Endosonographic and manometric evaluation of internal anal sphincter in patients with chronic anal fissure and its correlation with clinical outcome after topical glyceryl trinitrate therapy

Botulinum toxin associated with fissurectomy and anoplasty for hypertonic chronic anal fissure: A case-control study

BACKGROUND

Lateral internal sphincterotomy is still the approach of choice for the treatment of chronic anal fissure (CAF) with internal anal sphincter (IAS) hypertonia, but it is burdened by high-risk postoperative faecal incontinence (FI). Sphincter saving procedures have recently been reconsidered as treatments to overcome this risk. The most employed procedure is fissurectomy with anoplasty, eventually associated with pharmacological sphincterotomy.

AIM

To evaluate whether fissurectomy and anoplasty with botulinum toxin injection improves the results of fissurectomy and anoplasty alone.

METHODS

We conducted a case-control study involving 30 male patients affected by CAF with hypertonic IAS who underwent fissurectomy and anoplasty with V-Y cutaneous flap advancement. The patients were divided into two groups: Those in group I underwent surgery alone, and those in group II underwent surgery and a botulinum toxin injection directly into the IAS. They were followed up for at least 2 years. The goals were to achieve complete healing of the patient and to assess the FI and recurrence rate along with manometry parameters.

RESULTS

The intensity and duration of post-defecatory pain decreased significantly in both groups of patients starting with the first defecation, and this reduction was higher in group II. Forty days after surgery, we achieved complete wound healing in all the patients in group II but only in 80% of the patients in group I (P < 0.032). We recorded 2 cases of recurrence, one in each group, and both healed with conservative therapy. We recorded one temporary and low-grade postoperative case of "de novo" FI. Manometry parameters reverted to the normal range earlier for group II patients.

CONCLUSION

The injection of botulinum toxin A in association with fissurectomy and anoplasty with a V-Y advancement flap improves the results of surgery alone in patients affected by CAF with IAS hypertonia.

S3-Leitlinie: Analfissur

Die Analfissur ist eine der häufigsten Pathologien, welche sich dem Proktologen präsentiert. Entsprechend ist es wichtig, verlässliche Leitlinien dazu zu entwickeln. Die aktuelle Leitlinie wurde anhand eines systematischen Literaturreview von einem interdisziplinären Expertengremium diskutiert und verabschiedet.

Die akute Analfissur, soll auf Grund ihrer hohen Selbstheilungstendenz konservativ behandelt werden. Die Heilung wird am besten durch die Einnahme von Ballaststoff reicher Ernährung und einer medikamentösen Relaxation durch Kalziumkanal-Antagonisten (CCA) unterstützt. Zur Behandlung der chronischen Analfissur (CAF), soll den Patienten eine medikamentöse Behandlung zur „chemischen Sphinkterotomie“ mittels topischer CCA oder Nitraten angeboten werden. Bei Versagen dieser Therapie, kann zur Relaxation des inneren Analsphinkters Botulinumtoxin injiziert werden. Es ist belegt, dass die operativen Therapien effektiver sind. Deshalb kann eine Operation schon als primäre Therapie oder nach erfolgloser medikamentöser Therapie erfolgen. Die Fissurektomie, evtl. mit zusätzlicher Botulinumtoxin Injektion oder Lappendeckung, ist die Operation der Wahl. Obwohl die laterale Internus Sphinkterotomie die CAF effektiver heilt, bleibt diese wegen dem höheren Risiko für eine postoperative Stuhlinkontinenz eine Option für Einzelfälle.

Operative and medical treatment of chronic anal fissures-a review and network meta-analysis of randomized controlled trials

Anal fissures are a common problem and have a cumulative lifetime incidence of 11%. Previous reviews on anal fissures show inconsistent results regarding post-interventional healing and incontinence rates. In this review our aim was to compare the treatments for chronic anal fissures by incorporating indirect comparisons using network meta-analysis. The PubMed database was searched for randomized controlled trials (RCTs) published between 1975 and 2015. The primary outcome measures were healing and incontinence rates after lateral internal sphincterotomy (LIS), anal dilatation (DILA), anoplasty and/or fissurectomy (FIAP), botulinum toxin (BT) and noninvasive treatment (NIT). Random effects network meta-analyses were complemented by fixed effects and Bayesian models. The present analysis included 44 RCTs and 3268 patients. After a median follow-up of 2 months, the healing rates for LIS, DILA, FIAP, BT and NIT were 93.1, 84.4, 79.8, 62.6, and 58.6% and the incontinence rates were 9.4, 18.2, 4.9, 4.1, and 3.0%, respectively. Compared with NIT, the odds ratio (OR) [95% confidence interval (CI)] for healing after LIS, DILA, FIAP and BT was 9.9 (5.4-18.1), 8.6 (3.1-24.0), 3.5 (1.0-12.7) and 1.9 (1.1-3.5), respectively, on network meta-analysis. The OR (95% CI) for incontinence after LIS, DILA, FIAP and BT was 6.8 (3.1-15.1), 16.9 (6.0-47.8), 3.9 (1.0-15.1) and 1.6 (0.7-3.7), respectively. Ranking of treatments, fixed effects and Bayesian models confirmed these findings. In conclusion, based on our meta-analysis LIS is the most efficacious treatment but is compromised by a high rate of postoperative incontinence. Given the trade-offs between the risks and benefits, FIAP and BT might be good alternatives for the treatment of chronic anal fissures.

Chronic anal fissure: morphometric analysis of the anal canal at 3.0 Tesla MR imaging

OBJECTıVE: To compare the morphometric data relating to the muscular structures of the anal canal, in patients with chronic anal fissure and in control group, examined at a 3.0 Tesla MR system.

SUBJECTS AND METHODS

Forty-seven consecutive patients with chronic anal fissure and randomly selected 40 patients who had no claims for perianal disease during their life time were included in the study. T2-weighted sagittal, high-resolution (HR) T2-weighted, and contrast-enhanced fat-suppressed T1-weighted oblique axial and oblique coronal images were retrospectively analyzed by two observers in consensus. Thickness of sphincteric muscles, anal canal length, anorectal angle, thickness of anococcygeal ligament, depth of Minor triangle, width between subcutaneous sphincters, vascularity of posterior commissure, visibility of posterosuperior projection of external sphincter, and angle between the distal anal canal and posterosuperior projection of external sphincter (H angle) in patients and in controls were compared and analyzed using t test, Mann-Whitney U test, and Spearman correlation.

RESULTS

The patients with chronic anal fissure had longer anal canal (51.50 mm ± 0.91 vs. 44.11 mm ± 0.71; p = 0.000), thicker internal anal sphincter muscle at mid-anal level (4.18 ± 0.15 vs. 3.39 ± 0.07; p = 0.007), and wider space between subcutaneous external sphincters (11.39 ± 0.50 vs. 6.89 ± 0.22; p = 0.000). In patients, there was a positive correlation between H angle and external sphincter thickness at proximal (r = 0.347; p = 0.021), middle (r = 0427; p = 0.000), and distal (r = 0.518; p = 0.000)) levels of the anal canal. CONCLUSıON: 3.0 Tesla MR imaging provides detailed information about the morphometric changes in the anal sphincter muscles in patients with chronic anal fissure.

Transperineal sonographic anal sphincter complex evaluation in chronic anal fissures

OBJECTIVES

The purpose of this study was to assess the role of transperineal sonography in assessment of pathologic changes to the anal sphincter complex in patients with chronic anal fissures.

METHODS

We conducted a prospective case-control study of 100 consecutive patients of any age and both sexes with chronic anal fissures who presented to a colorectal clinic between January 2012 and August 2013 (group A) and 50 healthy volunteers (group B).

RESULTS

The most common patterns of radiologic changes to anal sphincters associated with chronic anal fissures were circumferential thickening of the anal sphincter complex in 5 patients (5%), circumferential thickening of the internal anal sphincter in 3 patients (3%), preferential thickening of the internal anal sphincter at the 6-o'clock position in 80 patients (80%) and the 12-o'clock position in 7 patients (7%), preferential thickening of the internal and external anal sphincters in 3 patients (3%), and thinning of the internal anal sphincter in 2 patients (2%).

CONCLUSIONS

Chronic anal fissures cause differential thickening of both internal and external anal sphincters, with a trend toward increased thickness in relation to the site of the fissure. Routine preoperative transperineal sonography for patients with chronic anal fissures is recommended, and it is mandatory in high-risk patients.

Manometric Evaluation of Internal Anal Sphincter after Fissurectomy and Anoplasty for Chronic Anal Fissure: A Prospective Study

Chronic anal fissure (CAF) is a common painful clinical disease and its pathogenesis remains poorly understood. After failure of pharmacological therapy, that is the first-line treatment, surgical sphincterotomy remains the treatment of choice although it is followed by a high rate of anal incontinence resulting from the sphincter damage; therefore, the research of a sphincter-saving surgical option has become an important goal. The aim of this study was to evaluate the manometric modifications and the incidence of anal incontinence after fissurectomy and anoplasty with advancement skin flap in patients affected by CAF with hypertonia of the internal anal sphincter (IAS). Fifteen patients affected by CAF with hypertonia of IAS, unresponsive to medical therapy, were enrolled. All subjects underwent fissurectomy and anoplasty with advancement skin flap. Anorectal manometry was performed preoperatively and after 6 and 12 months from surgery. Maximum resting pressure (MRP), maximum squeeze pressure (MSP), ultraslow wave activity (USWA), fissure healing, anal continence, and postoperative complications were recorded. All patients healed within 30 days from surgery. No intra- or postoperative complications were recorded except for a case of partial donor site break. No significant modifications of MSP were detected. Six months after surgery, MRP was higher with respect to healthy subjects but significantly reduced in comparison to baseline levels. At 12 months, it was higher have versus 6-month values but significantly lower versus preoperative values. USWA was significantly represented in patients with CAF versus healthy subject. Both at 6 and 12 months, they decreased significantly with respect to preoperative values without significant differences versus healthy subjects. Both at 6 and 12 months, anal continence did not differ with respect to preoperative time. The fissurectomy with anoplasty resulted in a high healing rate without surgical sequelae or anal incontinence. Also, it was able to reduce IAS pressure in the same manner as surgical sphincterotomy or forceful dilatation.

A contraction response of the internal anal sphincter to Botulinum toxin: does low-pressure chronic anal fissure have a different pathophysiology?

AIM

A subset of low-pressure fissures is not associated with typical internal anal sphincter hypertonia and may involve a different pathophysiological mechanism. We aimed to assess the manometric response of the internal anal sphincter to botulinum toxin in low-pressure fissures compared to high-pressure fissures.

METHOD

Twenty five units of botulinum toxin (Botox(TM)) were injected directly into the internal anal sphincter. Maximum resting pressure (MRP) and maximum squeeze increment (MSI) were documented at baseline and four weeks after injection.

RESULTS

Nine (31%) of 29 patients had a low-pressure fissure. Those with an anterior fissure had a significantly lower median baseline MRP than those with a posterior fissure (66 vs 83 mmHg, P = 0.009). Significantly more patients with low-pressure fissures developed a contraction or no response (78%vs 30%, difference 48%, 95% CI 14-82%, P = 0.006). Those developing a contraction response had a lower mean baseline MRP than those developing a relaxation response (56 vs 86 mmHg, difference 30 mmHg, 95% CI 17-43%, P < 0.001).

CONCLUSION

Botulinum toxin appears to have an atypical contraction effect on the internal anal sphincter in low-pressure (usually anterior) fissures. This may be accounted for by blockade of acetylcholine released at parasympathetic nerve terminals and the sympathetic ganglion (relaxation). Low pressure fissures may be physiologically different from high-pressure fissures.

Identifying the best therapy for chronic anal fissure

Chronic anal fissure (CAF) is a painful tear or crack which occurs in the anoderm. The optimal algorithm of therapy for CAF is still debated. Lateral internal sphincterotomy (LIS) is a surgical treatment, considered as the ‘gold standard’ therapy for CAF. It relieves CAF symptoms with a high rate of healing. Chemical sphincterotomy (CS) with nitrates, calcium blockers or botulinum toxin (BTX) is safe, with the rapid relief of pain, mild side-effects and no risk of surgery or anesthesia, but is a statistically less effective therapy for CAF than LIS. This article considers if aggressive treatment should only be offered to patients who fail pharmacological sphincterotomy. Aspects of anal fissure etiology, epidemiology and pathophysiology are considered with their meaning for further management of CAF. A molecular model of chemical interdependence significant for the chemistry of CAF healing is examined. Its application may influence the development of optimal therapy for CAF. BTX is currently considered the most effective type of CS and discussion in this article scrutinizes this method specifically. Although the effectiveness of BTX vs. LIS has been discussed, the essential focus of the article concerns identifying the best therapy application for anal fissure. Elements are presented which may help us to predict CAF healing. They provide rationale for the expansion of the CAF therapy algorithm. Ethical and economic factors are also considered in brief. As long as the patient is willing to accept the potential risk of fecal incontinence, we have grounds for the ‘gold standard’ (LIS) as the first-line treatment for CAF. We conclude that, when the diagnosis of the anal fissure is established, CS should be considered for both ethical and economic reasons. The author is convinced that a greater understanding and recognition of benign anal disorders by the GP and a proactive involvement at the point of initial diagnosis would facilitate the consideration of CS at an earlier, more practical stage with improved outcomes for the patient.

Fissurectomy and anal advancement flap for anterior chronic anal fissure without hypertonia of the internal anal sphincter in females

AIM

Lateral internal sphincterotomy is considered the surgical treatment of choice for chronic anal fissure after failure of medical therapy but it risks continence. The aim of the study was to evaluate fissurectomy with advancement flap for anterior chronic anal fissure (CAAF) resistant to medical therapy.

METHOD

Sixteen women with CAAF without hypertonia of the internal anal sphincter, unresponsive to previous medical treatment, were included in the study. Absence of hypertonia was defined as a maximum anal resting pressure (MRP) of less than 85 mmHg. All patients underwent fissurectomy with an advancement skin flap.

RESULTS

Complete healing occurred in all patients within 30 days. The intensity and the duration of pain after defecation reduced from the first postoperative defecation. MRP before surgery and at 6 months showed no significant difference. At 1 month, four patients experienced a continence disturbance, two of whom had it preoperatively. At 12 months, two (12.5%) patients continued to experience a continence disturbance.

CONCLUSION

Fissurectomy with skin advancement flap resulted in complete healing and full relief of symptoms in all patients. There was a low incidence of continence disturbance.

Fissurectomy combined with anoplasty and injection of botulinum toxin in treatment of anterior chronic anal fissure with hypertonia of internal anal sphincter: a pilot study

BACKGROUND

In patients affected by anterior chronic anal fissure (CAAF) with hypertonia of the internal anal sphincter (IAS), the role of IAS hypertonia remains unclear. The aim of this study was to evaluate the efficacy of fissurectomy combined with advancement flap and IAS injection of botulinum toxin in healing the CAAF with hypertonia of IAS resistant to medical therapy.

METHODS

Ten consecutive patients were enrolled. Anorectal manometry was performed preoperatively and at 6 months. CAAF with hypertonia was defined as those associated with maximum resting pressure (MRP) values higher than 85 mmHg. All patients underwent fissurectomy and anoplasty with advancement skin flap combined with the intrasphincter injection of 30 UI of botulinum toxin. Complete healing, MRP changes, relief of symptoms and immediate and long-term complications were recorded.

RESULTS

Complete healing was observed in all patients within 30 days of the operation. The intensity and duration of pain post-defecation was reduced significantly starting from the first defecation. In all subjects, the preoperative MRP values were significantly reduced at 6 months. One month after surgery, three patients reported anal incontinence, two of them had complained preoperatively. The only postoperative complications were minor.

CONCLUSIONS

Fissurectomy combined with advancement flap and intrasphincter injection of botulinum toxin results in complete healing, significant MRP reduction and full relief of symptom in all patients, thus it represents a valid procedure in preventing the occurrence of anal incontinence.

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.

Comparison of controlled-intermittent anal dilatation and lateral internal sphincterotomy in the treatment of chronic anal fissures: a prospective, randomized study

AIM

The results of controlled-intermittent anal dilatation (CIAD) or lateral internal sphincterotomy (LIS) in the treatment of chronic anal fissures are presented.

MATERIAL AND METHODS

Forty patients who were randomized to two groups underwent CIAD or a LIS. The pre- and post-operative mean anal canal resting pressures (MACRPs) and symptoms were recorded and the results were compared.

RESULTS

Two months post-operatively, 18 patients in the CIAD group and 17 patients in the LIS group had healed completely, and had no anal incontinence or other complications. The post-operative improvement in pain, bleeding, and constipation did not differ significantly between the two groups. In the CIAD and LIS groups, the pre-operative MACRPs were 89.7+/-16.5 and 87.6+/-12.3 mmHg, respectively; 2 months post-operatively, the MACRPs had significantly decreased to 76.9+/-13.7 and 78.1+/-11.3 mmHg in the CIAD and LIS groups, respectively. No statistical difference existed in the pre- or post-treatment MACRPs between the groups.

CONCLUSION

CIAD applied with a standardized technique reduced anal canal resting pressure and provided symptomatic healing that was equivalent to a LIS. Since there were no findings of incontinence, or situations which resulted in sphincter damage, we conclude that CIAD is suitable for patients with chronic anal fissures because it is less invasive than LIS, with equivalent efficacy and safety. In addition, the CIAD method may be an alternative procedure in older and multiparous women who has a higher risk of incontinence.

Posterior perineal support as treatment for anal fissures--preliminary results with a new toilet seat device

BACKGROUND

Anal fissures can cause morbidity in an otherwise healthy young patient. The process of evacuation results in stretching and descent of the anoderm and perineum especially posteriorly. Posterior perineal support may provide counter pressure at the posterior aspect of the pelvic floor, balancing the pressure exerted by the faeces on the anal wall, thus improving evacuation and reducing the trauma associated with it, and reducing symptoms of anal fissures. Symptoms of constipation may also be reduced secondarily. We report the preliminary results with a novel, simple and noninvasive method of treatment provided by a toilet seat device.

METHODS

A prospective study was performed in 32 patients. The study was designed mainly to investigate the patients' subjective perceptions of their symptoms related to anal fissures and constipation. Questionnaires were provided to patients before, during and after treatment.

RESULTS

The study revealed statistically significant improvement in pain, bleeding, symptoms of constipation and abdominal discomfort after 3 months usage of the device. The odds of patients perceiving an improvement in symptoms were also significantly increased after 3 months of treatment compared to 2 weeks of treatment.

CONCLUSION

This preliminary study revealed that a posterior perineal support device can bring about significant improvement in the symptoms of patients with anal fissures. There may also be secondary benefits of a reduction in the symptoms of constipation. Although not conclusive, these results should serve as a springboard for further research into this area.

Endoanal ultrasound in benign anorectal disorders: clinical relevance and possibilities

Endoanal ultrasound is a well-established technique used to evaluate benign anorectal disorders. The technique is easy to perform, has a short learning curve and causes very little discomfort. Reconstruction of 3D images is possible. The clinical indications for endoanal ultrasound in benign anorectal diseases are fecal incontinence and peri-anal fistula. Sphincter defects can be depicted with precision and correlate perfectly with surgical findings. Furthermore, an impression of sphincter atrophy can be established. With perianal fistula the tracts can be visualized. Introducing hydrogen peroxide via the external fistula opening improves imaging. Endoanal ultrasound and MRI have comparable results in diagnosing anorectal disorders.