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Botulinum toxin versus other therapies for treatment of chronic anal fissure. COLOPROCTOLOGY 2020. [DOI: 10.1007/s00053-020-00497-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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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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Alvandipour M, Ala S, Khalvati M, Yazdanicharati J, Koulaeinejad N. Topical Minoxidil Versus Topical Diltiazem for Chemical Sphincterotomy of Chronic Anal Fissure: A Prospective, Randomized, Double-Blind, Clinical Trial. World J Surg 2018; 42:2252-2258. [PMID: 29290068 DOI: 10.1007/s00268-017-4449-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Anal fissure is a common anorectal problem causing severe pain and discomfort to the patients. Chemical sphincterotomy has emerged as a noninvasive alternative to the surgical methods of fissure treatment. The objective of this study was evaluation of the efficacy and the adverse effects of topically applied minoxidil in chemical sphincterotomy of chronic anal fissure in comparison with topical diltiazem. METHODS A total of 88 patients with chronic anal fissure aged between 15 and 65 years were included in this double-blind, randomized clinical trial and were randomly assigned to either 0.5% minoxidil cream or 2% diltiazem cream twice daily for 2 weeks. The pain intensity, bleeding, wound healing, itching, headache, dizziness, significant drop in blood pressure, allergy and fissure relapse were assessed on a monthly basis for 2 months. RESULTS Both diltiazem and minoxidil reduced the pain, bleeding and improved fissure healing with no significant difference. There were no between-groups differences in the frequencies of adverse effects, except for itching which was slightly higher with minoxidil during the first month. Allergy occurred in two patients in the minoxidil group, which was not severe and did not lead to discontinuation of the trial. CONCLUSION Topically administered minoxidil is of equal efficacy as diltiazem in the treatment of chronic anal fissure with low frequency of adverse effects. Thus, it can be considered as an agent for chemical sphincterotomy of anal fissure, but the itching at the beginning of the treatment can affect the adherence of the patient to treatment. Trial registration number IRCT2015041414483N6 (the full trial protocol could be accessed online at www.irct.ir ).
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Affiliation(s)
- Mina Alvandipour
- Department of Surgery, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Mazandaran Province, Iran
| | - Shahram Ala
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, 18th Km Farahabad Boulevard, Sari, Mazandaran Province, 48175861, Iran.
| | - Mehdi Khalvati
- Department of Surgery, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Mazandaran Province, Iran
| | - Jamshid Yazdanicharati
- Department of Health, Biostatistics and Medical Research, Mazandaran University of Medical Sciences, Sari, Mazandaran Province, Iran
| | - Neda Koulaeinejad
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, 18th Km Farahabad Boulevard, Sari, Mazandaran Province, 48175861, Iran
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Ala S, Enayatifard R, Alvandipour M, Qobadighadikolaei R. Comparison of captopril (0.5%) cream with diltiazem (2%) cream for chronic anal fissure: a prospective randomized double-blind two-centre clinical trial. Colorectal Dis 2016; 18:510-6. [PMID: 26456162 DOI: 10.1111/codi.13147] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 07/17/2015] [Indexed: 02/08/2023]
Abstract
AIM This study compared the efficacy of topical captopril with topical diltiazem in the treatment of chronic anal fissure (CAF). METHOD Fifty patients aged between 15 and 75 years with CAF were included in a prospective randomized, double-blind clinical trial. They were randomly allocated to either captopril (0.5%) cream or diltiazem (2%) cream in a dose of 2 cm of cream on the perianal skin every 12 h for 8 weeks. The intensity of pain upon defaecation was evaluated every 10 days using a visual analogue scale. Bleeding on defaecation, pruritus and the presence of perianal irritation were also recorded before and during the trial. RESULTS The average pain scores were lower in the diltiazem group on the 20th and 30th days. From day 40 to the end of the trial the average pain scores of the two groups did not differ significantly. There were no significant differences in bleeding or perianal irritation between the groups, but the incidence of pruritus was considerably higher in the captopril group, and at the end of the trial 45.8% of the patients in this group still suffered from pruritus. CONCLUSION Topical captopril and diltiazem were found to be equally effective in the management of pain, bleeding and perianal irritation due to CAF, but due to the high incidence of pruritus observed with topical captopril this medication is not recommended for the treatment of CAF.
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Affiliation(s)
- S Ala
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran
| | - R Enayatifard
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran
| | - M Alvandipour
- Department of Surgery, Imam Khomeini General Hospital affiliated to Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran
| | - R Qobadighadikolaei
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran
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C M G, Babu P, Rao KS. A Comparative Study of Lateral Sphincterotomy and 2% Diltiazem Gel Local Application in the Treatment of Chronic Fissure in ANO. J Clin Diagn Res 2014; 8:NC01-2. [PMID: 25478389 DOI: 10.7860/jcdr/2014/10480.4925] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 07/21/2014] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Anal fissures are commonly encountered in routine clinical practice. Anal fissure has traditionally been treated surgically. Developments in the pharmacological understanding of the internal anal sphincter have resulted in more conservative approaches towards treatment. In this study we compare symptomatic relief, healing and side effects of topical 2% Diltiazem gel and lateral internal sphincterotomy in the treatment of chronic fissure in ano. MATERIALS AND METHODS In this prospective trial, 60 surgical out patients and/or admitted patients with chronic fissure in ano were randomly divided into Group 1 (Diltiazem gel) and Group 2 (internal sphincterotomy) with 30 patients in each Group. Patients were followed up at weekly intervals for six consecutive weeks and biweekly for subsequent 3 months. RESULTS Fissure was completely healed in 88.46% of patients in Group 1 and in 100% in Group 2. The mean duration required for healing of fissure was 5.04 weeks in Group 1 and 3.6 weeks in Group 2. 78.26% patients were free from pain in Group 1 whereas 85.18% patients were free from pain in Group 2. No patient had any side effects in either group. CONCLUSION Topical Diltiazem should be considered as first line treatment in chronic fissure in ano. Internal sphincterotomy should be reserved for patients with relapse and therapeutic failure to prior pharmacological treatment.
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Affiliation(s)
- Giridhar C M
- Ex-Resident, Department of General Surgery, Bangalore Medical College and Research Institute , Bangalore, India
| | - Preethitha Babu
- Resident, Department of General Surgery, Bangalore Medical College and Research Institute , Bangalore, India
| | - K Seshagiri Rao
- Professor, Department of General Surgery, Bangalore Medical College and Research Institute , Bangalore, India
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Topical diltiazem in management of chronic anal fissure: a review of the literature. ACTA ACUST UNITED AC 2014. [DOI: 10.4155/cli.14.86] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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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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Abstract
Anal fissure is a common anorectal disorder resulting in anal pain and bleeding. Fissures can either heal spontaneously and be classified as acute, or persist for 6 or more weeks and be classified as chronic, ultimately necessitating treatment. Anal stenosis is a challenging problem most commonly resulting from trauma, such as excisional hemorrhoidectomy. This frustrating issue for the patient is equally as challenging to the surgeon. This article reviews these 2 anorectal disorders, covering their etiology, mechanism of disease, diagnosis, and algorithm of management.
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Affiliation(s)
- Sherief Shawki
- Department of Colorectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Jindal T, Mandal SN, Biswas G, Karmakar D. Evaluation of the efficacy of a combination of diltiazem and periprostatic nerve block in pain control during transrectal ultrasonography-guided biopsy of the prostate. Ann R Coll Surg Engl 2013; 95:361-4. [PMID: 23838501 PMCID: PMC4165141 DOI: 10.1308/003588413x13629960046318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2012] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The choice of analgesia during prostate biopsy remains controversial. The pain has dual origin: from the insertion of the probe as well as the biopsy itself. Periprostatic nerve block (PPNB) is currently the gold standard modality for decreasing pain of prostate biopsy but it does not alleviate the pain of probe insertion. A randomised controlled trial was performed to test the efficacy and safety of the combination of topical application of diltiazem gel and PPNB for pain control during transrectal ultrasonography guided prostate biopsy. METHODS A total of 73 patients who were to undergo their first prostate biopsy were randomised to receive either 2ml of 2% topical diltiazem gel or a placebo 15 minutes before the biopsy. All the patients then had a PPNB using 1% lignocaine. A ten- point visual analogue scale was used to record the pain immediately after the insertion of the probe and during the biopsy. Any adverse effects were also recorded. RESULTS There was no significant difference in the mean age and prostate volumes between the groups. There was a significantly lower mean pain score due to probe insertion in those patients who received topical diltiazem than in the placebo group (p<0.0001). There was no significant difference between the pain scores during the biopsy itself between the two groups. CONCLUSIONS Topical diltiazem significantly reduces the pain of probe insertion during prostate biopsy and can be used effectively as an adjuvant to PPNB.
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Affiliation(s)
- T Jindal
- Department of Urology, Calcutta National Medical College, 32 Gorachand Road, Beniapukur, Kolkata - 700 014, India.
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Sajid MS, Whitehouse PA, Sains P, Baig MK. Systematic review of the use of topical diltiazem compared with glyceryltrinitrate for the nonoperative management of chronic anal fissure. Colorectal Dis 2013; 15:19-26. [PMID: 22487078 DOI: 10.1111/j.1463-1318.2012.03042.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
AIM The study analyzed clinical trials investigating the effectiveness of diltiazem (DTZ) and glyceryltrinitrate (GTN) for the nonsurgical management of chronic anal fissure (CAF). METHOD Randomized trials on the effectiveness of DTZ and GTN were analyzed systematically using RevMan(®) where combined outcome was expressed as risk ratio (RR). RESULTS Seven randomized controlled trials that included 481 patients were analyzed. Two-hundred and thirty-eight patients were treated with DTZ and 243 patients were treated with GTN. There was significant heterogeneity [Tau(2) = 0.24, χ2 = 13.16, d.f. = 6 (P < 0.05); I(2) = 54%] among the included trials. In the random-effects model, DTZ was associated with a lower incidence of side effects (RR = 0.48; 95% CI = 0.27, 0.86; z = 2.46; P < 0.01), headache (RR = 0.39; 95% CI = 0.24, 0.66; z = 3.54; P < 0.004) and recurrence (RR = 0.68; 95% CI = 0.52, 0.89; z = 2.77; P < 0.006) of CAF. Both GTN and DTZ were equally effective (RR = 1.10; 95% CI = 0.90, 1.34; z = 0.92; P = 0.36) in the nonsurgical management of CAF. CONCLUSION This systematic review of seven trials validates and strengthens the finding of a previously published meta-analysis of two randomized trials. Both DTZ and GTN are equally effective in the management of CAF. However, DTZ is associated with a lower incidence of headache and recurrent fissure. Therefore DTZ should be the preferred first line of treatment for CAF.
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Affiliation(s)
- M S Sajid
- Department of Colorectal Surgery, Worthing Hospital, Worthing, UK.
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Medhi B, Prakash A, Upadhyay S, Xess D, Yadav TD, Kaman L. Comparison of observational and controlled clinical trials of diltiazem in the treatment of chronic anal fissure. Indian J Surg 2011. [PMID: 23204700 DOI: 10.1007/s12262-011-0340-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Diltiazem has been extensively studied in the treatment of chronic anal fissures, but efficacy in clinical practice is not fully established. The aim of the present study was to evaluate the safety and efficacy of topical application diltiazem in observational studies as well as in controlled clinical trials in the treatment of chronic anal fissures. A systematic literature search was carried out from 1966 to 31 December, 2007 on PubMed, Medline, Embase and Cochrane database, using the appropriate search words. We found six observational studies with 392 patients and five controlled clinical trials with 289 patients in which topical diltiazem treatment was given. Efficacy was found to be very high in observational studies (56.88%), whereas it was found to be modest in controlled clinical trials (29.41%). In observational studies, most of the patients reported complete healing of fissures within 6-12 weeks, whereas in controlled trials healing was reported within 8 weeks, with tolerable adverse effects of diltiazem. On the basis of the above studies, it can be concluded that topical application of diltiazem is useful in the treatment of chronic anal fissure, but to fully establish its efficacy, larger prospective double-blind study is required in the near future.
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Affiliation(s)
- Bikash Medhi
- Department of Pharmacology and General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India ; Department of Clinical Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Puche JJ, García-Coret MJ, Villalba FL, Ali-Mahmoud I, Roig JV. Tratamiento local de la fisura anal crónica con diltiazem vs. nitroglicerina. Estudio comparativo. Cir Esp 2010; 87:224-30. [DOI: 10.1016/j.ciresp.2009.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Revised: 11/26/2009] [Accepted: 12/06/2009] [Indexed: 10/19/2022]
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Puche JJ, José García-Coret M, Villalba FL, Ali-Mahmoud I, Roig JV. Local treatment of a chronic anal fissure with diltiazem vs. nitroglycerin. A comparative study. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/s2173-5077(10)70052-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Medhi B, Rao RS, Prakash A, Prakash O, Kaman L, Pandhi P. Recent Advances in the Pharmacotherapy of Chronic Anal Fissure: An Update. Asian J Surg 2008; 31:154-63. [DOI: 10.1016/s1015-9584(08)60078-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Collins EE, Lund JN. A review of chronic anal fissure management. Tech Coloproctol 2007; 11:209-23. [PMID: 17676270 DOI: 10.1007/s10151-007-0355-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2007] [Accepted: 06/26/2007] [Indexed: 12/14/2022]
Abstract
Anal fissure management has rapidly progressed in the last 15 years as our understanding of fissure pathophysiology has developed. All methods of treatment aim to reduce the anal sphincter spasm associated with chronic anal fissures. Surgical techniques have been used for over 100 years with success. Lateral internal sphincterotomy remains the surgical treatment of choice for many practitioners. Postoperative impairment of continence remains controversial. Recently, less invasive methods of treatment have been explored. Topical nitrates, calcium channel blockers and botulinum toxin are established treatments. These and other non-surgical treatments are described in this review. Various guidelines and treatment algorithms for anal fissure are also discussed.
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Affiliation(s)
- E E Collins
- Department of Surgery, University of Nottingham Medical School, Derby, Derby City General Hospital, Uttoxeter Road, Derby, DE22 3DT, UK.
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Abstract
INTRODUCTION Anal fissures are commonly encountered in routine colorectal practice. Developments in the pharmacological understanding of the internal anal sphincter have resulted in more conservative approaches towards treatment. Simple measures are often effective for early fissures. Glyceryl trinitrate is well established as a first-line pharmacological therapy. The roles of diltiazem and botulinum, particularly as rescue therapy, are not well understood. Surgery has a defined role and should not be discounted completely. METHODS Data were obtained from Medline publications citing 'anal fissure'. Manual cross-referencing of salient articles was conducted. We have sought to highlight various controversies in the management of anal fissures. FINDINGS Acute fissures may heal spontaneously, although simple conservative measures are sufficient. Idiopathic chronic anal fissures need careful evaluation to decide what therapy is suitable. Pharmacological agents such as glyceryl trinitrate (GTN), diltiazem and botulinum toxin have been subjected to most scrutiny. Though practices in the UK vary, GTN or diltiazem would be suitable as first-line therapy with botulinum toxin used as rescue treatment. Sphincterotomy is indicated for unhealed fissures; fissurectomy has been revisited and advancement flaps have a role in patients in whom sphincter division is not suitable.
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Affiliation(s)
- R Bhardwaj
- Department of Surgery, Darent Valley Hospital, Dartford, Kent, UK
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Placer C, Elósegui JL, Irureta I, Mujika JA, Goena I, Enríquez Navascués JM. La respuesta inicial al diltiazem tópico puede predecir la evolución de la fisura anal crónica. Cir Esp 2007; 82:16-20. [PMID: 17580026 DOI: 10.1016/s0009-739x(07)71655-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION In the last few years, the medical treatment of chronic anal fissure (chemical sphincterotomy) has been introduced as a consequence of the morbidity attributed to surgical sphincterotomy. However, medical treatment has two disadvantages: moderate effectiveness (between 30% and 80%) and the need for treatment to be prolonged for more than 8 weeks. OBJECTIVE To evaluate initial response to topical diltiazem 2% topical gel as a predictive factor in the curability of chronic anal fissure. PATIENTS AND METHOD From February 2004 to December 200, all patients with a history of anal fissure of more than 6 weeks were included in this study. Pregnant patients and those with prior anal surgery, inflammatory bowel disease, diltiazem intolerance and problems for maintaining contact during follow-up were excluded. A magistral formula of diltiazem 2% gel was used in three applications daily for 8 weeks. Patients were followed-up clinically and pain was measured through a visual analog scale (VAS) at the end of weeks 1, 3, 6, and 8. Groups with and without response to diliazem were compared through the chi2 test, Fisher's exact test and Student's t-test. A Receiver Operating Characteristic (ROC) curve was used to evaluate the diagnostic efficacy of initial pain response to diliazem, as well as sensitivity, specificity and predictive values. RESULTS One hundred patients (70 men), with a mean age of 43 years (22-76) were analyzed. Localization was posterior in 87%, anterior in 11% and lateral in 2%. All patients had pain, 65 had bleeding, and 13 had pruritus. At the end of the 8-week treatment, cure was achieved in 62%, with morbidity of 5% (mild headache in 2%, and pruritus in 3%). No significant differences were found between the groups with and without response to diltiazem 2% in terms of age, sex, localization, bleeding, or pruritus. Notable differences were found in the VAS for pain at the end of weeks 1, 3, 6, and 8 between the two groups (p = 0.00). ROC curves established a cut-off point of 4 in the VAS at the end of week 1, with an area below the curve of 0.925 (95% CI, 0.858-0.989). The capacity of early response to diliazem to predict curability showed a sensitivity of 85.5% (95% CI, 74.7%-92.2%), a specificity of 92.1% (95% CI, 79.2%-97.3%), a positive predictive value of 94.6% (95% CI, 85.4%-98.2%), and a negative predictive value of 79.5% (95% CI, 65.5%-88.8%). Among patients who showed no response to diltiazem by the end of week 1, cure was achieved in only 9% at 8 weeks. In contrast, among those with a favorable response in the first week, cure was achieved in 94.6%. CONCLUSIONS Lack of response to topical diltiazem 2% gel at the end of the first week reliably predicts failure of medical treatment for chronic anal fissure, obviating the need to prolong treatment for 8 weeks.
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Affiliation(s)
- Carlos Placer
- Sección de Cirugía Colorrectal, Departamento de Cirugía, Hospital Donostia, San Sebastián, Guipúzcoa, Spain.
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Abstract
Chronic anal fissure (CAF) is usually associated with internal anal sphincter spasm, the relief of which is central to provide fissure healing. The treatment for CAF has undergone a transformation in recent years from surgical to medical. Both the approaches share the common goal of reducing the spasm. Though surgical treatment has a high success rate, it can permanently impair fecal continence in a large number of patients. Smooth muscle relaxation seems to be a novel way by which more than 60% of the patients can be cured with the topical use of the agents. This treatment is in addition to the normalization of stools mostly. Smooth muscle relaxation is well tolerated, can be administered on an outpatient basis, does not cause any lesion of the continence organ, and subsequently, does not lead to any permanent latent or apparent fecal incontinence. This review encompasses various agents that are used for smooth muscle relaxation. In addition, it describes various clinical studies reported in the literature with their success rates and side effects.
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Affiliation(s)
- Sanju Dhawan
- University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, India
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Abstract
INTRODUCTION Anal fissure is a common and distressing problem the true incidence of which is probably higher than recorded. There is a progressive understanding of the etiopathogenesis of this entity and the changing trend in its management approach. This is a systematic review of available published literature looking at current management options in anal fissures. METHODS A MEDLINE-based search of the relevant literature from 1970 to 2004 was performed on the current concepts in etiopathogenesis and management of anal fissure. RESULTS The current opinion is a drift toward conservative measures as the first- and second-line approaches rather than surgery for treatment of anal fissure. Simple and readily available measures with less complication, good patient compliance, and satisfaction requiring no hospitalization should first be considered. CONCLUSIONS Most anal fissures heal with medical therapy, but their limitations include side effects, poor compliance, and recurrence of the fissure. A cautious surgical approach is required to treat those who do not respond to medical therapy.
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Abstract
BACKGROUND Anal fissure is one of the most common anorectal conditions encountered in clinical practice. Most patients experience anal pain with defecation and minor bright red rectal bleeding, allowing a focused history to direct the evaluation. METHODS A systematic medical literature search of NIH, Pubmed, and MEDLINE using the search terms anal fissure, sphincterotomy, anal surgery and anal fissure medical therapy. English language was not a restriction. Cited references were used to find additional studies. RESULTS No single treatment is the best choice for all patients. Because pharmacological therapy is not associated with permanent alterations in continence, a trial of either a topical sphincter relaxant or botulin toxin injection, along with adequate fluid and fibre intake, is a reasonable option. However, because pharmacological therapy has lower healing and higher relapse rates, surgery can be offered in the first instance to patients without incontinence risk factors who have severe, unrelenting pain and are willing to accept a small risk of incontinence, for the highest likelihood of prompt healing and the lowest risk of recurrence. CONCLUSIONS Both non-operative and operative approaches currently exist for the management of anal fissure. Improved non-surgical therapies may continue to lessen the role of sphincter-dividing surgery in future.
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Affiliation(s)
- S R Steele
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA, USA
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Acheson AG, Scholefield JH. Pharmacological advancements in the treatment of chronic anal fissure. Expert Opin Pharmacother 2005; 6:2475-81. [PMID: 16259578 DOI: 10.1517/14656566.6.14.2475] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Chronic anal fissure is a tear in the lining of the anal canal that, if not treated appropriately at an early stage, causes considerable anal pain during defaecation. Surgery is no longer considered the first-line treatment of this common condition, as recent advancements in medical treatment has produced promising results in the healing of fissures, thus avoiding the unwanted complications that frequently occur following operative treatment. This review looks at those pharmacological agents used commonly in the treatment of chronic anal fissures and explores alternative therapies that may be of benefit in the future.
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Affiliation(s)
- Austin G Acheson
- Division of Gastrointestinal Surgery, Queen's Medical Centre, Nottingham, NG7 2UH, UK.
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Abstract
BACKGROUND The treatment of chronic anal fissure has shifted in recent years from surgical to medical. METHODS A Medline search of studies relevant to modern management of chronic anal fissure was undertaken. RESULTS Traditional surgery that permanently weakens the internal sphincter is associated with a risk of incontinence. Medical therapies temporarily relax the internal sphincter and pose no such danger, but their limited efficacy has led to displacement rather than replacement of traditional surgery. Emerging medical therapies promise continued improvement and new sphincter-sparing surgery may render traditional surgery redundant. CONCLUSION First-line use of medical therapy cures most chronic anal fissures cheaply and conveniently. The few non-responders can be targeted for sphincter assessment before traditional surgery. If the initial good results of new sphincter-sparing surgery are confirmed, it may be possible to avoid any risk of incontinence, while achieving high rates of fissure healing.
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Affiliation(s)
- I Lindsey
- Department of Colorectal Surgery, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU,
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