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Burtic SR, Castiglione L, Murariu M, Rosca O, Dumitru C, Neagoe O. Assessment of Quality of Life in Patients with Chronic Anal Fissures: A 1-Year Follow-Up Study before and after Botulinum Toxin (Botox) Injection. J Clin Med 2024; 13:316. [PMID: 38256449 PMCID: PMC10816032 DOI: 10.3390/jcm13020316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
This longitudinal study aimed to assess the quality of life in patients with anal fissures treated with botulinum toxin (Botox) injections over a one-year period. The study hypothesized that Botox injections would significantly improve quality of life and that these improvements would be sustained over a year. Conducted as a cross-sectional study, it assessed adults diagnosed with chronic anal fissures unresponsive to conventional treatments. Participants received 25 U of Botox in two sessions and their quality of life was assessed using the WHOQOL-BREF, COPE-60, Hospital Anxiety and Depression Scale (HADS), and SF-36 surveys. Data were collected at baseline six months and one year post-treatment. The study involved 113 patients, with a mean age of 38.1 years. Significant improvements were observed in the WHOQOL-BREF scores across all domains from baseline to 12 months (physical domain: 49.4 ± 10.5 to 70.2 ± 10.6, p < 0.001; mental domain: 34.8 ± 11.2 to 61.9 ± 11.5, p < 0.001). SF-36 scores also showed significant enhancements in physical and mental health components (physical: 44.3 ± 7.5 to 56.9 ± 5.9, p < 0.001; mental: 41.1 ± 7.2 to 54.4 ± 6.3, p < 0.001). Additionally, significant improvements were noted in patient perception on quality of life from the perspective of various aspects including physical discomfort, pain management, and mood and emotional well-being. The study demonstrated that Botox injections significantly improved the quality of life in patients with chronic anal fissures, with sustained benefits observed over a year. These findings suggest Botox as an effective treatment modality for enhancing life quality in patients with this condition, highlighting the potential for broader applications in managing chronic anal fissures.
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Affiliation(s)
- Sonia-Roxana Burtic
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania;
- Department II, Discipline of Medical Communication, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Luca Castiglione
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania;
- Department of General Surgery, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania;
| | - Marius Murariu
- Department of General Surgery, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania;
| | - Ovidiu Rosca
- Department of Infectious Diseases, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania;
| | - Catalin Dumitru
- Department of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania;
| | - Octavian Neagoe
- Second Discipline of Surgical Semiology, First Department of Surgery, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
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Hormati A, Ghadir MR, Alemi F, Sarkeshikian SS, Mohammadbeigi A, Ahmadpour S, Eshagh-Hoseini SJ. Comparison of the Effects of Diltiazem Gel with Lidocaine Gel on Reducing Pain and Discomfort in Patients Undergoing Rectosigmoidoscopy: A Randomized Double-blinded Clinical Trial. CURRENT DRUG THERAPY 2021. [DOI: 10.2174/1574885516666210125112637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
Flexible rectosigmoidoscopy is an easy and accessible exam to diagnose
distal colon diseases, although many patients refuse to undergo it due to pain and discomfort during
the procedure. Studies show that the application of local lidocaine, as an analgesic has no effect
on pain relief in patients undergoing rectosigmoidoscopy. The current study aims at comparing the
effects of diltiazem gel, an antispasmoic drug with local pain-reducing effects, with lidocaine gel in
patients undergoing flexible rectosigmoidoscopy.
Materials and Methods:
The current double-blinded, randomized, clinical trial was performed to
compare the effect of two topical drugs, lidocaine and diltiazem, on pain relief in patients undergoing
rectosigmoidoscopy. A total of 80 patients who were potential candidates for rectosigmoidoscopy
were enrolled in the study after obtaining the informed consent and then randomly assigned
to one of the lidocaine gel (2 mL) or diltiazem gel (2 mL) group, 10 minutes prior to rectosigmoidoscopy.
The level of pain in the patients during the procedure was measured using the visual analogue
scale (VAS) and the results were recorded. The data were analyzed using paired samples ttest
and independent t-test as well as analysis of covariance (ANOVA) with SPSS version 18. P-value
<0.05 was considered the level of significance.
Results:
Of 80 patients, 35 (43.75%) were male and 45 (56.25%) female. The mean age and body
mass index (BMI) of the patients were 51.45 ± 15.21 years and 25.95 ± 7.47 kg/m2, respectively,
and there was no significant difference between the groups. The most frequent indications for rectosigmoidoscopy
were abdominal pain (46.3%) and rectorrhagia (31.3%). The mean VAS score for
pain reported by the patients in the lidocaine and diltiazem groups was 3.97 ± 2.89 and 2.60 ± 2.36,
respectively. The VAS score for pain in the diltiazem group was significantly lower than lidocaine
group (P = 0.023).
Conclusion:
The application of local diltiazem gel around the anus, in spite of no side effects, can
effectively reduce the pain and discomfort in patients during rectosigmoidoscopy. Iranian Registry
of Clinical Trials (Reg. No 31055).
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Affiliation(s)
- Ahmad Hormati
- Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences, Qom, Iran
| | - Mohammad Reza Ghadir
- Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences, Qom, Iran
| | - Faezeh Alemi
- Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences, Qom, Iran
| | - Seyed Saeid Sarkeshikian
- Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences, Qom, Iran
| | - Abolfazl Mohammadbeigi
- Department of Biostatistics and Epidemiology, School of Health Research Center for Environmental Pollutants, Qom University of Medical Sciences, Qom, Iran
| | - Sajjad Ahmadpour
- Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences, Qom, Iran
| | - Seyed Jalal Eshagh-Hoseini
- Department of Surgery, School of Medicine, Shahid Beheshti Hospital, Qom University of Medical Sciences, Qom, Iran
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Mosleh G, Hosseini SV, Azadi A, Bahrami F, Ghahramani L, Badr P, Zaeri M, Abolhassanzadeh Z, Mohagheghzadeh A. Erysimum cheiri and Rosa × damascena cerate vs. Diltiazem 2% gel in the treatment of acute anal fissure: A randomized, controlled clinical trial. Eur J Integr Med 2020. [DOI: 10.1016/j.eujim.2020.101230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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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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Vaithianathan R, Panneerselvam S. Randomised Prospective Controlled Trial of Topical 2 % Diltiazem Versus Lateral Internal Sphincterotomy for the Treatment of Chronic Fissure in Ano. Indian J Surg 2015; 77:1484-7. [PMID: 27011607 PMCID: PMC4775569 DOI: 10.1007/s12262-014-1080-z] [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] [Received: 11/29/2013] [Accepted: 04/23/2014] [Indexed: 11/25/2022] Open
Abstract
Fissure in ano is a very common disorder of the anorectal region. Internal sphincter hypertonia with decreased relaxation coupled with mucosal ischemia of posterior anal canal are the major pathologies in chronic anal fissure (CAF). Though lateral internal sphincterotomy (LIS) remains the gold standard of treatment for the disease, it is accompanied by the potential complication of incontinence to both flatus and faecal matter. The aim of our study was to explore the role of topical diltiazem as an effective and a safe alternative to sphincterotomy for chronic anal fissure. Ninety patients with CAF were randomly assigned to group A and group B, with 45 patients each. Group A patients received 2 % diltiazem topical application, twice daily, and group B patients underwent LIS. All the patients were reviewed at first, fourth and sixth week after initiation of treatment. Visual analogue scores for pain and healing of fissure by visual inspection were recorded and compared. In group A, 71 % had complete healing of fissure at 6 weeks, with fair amount of pain relief (mean VAS-3.38), and in group B, 96 % showed healing of fissure, with excellent pain relief (mean VAS-1.87). Headache and flushing were noted in two patients in group A while no patients in group B developed incontinence. We conclude that LIS is more effective than topical diltiazem in the treatment of CAF. Topical diltiazem may be employed as an initial conservative treatment option before considering the surgical alternative.
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Affiliation(s)
- Rajan Vaithianathan
- />Department of General Surgery, Mahatma Gandhi Medical College & Research Institute, Puducherry, 607402 India
| | - Senthil Panneerselvam
- />Department of General Surgery, Chennai Medical College Hospital & Research Centre, Trichy, 621105 India
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Imani F, Moghaddam Y, Shariat Moharari R, Etezadi F, Khajavi MR, Hosseini SR. Intrarectal Lidocaine-Diltiazem-Meperidine Gel for Transrectal Ultrasound Guided Prostate Biopsy. Anesth Pain Med 2015; 5:e22568. [PMID: 26161317 PMCID: PMC4493733 DOI: 10.5812/aapm.5(3)2015.22568] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 09/01/2014] [Accepted: 10/04/2014] [Indexed: 12/02/2022] Open
Abstract
Background: TRUS-guided needle biopsy of the prostate gland is the current standard method used for diagnosis of prostate cancer. Pain control during this procedure is through the use of i.v. sedation or local anaesthetic (LA), depending on clinician preference. Objectives: The aim of this study was to evaluate the effectiveness of intrarectal lidocaine, lidocaine-diltiazem and lidocaine-meperidine-diltiazem gel for anesthetizing transrectal ultrasound guided prostate biopsy. Patients and Methods: In a randomized double-blind clinical trial, 100 consecutive patients were divided into three groups. The patients received one of the gels before transrectal ultrasound guided prostate needle biopsy: group A, intrarectal and perianal lidocaine, gel 1 g; group B, intrarectal lidocaine gel, 1 g, + perianal diltiazem, 1 g; group C, intrarectal lidocaine gel, 1 g, + meperidine, 25 mg, and perianal diltiazem, 1 g. Visual analog pain scale was used to estimate pain during probe insertion and biopsy. Heart rate and blood pressure during probe insertion and biopsy were recorded too. Results: The mean of visual analog pain scale was 4.5 in group A, 3.5 in group B, and 2.0 in group C during probe insertion (P value = 0.01). The mean of visual analog pain scale was 5.1 in group A, 3.5 group B, and 2.5 in group C during biopsy (P value = 0.001). The groups were comparable for patients' age, weight, serum prostate-specific antigen (PSA), and prostate size (P > 0.05). No side effects of meperidine and lidocaine including drowsiness, dizziness, tinnitus and light-headedness or requiring assistance for activity were noted. Conclusions: Lidocaine-meperidine-diltiazem gel provides significantly better pain control than lidocaine-diltiazem gel and lidocaine gel alone during transrectal ultrasound guided prostate biopsy and probe insertion. This mixture gel is safe, easy to administer and well accepted by patients.
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Affiliation(s)
- Farsad Imani
- Department of Anesthesia, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Yasaman Moghaddam
- Department of Anesthesia, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Shariat Moharari
- Department of Anesthesia, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Farhad Etezadi
- Department of Anesthesia, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Khajavi
- Department of Anesthesia, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Reza Hosseini
- Department of Urology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Corresponding author: Seyed Reza Hosseini, Department of Urology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran. Tel: +98-9122083800, E-mail:
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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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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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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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A pilot comparative study of fissurectomy/diltiazem and fissurectomy/botulinum toxin in the treatment of chronic anal fissure. Tech Coloproctol 2008; 12:331-6; discussion 336. [PMID: 19018466 DOI: 10.1007/s10151-008-0444-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2008] [Accepted: 09/15/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND Treatment of chronic anal fissure (CAF) by fissurectomy with botulinum toxin A (BTA) injection results in a healing rate of greater than 90%. BTA injection, however, can cause incontinence and perianal sepsis. The decrease in sphincter pressure following topical treatment with 2% diltiazem cream (DTC) is comparable to that following BTA injection but with potentially fewer complications and at less cost. We report the shortterm results of a pilot study comparing fissurectomy with BTA and fissurectomy followed by DTC for the treatment of CAF. METHODS The recorded outcomes of CAF following treatment with the two methods were analysed retrospectively. Patients underwent either fissurectomy followed by injection of 40 U BTA into the internal sphincter (group A) or fissurectomy followed by the perianal application of DTC twice daily for 8 weeks (group B). Symptom resolution and treatment side effects at the initial follow-up were compared. RESULTS Demographics, fissure characteristics and the number of multiparous women between the two groups were comparable. At a median follow-up of 12 weeks (range 8-20 weeks), the two groups had similar rates of complete symptom resolution (group A, 25/28, 89.3%; group B, 19/23, 82.6%; p=0.7739), with minor side effects. CONCLUSIONS In this small pilot study fissurectomy combined with chemical sphincterotomy resulted in high short-term fissure healing rates. The study also suggested that fissurectomy followed by 8 weeks of topical DTC may be as good as fissurectomy with BTA injection in the treatment of CAF. A prospective study, adequately powered to determine the significance of differences is needed.
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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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Cesar MAP, Klug WA, Bassi DG, Paula PRD, Cesar RP, Ortiz JA, Speranzini MB. Efeito da nifedipina gel 0,2% nas pressões de canal anal e na dor pós-operatória: estudo após hemorroidectomia pela técnica aberta. ACTA ACUST UNITED AC 2007. [DOI: 10.1590/s0101-98802007000400002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUÇÃO: As hemorróidas são muito freqüentes e após o seu tratamento cirúrgico tem se observado que a dor causa muito sofrimento. Várias alternativas tem sido estudadas para melhorar a dor pós-operatória dentre elas a esfincterotomia cirúrgica que pode em alguns casos causar algum grau de incontinência fecal. Por esse motivo vários estudos tem utilizado a esfincterotomia química com nifedipina, diltiazen, trinitrato de glicerina e toxina botulínica. O objetivo dessa pesquisa foi avaliar o efeito da nifedipina tópica nas diminuições das pressões do canal anal e consequente influência na melhora da dor pós-operatória. MATERIAL E MÉTODO: Utilização da nifedipina tópica gel 0,2% (Grupo 1) e lidocaina 2% (Grupo 2) no pós operatório de hemorroidectomia aferindo as pressões no pré, primeiro, quarto e sétimo dias de pós operatório, associado de medida de dor todos os dias do pós-operatório através de tabela analógica. RESULTADOS: Os autores não encontraram diferenças em relação às pressões de canal anal mas em relação à dor referida estas foram em menor intensidade no grupo que recebeu a nifedipina. CONCLUSÕES: a nifedipina gel foi eficiente na analgesia pós-operatória, no entanto não alterou as pressões do canal anal.
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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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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
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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Abstract
Treating common benign anal diseases has evolved towards more outpatient procedures with better outcome. However, minimizing post-procedure morbidities such as pain and the avoidance incontinence remain the most significant concerns. We introduce some controversies and highlight the developments in current surgical practice for the treatment of common anal problems.
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Affiliation(s)
- Ismail Sagap
- Department of Colorectal Surgery (A-30), Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, 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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