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Akinmoladun O, Oh W. Management of Hemorrhoids and Anal Fissures. Surg Clin North Am 2024; 104:473-490. [PMID: 38677814 DOI: 10.1016/j.suc.2023.11.001] [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: 04/29/2024]
Abstract
Hemorrhoids and anal fissures are two of the most common benign anorectal diseases. Despite their high prevalence, diagnostic accuracy of benign anorectal disease is suboptimal at 70% for surgeons, especially for hemorrhoidal diseases. Once the diagnosis is correctly made, numerous medical and surgical treatment options are available, each with different rates of success and complications. In this article, the authors review each step of patient management, with emphasis on evidence-based treatment options for hemorrhoids and anal fissures. The article discusses the pathophysiology, diagnosis, medical management, and procedures for hemorrhoids followed by a detailed overview on the management of anal fissures.
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Affiliation(s)
- Oladapo Akinmoladun
- General Surgery, Madigan Army Medical Center, 9040 Jackson Avenue, Tacoma, WA 98431, USA
| | - William Oh
- Colon and Rectal Surgery, Hoag Speicalty Clinic, 16305 Sand Canyon Avenue, Suite 260, Irvine, CA 92618, USA.
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Brisinda G, Fico V, Tropeano G, Altieri G, Chiarello MM. Effectiveness and safety of botulinum toxin injection in the treatment of recurrent anal fissure following lateral internal sphincterotomy: cohort study. BJS Open 2024; 8:zrad156. [PMID: 38323879 PMCID: PMC10848301 DOI: 10.1093/bjsopen/zrad156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/03/2023] [Accepted: 11/18/2023] [Indexed: 02/08/2024] Open
Affiliation(s)
- Giuseppe Brisinda
- University Department of Translational Medicine and Surgery, Catholic School of Medicine, Rome, Italy
- Emergency and Trauma Surgery Unit, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCS, Rome, Italy
| | - Valeria Fico
- Emergency and Trauma Surgery Unit, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCS, Rome, Italy
| | - Giuseppe Tropeano
- Emergency and Trauma Surgery Unit, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCS, Rome, Italy
| | - Gaia Altieri
- Emergency and Trauma Surgery Unit, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCS, Rome, Italy
| | - Maria Michela Chiarello
- General Surgery Operative Unit, Department of Surgery, Provincial Health Authority, Cosenza, Italy
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Asefa Z, Awedew AF. Comparing closed versus open lateral internal sphincterotomy for management of chronic anal fissure: systematic review and meta-analysis of randomised control trials. Sci Rep 2023; 13:20957. [PMID: 38017243 PMCID: PMC10684486 DOI: 10.1038/s41598-023-48286-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: 01/21/2023] [Accepted: 11/24/2023] [Indexed: 11/30/2023] Open
Abstract
Chronic anal fissure is one of the most common benign anorectal health conditions, causing significant morbidity, quality of life, and economic loss. Eight randomized controlled trials with a total population size of 1035 were eligible for analysis. Seven studies included both males and female, while one only included females. The majority of randomized controlled trials involved female dominance [54.9% (43.5-66.3)] and posterior midline location [86.1% (95% CI 81.5-90.8%)]. This meta-analysis of randomised control trials found that overall postoperative healing was 90.2%, recurrent anal fissure was 3.7%, and postoperative incontinence was 8.9% after LIS. Even though there was no statistically significant difference, closed lateral internal sphincterotomy (LIS) had higher rates of recurrent anal fissure (RR = 1.73 (95% CI 0.86-3.47, p = 0.90, I2 = 0%) and lower rates of postoperative incontinence rate (RR = 0.60 (95% CI 0.37-0.96, p = 0.76, I2-0) as compared with open LIS. We recommended that closed lateral internal sphincterotomy (LIS) is a safe and effective surgical treatment option for chronic anal fissures.
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Affiliation(s)
- Zelalem Asefa
- Department of Surgery, SoM, Addis Ababa University, Addis Ababa, Ethiopia
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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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Alyanak A, Gulen M, Ege B. Comparison of botulinum toxin (BoNT) injection and lateral internal sphincterotomy (redo-LIS) for recurrent anal fissure treatment. Front Surg 2022; 9:988082. [PMID: 36204342 PMCID: PMC9530271 DOI: 10.3389/fsurg.2022.988082] [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: 07/06/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Today's gold standard for treating chronic anal fissure is the Lateral Internal Sphincterotomy (LIS). Botulinum Toxin (BoNT) injection is, on the other hand, an alternative treatment for patients who do not want to have surgical treatment, patients undergoing chemotherapy, patients of high risk for surgery, and those who have the risk of anal incontinence (e.g., elderly, past anorectal surgery, vaginal multiple births, etc.). The aim of this study is to compare the effectiveness of BoNT and redo-LIS for treatment of post-LIS recurrent chronic anal fissure, and reveal differences if any.This study aims to compare redo-LIS and BoNT injection for treating post-LIS recurrent anal fissure. Material and method Nineteen patients who received LIS treatment and then redo-LIS or BoNT injection due to recurrence in the follow-up were included in this study. Group I (redo-LIS group) include 11 patients and group 2 (BoNT group) includes 8 patients. Their data on age, sex, anal incontinence scores and pain (VAS score) score as well. Results During the 3-month post-surgery follow-up period, there was statistically significant difference (p < 0.01) between groups by pain. No deterioration in the incontinence scores of patients in the group during the 6-month post-surgery period. Conclusion This study demonstrates that redo lateral internal sphincterotomy (LIS) is a reliable method for patients who received LIS but developed recurrent chronic anal fissure, and achieves successful results in terms of recurrence and relief of pain.
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Affiliation(s)
- Ahmet Alyanak
- Department of General Surgery, Yuksek Ihtisas University Affiliated Medical Park Ankara Private Hospital, Ankara, Turkey
- Correspondence: Ahmet Alyanak
| | - Merter Gulen
- Department of General Surgery, Medicana Hospital, Ankara, Turkey
| | - Bahadır Ege
- Department of General Surgery, Yuksek Ihtisas University Affiliated Medical Park Ankara Private Hospital, Ankara, Turkey
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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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Jia L, Hou M, Cheng H, Liu R. "Hand As Foot" teaching method in anal anatomy: A surgeon's teaching experience. Asian J Surg 2021; 44:704-705. [PMID: 33674182 DOI: 10.1016/j.asjsur.2021.01.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 01/21/2021] [Indexed: 10/22/2022] Open
Affiliation(s)
- Longlong Jia
- Inner Mongolia Medical University, Department of Gastrointestinal Surgery, Affiliated Hospital of Inner Mongolia Medical University, Huhehot North Street, Inner Mongolia, 010050, China
| | - Mingxing Hou
- Inner Mongolia Medical University, Department of Gastrointestinal Surgery, Affiliated Hospital of Inner Mongolia Medical University, Huhehot North Street, Inner Mongolia, 010050, China.
| | - Haidong Cheng
- Inner Mongolia Medical University, Department of Gastrointestinal Surgery, Affiliated Hospital of Inner Mongolia Medical University, Huhehot North Street, Inner Mongolia, 010050, China
| | - Rui Liu
- Inner Mongolia Medical University, Department of Gastrointestinal Surgery, Affiliated Hospital of Inner Mongolia Medical University, Huhehot North Street, Inner Mongolia, 010050, China
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Al-Thoubaity F. Safety and efficacy of the treatment of chronic anal fissure by lateral internal sphincterotomy: A retrospective cohort study. Ann Med Surg (Lond) 2020; 57:291-294. [PMID: 32904150 PMCID: PMC7452092 DOI: 10.1016/j.amsu.2020.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/07/2020] [Accepted: 08/07/2020] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Fatma Al-Thoubaity
- Department of Surgery, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
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