic bacteria in their swabs who received topical metronidazole treatment experienced rapid relief of pain and anal sphincter spasm along with enhanced fissure healing (95.6 % healing rate compared with 70.8 % in the control group, p = 0.048). CONCLUSION Topical antimicrobial treatment can be effective in patients with CAF provided the relevant microorganisms are correctly identified.
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Brisinda G, Bianco G, Silvestrini N, Maria G. Cost considerations in the treatment of anal fissures. Expert Rev Pharmacoecon Outcomes Res 2014; 14:511-25. [PMID: 24867398 DOI: 10.1586/14737167.2014.924398] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Anal fissure is a split in the lining of the distal anal canal. Lateral internal sphincterotomy remains the gold standard for treatment of anal fissure. Although technique is simple and effective, a drawback of this surgical procedure is its potential to cause minor but some times permanent alteration in rectal continence. Conservative approaches (such as topical application of ointment or botulinum toxin injections) have been proposed in order to treat this condition without any risk of permanent injury of the internal anal sphincter. These treatments are effective in a large number of patients. Furthermore, with the ready availability of medical therapies to induce healing of anal fissure, the risk of a first-line surgical approach is difficult to justify. The conservative treatments have a lower cost than surgery. Moreover, evaluation of the actual costs of each therapeutic option is important especially in times of economic crisis and downsizing of health spending.
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Affiliation(s)
- Giuseppe Brisinda
- Department of Surgery, Catholic School of Medicine, University Hospital "Agostino Gemelli", Largo Agostino Gemelli 8, 00168, Rome, Italy
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Long term outcomes after lateral anal sphincterotomy for anal fissure: a retrospective cohort study. Surg Today 2013; 44:1032-9. [DOI: 10.1007/s00595-013-0785-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 05/08/2013] [Indexed: 12/31/2022]
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Deng ZH, Zhao BM. Choice of treatments for anal fissure. Shijie Huaren Xiaohua Zazhi 2013; 21:1197-1204. [DOI: 10.11569/wcjd.v21.i13.1197] [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] [Indexed: 02/06/2023] Open
Abstract
Chronic anal fissure (CAF) is one of the most common and painful proctologic diseases. Its treatment has long been discussed and several different therapeutic options have been proposed. The understanding of its pathophysiology has led to a progressive reduction of invasive and potentially invalidating treatments in favor of conservative treatment. Lateral internal sphincterotomy (LIS) is a surgical treatment that is considered the 'gold standard' therapy for CAF. It relieves CAF symptoms with a high rate of healing. The risk of incontinence after this procedure seems to be severe. Chemical sphincterotomy (CS) is safe, with the rapid relief of pain, no risk of surgery or anesthesia, but is a statistically less effective therapy for CAF than LIS. In recent years, fissurectomy coupled with CS has been demonstrated to be a satisfactory treatment for chronic anal fissure and an alternative to lateral sphincterotomy when conservative measures fail.
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How much of the internal sphincter may be divided during lateral sphincterotomy for chronic anal fissure in women? Morphologic and functional evaluation after sphincterotomy. Dis Colon Rectum 2013; 56:645-51. [PMID: 23575405 DOI: 10.1097/dcr.0b013e31827a7416] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Sphincterotomy is used to treat chronic anal fissure, but the length of the sphincterotomy is associated with incontinence. OBJECTIVE We used 3-dimensional anal ultrasonography to determine the proportion of the internal anal sphincter that may be divided during lateral internal sphincterotomy in women without predisposing them to a high risk of fecal incontinence. DESIGN AND SETTING This was a prospective, observational cohort study conducted at a tertiary-care hospital. PATIENTS Women treated for chronic anal fissure with high anal resting pressure and no symptoms of fecal incontinence were selected. Asymptomatic women recruited from different departments of the same hospital served as controls to provide reference values for anal canal measurements. INTERVENTION Patients underwent a standardized technique of lateral internal sphincterotomy. MAIN OUTCOME MEASURES Three-dimensional ultrasonography was used to measure sphincter lengths. Continence was assessed with the Cleveland Clinic Florida (Wexner) score. The relationship between the extent of the surgically divided portion of the internal anal sphincter and the continence score was evaluated. RESULTS Successful healing was achieved in all patients within 2 months. Follow-up continence scores were significantly correlated with the extent of sphincter division. The proportion of patients with a continence score of 0 was significantly greater in patients in whom sphincter division was less than 25% in comparison with patients with a division of 25% or more. Anal canal and sphincter lengths in patients after sphincterotomy did not significantly differ from those in asymptomatic women. LIMITATIONS The study is limited by its nonrandomized nature and the lack of preoperative ultrasound assessment. CONCLUSIONS Based on data from this study, the safe extent of division is less than 25% of the total sphincter length, which in women corresponds to less than 1 cm.
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D'Ugo S, Franceschilli L, Cadeddu F, Leccesi L, Blanco GDV, Calabrese E, Milito G, Di Lorenzo N, Gaspari AL, Sileri P. Medical and surgical treatment of haemorrhoids and anal fissure in Crohn's disease: a critical appraisal. BMC Gastroenterol 2013; 13:47. [PMID: 23496835 PMCID: PMC3602071 DOI: 10.1186/1471-230x-13-47] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Accepted: 02/28/2013] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The principle to avoid surgery for haemorrhoids and/or anal fissure in Crohn's disease (CD) patients is still currently valid despite advances in medical and surgical treatments. In this study we report our prospectively recorded data on medical and surgical treatment of haemorrhoids and anal fissures in CD patients over a period of 8 years. METHODS Clinical data of patients affected by perianal disease were routinely and prospectively inserted in a database between October 2003 and October 2011 at the Department of Surgery, Tor Vergata University Hospital, Rome. We reviewed and divided in two groups records on CD patients treated either medically or surgically according to the diagnosis of haemorrhoids or anal fissures. Moreover, we compared in each group the outcome in patients with prior diagnosis of CD and in patients diagnosed with CD only after perianal main treatment. RESULTS Eighty-six CD patients were included in the study; 45 were treated for haemorrhoids and 41 presented with anal fissure. Conservative approach was initially adopted for all patients; in case of medical treatment failure, the presence of stable intestinal disease made them eligible for surgery. Fifteen patients underwent haemorrhoidectomy (open 11; closed 3; stapled 1), and two rubber band ligation. Fourteen patients required surgery for anal fissure (Botox ± fissurectomy 8; LIS 6). In both groups we observed high complication rate, 41.2% for haemorrhoids and 57.1% for anal fissure. Patients who underwent haemorrhoidectomy without certain diagnosis of CD had significantly higher risk of complications. CONCLUSIONS Conservative treatment of proctologic diseases in CD patients has been advocated given the high risk of complications and the evidence that spontaneous healing may also occur. From these preliminary results a role of surgery is conceivable in high selected patients, but definitve conclusions can't be made. Further randomized trials are needed to establish the efficacy of the surgical approach, giving therapeutic recommendations and guidelines.
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Affiliation(s)
- Stefano D'Ugo
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Luana Franceschilli
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Federica Cadeddu
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Laura Leccesi
- Department of Internal Medicine, Catholic University, Rome, Italy
| | | | - Emma Calabrese
- Department of Gastroenterology, University Hospital Tor Vergata, Rome, Italy
| | - Giovanni Milito
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Nicola Di Lorenzo
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Achille L Gaspari
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Pierpaolo Sileri
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
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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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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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Arslan K, Erenoğlu B, Doğru O, Kökçam S, Turan E, Atay A. Effect of chronic anal fissure components on isosorbide dinitrate treatment. World J Surg 2012; 36:2225-9. [PMID: 22526048 DOI: 10.1007/s00268-012-1604-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic anal fissure is diagnosed in the presence of persistent symptoms: The classic triad includes a linear mucosal tear exposing the internal sphincter fibers, hypertrophied anal papilla, and a sentinel skin tag. Thus, chronic anal fissure can be divided into three components: the fissure itself; hypertrophied anal papilla; the sentinel skin tag. Not every chronic anal fissure has all three components; some have two components, and others present with only a persistent fissure. The success rate of medical treatment for chronic anal fissure is reported as 42-86 %. In this study, we intended to observe the effect of said components on healing with isosorbide dinitrate treatment. METHODS A total of 105 patients with chronic anal fissures were admitted and were divided into three groups. Patients in group I had a single component (only the fissure with a linear mucosal tear exposing the internal sphincter fibers); group II had two components (skin tag or hypertrophied papilla in addition to the fissure); group III had all three components (fissure, skin tag, hypertrophied papilla). Isosorbide dinitrate 0.25 % was applied three times a day. RESULTS The success rates in the study groups were 93, 74, and 64 %, respectively. The success rate was significantly higher for group I than for groups II and III. CONCLUSIONS Chronic anal fissure components should be considered when evaluating the success rates of studies reporting the results of various medical treatments. The number of components seems to be an important factor that affects the results of isosorbide dinitrate treatment.
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Affiliation(s)
- K Arslan
- Department of General Surgery, Konya Training and Research Hospital, Konya 42100, Turkey.
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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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Abstract
PURPOSE The main purpose of this study was to investigate the efficacy and safety of botulinum toxin in the treatment of anal fissure. An answer was attempted to the following research questions: (i) what is the efficacy of botulinum toxin in healing of anal fissure compared to placebo, (ii) what is the efficacy of botulinum toxin in healing of anal fissure compared to other means of chemical sphincterotomy, (iii) what is the efficacy of botulinum toxin in healing of anal fissure compared to surgical sphincterotomy, (iv) what is the short term safety of botulinum toxin injections and (v) what is the long term safety of botulinum toxin injections. METHODS Clinical trials investigating the effect of botulinum toxin in the treatment of anal fissure met inclusion criteria. Case reports and case series were also included for the estimation of safety. Meta-analysis was not performed due to clinical heterogeneity. RESULTS The comparator could be placebo, nitroglycerin ointment, or lateral internal sphincterotomy, with dosage ranging from 20 IU to 50 IU of botulinum toxin. Fissure healing was the most commonly reported primary endpoint but the time period from botulinum toxin injection to fissure healing ranged from 2 weeks to 4 months. Accordingly, outcome data were also heterogenous. CONCLUSIONS Botulinum toxin injections should be considered a minimally invasive therapeutic option for the treatment of chronic anal fissure. However, well designed randomized trials are needed for the valid estimation of the efficacy and safety of botulinum toxin in this therapeutic indication.
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Madalinski MH. Identifying the best therapy for chronic anal fissure. World J Gastrointest Pharmacol Ther 2011; 2:9-16. [PMID: 21577312 PMCID: PMC3091162 DOI: 10.4292/wjgpt.v2.i2.9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2010] [Revised: 03/20/2011] [Accepted: 03/28/2011] [Indexed: 02/06/2023] Open
Abstract
Chronic anal fissure (CAF) is a painful tear or crack which occurs in the anoderm. The optimal algorithm of therapy for CAF is still debated. Lateral internal sphincterotomy (LIS) is a surgical treatment, considered as the ‘gold standard’ therapy for CAF. It relieves CAF symptoms with a high rate of healing. Chemical sphincterotomy (CS) with nitrates, calcium blockers or botulinum toxin (BTX) is safe, with the rapid relief of pain, mild side-effects and no risk of surgery or anesthesia, but is a statistically less effective therapy for CAF than LIS. This article considers if aggressive treatment should only be offered to patients who fail pharmacological sphincterotomy. Aspects of anal fissure etiology, epidemiology and pathophysiology are considered with their meaning for further management of CAF. A molecular model of chemical interdependence significant for the chemistry of CAF healing is examined. Its application may influence the development of optimal therapy for CAF. BTX is currently considered the most effective type of CS and discussion in this article scrutinizes this method specifically. Although the effectiveness of BTX vs. LIS has been discussed, the essential focus of the article concerns identifying the best therapy application for anal fissure. Elements are presented which may help us to predict CAF healing. They provide rationale for the expansion of the CAF therapy algorithm. Ethical and economic factors are also considered in brief. As long as the patient is willing to accept the potential risk of fecal incontinence, we have grounds for the ‘gold standard’ (LIS) as the first-line treatment for CAF. We conclude that, when the diagnosis of the anal fissure is established, CS should be considered for both ethical and economic reasons. The author is convinced that a greater understanding and recognition of benign anal disorders by the GP and a proactive involvement at the point of initial diagnosis would facilitate the consideration of CS at an earlier, more practical stage with improved outcomes for the patient.
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Affiliation(s)
- Mariusz H Madalinski
- Mariusz H Madalinski, NHS Lothian-University Hospitals Division, Edinburgh EH4 2XU, United Kingdom
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