Randomised Prospective Controlled Trial of Topical 2 % Diltiazem Versus Lateral Internal Sphincterotomy for the Treatment of Chronic Fissure in Ano

A systematic review and network meta-analysis comparing treatments for anal fissure

BACKGROUND

There are multiple treatments for anal fissures. These range from medical treatment to surgical procedures, such as sphincterotomy. The aim of this study was to compare the relative clinical outcomes and effectiveness of interventional treatments for anal fissure.

METHODS

Randomized controlled trials were identified by means of a PRISMA-compliant systematic review using the Medline, EMBASE, and CENTRAL databases. Inclusion criteria were randomized controlled trials comparing treatments for anal fissure. A Bayesian network meta-analysis was performed using BUGSnet package in R. Outcomes of interest were healing (6-8-, 10-16-, and >16-week follow-up), symptom recurrence, pain (measured on a visual analog scale), and fecal or flatus incontinence. PROPSERO Registration: CRD42021229615.

RESULTS

Sixty-nine randomized controlled trials were included in the analysis. Lateral sphincterotomy remains the treatment with the highest odds of healing compared to botulinum toxin and medical therapy at all follow-up time points. There was no significant difference in healing between botulinum toxin and medical therapy at any time point. Advancement flap showed similar effectiveness compared to lateral sphincterotomy. Medical treatment and botulinum toxin had the highest pain scores at follow-up. Sphincterotomy had the highest odds of fecal and flatus incontinence.

CONCLUSION

Lateral sphincterotomy had the highest rates of healing and should be considered as the definitive treatment after failed initial therapy with botulinum toxin or medical treatment. Botulinum toxin was equally effective compared to medical treatment. Advancement flap shows similar effectiveness compared to lateral sphincterotomy, but more studies are needed to evaluate its efficacy.

Safety and efficacy of the treatment of chronic anal fissure by lateral internal sphincterotomy: A retrospective cohort study

Background

An anal fissure is one of the most common anorectal diseases resulting from a longitudinal tear in anoderm under the dentate line. It causes severe pain during defecation, and the resulting emotional stress leads to a reduction in the overall quality of life of a person. There are several medical and surgical treatment procedures that are employed to treat anal fissures. In the present retrospective study, we aimed to evaluate the safety and efficacy of lateral internal sphincterotomy (LIS) surgical procedure for the treatment of chronic anal fissure. Additionally, we also analyzed the complications arising after the surgery and the factors affecting the complications.

Methods

The present study is a retrospective study that included 691 patients treated for chronic anal fissure in a private sector setting, by a single Saudi female surgeon, starting from April 2004 to April 2020.

Results

Out of the 691 patients included in the study, all the patients were female, with an average age of 45.77 years (ranging from 17 to 82 years). Major complaints of the patients were as follows: pain, bleeding, constipation, pruritus, perianal discharge. Recurrence was reported in 2 patients (0.3%) while, 3 patients (0.4%) developed gas incontinence.The complaints of all patients with gas incontinence regressed over a period of time.

Conclusion

This study reports that lateral internal sphincterotomy (LIS) is a safe surgical treatment for chronic anal fissure, leading to a reduction in recurrence, incontinence rate and substantially improves symptoms, especially pain.

S3-Leitlinie: Analfissur

Die 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.

In vitro and ex vivo studies on diltiazem hydrochloride-loaded microsponges in rectal gels for chronic anal fissures treatment

Diltiazem hydrochloride, topically applied at 2% concentration, is considered effective for the treatment of chronic anal fissures, although it involves several side effects among which anal pruritus and postural hypotension. To test the hypothesis that a sustained delivery system of diltiazem hydrochloride may be helpful for the treatment of chronic anal fissures, in the present study we evaluated the potential of gels containing diltiazem hydrochloride entrapped in microsponges. Such microsponges were based on Eudragit RS 100 and the effect of some formulation variables was assessed by a 2³ full factorial screening design. An optimized formulation of diltiazem hydrochloride microsponges was dispersed in Methylcellulose 2% or Poloxamer 407 20% and the resulting gels (micro-l-diltiazem hydrochloride 2%) were subjected to in vitro drug release, ex vivo permeability and drug deposition after application on porcine rectal mucosa. The results showed a prolonged release up to 24 h from micro-l-diltiazem hydrochloride at 2% in the gels. The permeation tests revealed up to 18% higher drug retention on the mucosal tissue after 24 h by the micro-l-diltiazem hydrochloride 2% gels compared to conventional diltiazem hydrochloride gels at 2%. These results suggest that diltiazem hydrochloride-loaded microsponges dispersed in rectal gels may be useful to overcome some limitations of conventional local chronic anal fissure therapy.

Could local antibiotics be included in the treatment of acute anal fissure?

OBJECTIVE

Acute anal fissure is a very common disorder of the anorectal region. Its most widely used treatment method is the medications given in addition to conservative therapies. The objective of the present study was to investigate the effects of local metronidazole use in the treatment of acute anal fissure on the symptoms and remission processes of the patients.

MATERIAL AND METHODS

This was a prospective, randomized, controlled clinical study conducted on 100 consecutive patients who presented to our clinic between March 2016 and March 2017 and who were diagnosed with acute anal fissure. Patients were randomly divided into two groups of 50 persons. Patients in Group 1 were given only 5% lidocaine pomade as a local anesthesia, and those in Group 2 were given 5% lidocaine pomade and metronidazole cream. Patients applied the medications topically to the anal margin 3 times per day for 4 weeks. Patients' demographic characteristics, such as age and gender, were recorded. All patients were invited for check-up at the end of weeks 1, 2, and 4 of treatment. The Visual Analogue Scale scores for pain and the healing status of their fissure by visual inspection, as well as any adverse effects of the drugs, were recorded. The results were compared statistically. A p-value <0.05 was considered significant.

RESULTS

The mean ages of the patients were 34.2±4.1 years in Group 1 and 36.6±3.8 years in Group 2. As a result of the statistical comparison of the Visual Analogue Scale scores, there was a statistically significant difference between the two groups at the end of weeks 2 and 4 (p=0.004 and p<0.001, respectively). In Group 1, 28 (56%) patients recovered, but no recovery was observed in 22 (44%) patients. In Group 2, 43 (86%) patients recovered, whereas 7 (14%) patients had no recovery (p=0.004).

CONCLUSION

The topical antimicrobial treatment with metronidazole as an addition to the classical medical treatments in acute anal fissure is an effective and safe practice resulting in further reduction in pain and increased healing rate.

A systematic review and meta-analysis of the treatment of anal fissure

BACKGROUND

Anal fissure has a very large number of treatment options. The choice is difficult. In an effort to assist in that, choice presented here is a systematic review and meta-analysis of all published treatments for anal fissure that have been studied in randomized controlled trials.

METHODS

Randomized trials were sought in the Cochrane Controlled Trials Register, Medline, EMBASE and the trials registry sites clinicaltrials.gov and who/int/ictrp/search/en. Abstracts were screened, full-text studies chosen, and finally eligible studies selected and abstracted. The review was then divided into those studies that compared two or more surgical procedures and those that had at least one arm that was non-surgical. Studies were further categorized by the specific interventions and comparisons. The outcome assessed was treatment failure. Negative effects of treatment assessed were headache and anal incontinence. Risk of bias was assessed for each study, and the strength of the evidence of each comparison was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

RESULTS

One hundred and forty-eight eligible trials were found and assessed, 31 in the surgical group and 117 in the non-surgical group. There were 14 different operations described in the surgical group and 29 different non-surgical treatments in the non-surgical group along with partial lateral internal sphincterotomy (LIS). There were 61 different comparisons. Of these, 47 were reported in 2 or fewer studies, usually with quite small patient samples. The largest single comparison was glyceryl trinitrate (GTN) versus control with 19 studies. GTN was more effective than control in sustained cure (OR 0.68; 95% CI 0.63-0.77), but the quality of evidence was very poor because of severe heterogeneity, and risk of bias due to inadequate clinical follow-up. The only comparison to have a GRADE quality of evidence of high was a subgroup analysis of LIS versus any medical therapy (OR 0.12; CI 0.07-0.21). Most of the other studies were downgraded in GRADE due to imprecision.

CONCLUSIONS

LIS is superior to non-surgical therapies in achieving sustained cure of fissure. Calcium channel blockers were more effective than GTN and with less risk of headache, but with only a low quality of evidence. Anal incontinence, once thought to be a frequent risk with LIS, was found in various subgroups in this review to have a risk between 3.4 and 4.4%. Among the surgical studies, manual anal stretch performed worse than LIS in the treatment of chronic anal fissure in adults. For those patients requiring surgery for anal fissure, open LIS and closed LIS appear to be equally efficacious, with a moderate GRADE quality of evidence. All other GRADE evaluations of procedures were low to very low due mostly to imprecision.

Pharmacodynamic evaluation of Lys5, MeLeu9, Nle10-NKA(4-10) prokinetic effects on bladder and colon activity in acute spinal cord transected and spinally intact rats

The purpose of this study was to determine feasibility of a novel therapeutic approach to drug-induced voiding after spinal cord injury (SCI) using a well-characterized, peptide, neurokinin 2 receptor (NK2 receptor) agonist, Lys5, MeLeu9, Nle10-NKA(4-10) (LMN-NKA). Cystometry and colorectal pressure measurements were performed in urethane-anesthetized, intact, and acutely spinalized female rats. Bladder pressure and voiding were monitored in response to intravenous LMN-NKA given with the bladder filled to 70% capacity. LMN-NKA (0.1-300 μg/kg) produced dose-dependent, rapid (<60 s), short-duration (<15 min) increases in bladder pressure. In intact rats, doses above 0.3-1 μg/kg induced urine release (voiding efficiency of ~70% at ≥1 μg/kg). In spinalized rats, urine release required higher doses (≥10 μg/kg) and was less efficient (30-50%). LMN-NKA (0.1-100 μg/kg) also produced dose-dependent increases in colorectal pressure. No tachyphylaxis was observed, and the responses were blocked by an NK2 receptor antagonist (GR159897, 1 mg/kg i.v.). No obvious cardiorespiratory effects were noted. These results suggest that rapid-onset, short-duration, drug-induced voiding is possible in acute spinal and intact rats with intravenous administration of an NK2 receptor agonist. Future challenges remain in regard to finding alternative routes of administration that produce clinically significant voiding, multiple times per day, in animal models of chronic SCI.