The management of persistent and recurrent chronic anal fissures

The Association of Coloproctology of Great Britain and Ireland guideline on the management of anal fissure

AIM

The management of anal fissure: ACPGBI position statement was written 15 years ago. [KLR Cross et al., Colorectal Dis, 2008]. Our aim was to update the guideline and provide recommendations on the most effective treatment for patients with anal fissures utilising a multidisciplinary, rigorous guideline methodology.

METHODS

The development process consisted of six phases. In phase 1 we defined the scope of the guideline. The patient population included patients with acute and chronic anal fissure. The target group was all practitioners (primary and secondary care) treating patients with fissures and, in addition, healthcare workers and patients who desired information regarding fissure management. In phase 2 we formed a guideline development group (GDG) including a methodologist. In phase 3 review questions were formulated, using a reversed PICO process, starting with possible recommendations based on the GDG's knowledge. In phase 4 a comprehensive literature search focused on existing systematic reviews addressing each review question, supplemented by more recent studies if appropriate. In phase 5 data were extracted from the included papers and checked by the GDG. If indicated, meta-analysis of systematic review data was updated by the GDG. During phase 6 the GDG members decided what recommendations could be made based on the evidence in the literature and strength of the recommendation was assessed using 'grade'.

RESULTS

This guideline is divided into two sections: Primary care which includes (i) diagnosis; (ii) basic treatment; (iii) topical treatment; and secondary care which includes (iv) botulinum toxin therapy; (v) surgical intervention and (vi) special situations (including pregnancy and breast-feeding patients, children, receptive anal intercourse and low-pressure fissures). A total of 23 recommendations were formulated. A new term clinically healed was described by the GDG.

CONCLUSION

This guideline provides an up-to-date evidence-based summary of the current knowledge of the management of anal fissure and may serve as a useful guide for clinicians as well as a potential reference for patients.

Anoplastia com plicoma sentinela para o tratamento de fissura anal crônica

RESUMO Objetivo: avaliar os resultados de longo prazo da correção de fissuras anais crônicas em pacientes sem hipertonia anal usando a técnica de anoplastia com o plicoma sentinela. Métodos: estudo prospectivo de pacientes com fissura anal crônica refratários ao tratamento conservador e sem hipertonia anal, submetidos à operação de anoplastia com utilização do plicoma anal para cobrir a área cruenta. Foi confirmada a ausência de hipertonia anal através do toque retal e da eletromanometria. Foi aplicado um questionário de dor visual e o escore de incontinência fecal da Cleveland Clinic, antes e após a cirurgia. Resultados: quinze pacientes com fissura anal crônica foram acompanhados por um período médio de 29 meses (12 a 56). A média de idade foi 41 anos (29 a 69) e a duração dos sintomas variou entre seis meses e cinco anos. A cicatrização ocorreu entre três e seis semanas para 13 pacientes (86,7%). Os outros dois pacientes foram submetidos a desbridamento e nova anoplastia, com sucesso. Em nenhum paciente ocorreu necrose do plicoma ou estenose anal. O escore de incontinência anal não se alterou após o procedimento e todos os pacientes referiram melhora da dor. Após 12 meses de seguimento, nenhum paciente apresentou recorrência ou incontinência anal e 93,3% (14/15) dos pacientes responderam estar muito satisfeitos. Conclusão: fissurectomia e anoplastia com o uso do plicoma sentinela é uma técnica segura que resulta em melhora da dor sem alterações da continência fecal e com altas taxas de satisfação.

Early Results of Fissurectomy and Advancement Flap for Resistant Chronic Anal Fissure without Hypertonia of the Internal Anal Sphincter

The aim of this study was to assess the efficacy of fissurectomy with skin advancement flap in healing chronic anal fissures without hypertonia of the internal anal sphincter. Twenty-six consecutive patients who failed healing after well-practiced topical medical therapy were enrolled. Anorectal manometry was performed preoperative and 6 months postoperatively. All patients were treated with fissurectomy and advancement flap through healthy skin tissue. All patients healed completely within 30 days from operation. The intensity and the duration of pain post-defecation was reduced significantly with respect to the preoperative values starting from the first defecation. One patient suffered urinary retention, two patients suffered infections, and two partial breakdowns were recorded. At 6 months the maximum resting pressure values were similar to those were detected preoperatively. One month after surgery, anal incontinence was reported in seven patients, four of whom complained about it preoperatively. At 12 months, only three subjects reported incontinence. No patients needed reoperation and no recurrences were detected. The fissurectomy, in combination with advancement flap, is a safe sphincter-saving procedure for the treatment of chronic anal fissures without hypertonia of internal anal sphincter that fails medical conservative treatment.

Anal fissures associated with targeted therapies in ovarian cancer

Although ovarian cancer remains a leading cause of gynecologic cancer death, targeted therapies are improving patient outcomes. Anal fissures are a side effect of targeted therapies that can disrupt or stop treatment regimens. Diagnosis and management of anal fissures by advanced practice nurses are crucial for maintaining the quality of life of patients with ovarian cancer.

Subcutaneous lateral internal sphincterotomy (SLIS)--a safe technique for treatment of chronic anal fissure

OBJECTIVE

Subcutaneous lateral internal sphincterotomy (SLIS) is an effective treatment for fissure in ano but carries a definite risk of incontinence. The aim of this study was to assess the efficacy and complications of SLIS in patients with chronic fissure in ano.

MATERIALS AND METHODS

All patients presenting with a chronic anal fissure who underwent SLIS were entered into a prospective database. This is a review of these patients over 5 year's period (September 2002-2007). All operations were performed or directly supervised by a consultant colorectal surgeon. Short-term follow-up was at the first outpatient appointment (6 weeks postoperatively) and any impairment of continence was documented.

RESULTS

During the study period of 5 years, 96 patients underwent SLIS at our institution. Median patient age was 45 years (range 19-81). The median duration of symptoms was 65 days. No fissure failed to heal after SLIS. Minor complications were noted in five patients; 85% (82/96) attended the follow-up and out of these, 6% (5/82) reported early incontinence. One patient was incontinent to flatus, one to liquid and three to solid stool. After 12 weeks of follow-up, two patients were completely symptom free, one was incontinent to flatus and two were incontinent to liquid stool.

CONCLUSION

SLIS remains an effective treatment for chronic anal fissure. A small proportion of patients do suffer from faecal incontinence, which may be permanent in some cases. Careful patient selection and proper surgical training can reduce this risk.

Current concepts in anal fissures

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.