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Gentile M, Schiavone V, Franzese A, Di Lascio S, Velotti N. Tailored lateral internal sphincterotomy (T-LIS) for chronic anal fissure by LigaSure Small Jaws©: a comparison with other non-conservative treatments for anal fissures. Updates Surg 2024; 76:2205-2210. [PMID: 39256270 PMCID: PMC11541316 DOI: 10.1007/s13304-024-01943-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 07/08/2024] [Indexed: 09/12/2024]
Abstract
An anal fissure is a small tear in the thin tissue (mucosa) that lines the anus. Anal fissures typically cause pain and bleeding with bowel movements. The cause is not fully understood, but low intake of dietary fiber may be a risk factor. Chronic anal fissure was defined as a split or ulceration in the posterior or anterior anoderm for at least 6 weeks: have distinct anatomic features such as muscle fibers visible in the wound. Anal fissures can be attributed to constipation or repeated straining: a hard fecal bolus cut the mucosa of anal canal that is relatively thigh at sphincter level management and optimal treatment of the disease is controversial. Many studies recommend conservative and medical treatment modalities as the initial treatment options since they are non-invasive and do not have risks such as anal sphincter injury. Lateral internal sphincterotomy (LIS) is considered the gold standard for treatment of chronic anal fissure. Nonetheless, anal incontinence is one of the worrisome complications of LIS. Fissurectomy is another option among those techniques which address the issues with LIS. LigaSure© (Valleylab) is a bipolar electrosurgical device designed to deliver high current and very low voltage to tissue. It monitors tissue impedance between the jaws of the instrument and continuously adjusts the delivery of energy. The use of LigaSure Small Jaw was never reported for anal fissures in literature. We have applied the use of this device to a group of patients complaining for chronic anal fissure in order to verify if there is any advantage to perform it compared to traditional technique (blade, scissors, electrocautery).
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Affiliation(s)
- Maurizio Gentile
- Department of General Surgery, Endocrinology, Orthopedics and Rehabilitation, Federico II University of Naples, Naples, Italy.
| | - Vincenzo Schiavone
- Department of General Surgery, Endocrinology, Orthopedics and Rehabilitation, Federico II University of Naples, Naples, Italy
| | - Antonio Franzese
- Department of General Surgery, Endocrinology, Orthopedics and Rehabilitation, Federico II University of Naples, Naples, Italy
| | - Sebastiano Di Lascio
- Department of General Surgery, Endocrinology, Orthopedics and Rehabilitation, Federico II University of Naples, Naples, Italy
| | - Nunzio Velotti
- Department of General Surgery, Endocrinology, Orthopedics and Rehabilitation, Federico II University of Naples, Naples, Italy
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Davids JS, Hawkins AT, Bhama AR, Feinberg AE, Grieco MJ, Lightner AL, Feingold DL, Paquette IM. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anal Fissures. Dis Colon Rectum 2023; 66:190-199. [PMID: 36321851 DOI: 10.1097/dcr.0000000000002664] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Jennifer S Davids
- Division of Colon and Rectal Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Alexander T Hawkins
- Division of General Surgery, Section of Colon and Rectal Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anuradha R Bhama
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Adina E Feinberg
- Division of General Surgery, Joseph Brant Hospital, Burlington, Ontario, Canada
| | - Michael J Grieco
- Division of Colon and Rectal Surgery, New York University, New York, New York
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Daniel L Feingold
- Division of Colon and Rectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati, Cincinnati, Ohio
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Chiarello MM, Fico V, Brisinda G. A commentary on "Comparison of doses and injection sites of botulinum toxin for chronic anal fissure: A systematic review and network meta-analysis of randomized controlled trials" [Int. J. Surg. 104 (2022) 106798]. Int J Surg 2022; 106:106880. [PMID: 36113840 DOI: 10.1016/j.ijsu.2022.106880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 08/30/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Maria Michela Chiarello
- Unità Operativa di Chirurgia Generale, Azienda Sanitaria Provinciale di Cosenza, Cosenza, Italy
| | - Valeria Fico
- Chirurgia d'Urgenza e del Trauma, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy
| | - Giuseppe Brisinda
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
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GENTILE M, CESTARO G, VELOTTI N, DI MATTEO S, SCHIAVONE V, MUSELLA M. Lateral internal sphincterotomy (LIS) for chronic anal fissure by LigaSure™ Small Jaws: a comparison with traditional technique. Chirurgia (Bucur) 2022; 35. [DOI: 10.23736/s0394-9508.22.05411-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2025]
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Brisinda G, Chiarello MM, Crocco A, Bentivoglio AR, Cariati M, Vanella S. Botulinum toxin injection for the treatment of chronic anal fissure: uni- and multivariate analysis of the factors that promote healing. Int J Colorectal Dis 2022; 37:693-700. [PMID: 35149889 PMCID: PMC8885481 DOI: 10.1007/s00384-022-04110-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 02/05/2023]
Abstract
PURPOSE Anal fissure is caused by a pathological contraction of the internal anal sphincter. Lateral internal sphincterotomy remains the gold standard for the treatment of fissure. Botulinum toxin injections have been proposed to treat this condition without any risk of permanent injury of the internal sphincter. We investigate clinical and pathological variables and the effects of different dosage regimens of botulinum toxin to induce healing in patients with idiopathic anal fissure. METHODS This is a retrospective study at a single center. The patients underwent a pre-treatment evaluation that included clinical inspection of the fissure and anorectal manometry. We collected and analyzed demographic data, pathological variables, associated pathological conditions, and treatment variables. Success was defined as healing of the fissure, and improvement of symptoms was defined as asymptomatic persistent fissure. RESULTS The findings of 1003 patients treated with botulinum toxin injections were reported. At 2 months evaluation, complete healing was evident in 780 patients (77.7%). Resting anal tone (77.1 ± 18.9 mmHg) was significantly lower from baseline (P < 0.0001) and from 1-month value (P = 0.0008). Thirty-nine not healed patients underwent lateral internal sphincterotomy, and 184 were re-treated with 50 UI of botulinum toxin. In these patients, the healing rate was 93.9% (171 patients). Dose and injection site of toxin correlates with healing rate. There were no relapses during an average of about 71 months. CONCLUSION Our data show that injection of botulinum toxin into the internal anal sphincter is a safe and effective alternative to surgery in patients with chronic anal fissure.
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Affiliation(s)
- Giuseppe Brisinda
- Università Cattolica del Sacro Cuore, Roma, Italy.
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy.
| | | | - Anna Crocco
- Unità Operativa Di Chirurgia Oncologica Della Tiroide E Della Paratiroide, Istituto Nazionale Tumori, IRCCS Fondazione Pascale, Napoli, Italy
| | - Anna Rita Bentivoglio
- Università Cattolica del Sacro Cuore, Roma, Italy
- Unità Operativa Di Neurologia, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy
| | - Maria Cariati
- Unità Operativa Di Chirurgia Generale, Ospedale San Giovanni Di Dio, Crotone, Italy
| | - Serafino Vanella
- Unità Operativa Di Chirurgia Generale E Oncologica, Azienda Ospedaliera San Giuseppe Moscati, Avellino, Italy
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Hancke E, Suchan K, Voelke K. Anocutaneous advancement flap provides a quicker cure than fissurectomy in surgical treatment for chronic anal fissure-a retrospective, observational study. Langenbecks Arch Surg 2021; 406:2861-2867. [PMID: 34159437 PMCID: PMC8803790 DOI: 10.1007/s00423-021-02227-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 06/01/2021] [Indexed: 11/27/2022]
Abstract
Purpose Anocutaneous advancement flap is a surgical procedure for the treatment of chronic anal fissures. This study aimed to assess the results of anocutaneous advancement flap in a consecutive cohort of patients. Methods This is a retrospective, observational study. From 2000 to 2011, 481 patients had been operated for a single chronic anal fissure at the Maingau Clinic of the German Red Cross in Frankfurt am Main. The intention was to excise the fissure by fissurectomy (FIS) and then to cover the wound primarily with an anocutaneous advancement flap (AAF). The primary outcomes were resolution of symptoms and healing rates 1 month postoperatively. Secondary outcomes included incidences of early and late complications, postoperative incontinence, and recurrent fissure. Results Anocutaneous advancement flap was performed in 455 (94.6%). In 26 (5.4%) patients, AAF failed due to lacking skin and the wound left open after FIS. One month postoperatively, half of the patients with AAF were free of symptoms (53.2%) with complete wound healing (47.9%). The incidence of early complications within 1 month postoperatively was 0.9% after AAF. From 1 month to 5 years after operation anal abscesses and fistula occurred in 2.9%. Mild symptoms of anal incontinence were recorded in 0.2% and recurrent chronic anal fissure in 3.3% of patients. Subgroup analysis revealed improved wound healing 1 month postoperatively in patients with AAF compared to FIS. Conclusion Anocutaneous advancement flap is a very safe sphincter-sparing surgical option for CAF, provides a quicker cure than fissurectomy, and may be considered a good first-line surgical treatment option for chronic anal fissures if medical treatment failed.
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Affiliation(s)
- Edgar Hancke
- Sektion Proktologie, Klinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Ketteler Krankenhaus Offenbach, Lichtenplattenweg 85, D-63071, Offenbach am Main, Germany. .,Centrum Coloproctologie, Klinik Maingau Vom Roten Kreuz, Eschenheimer Anlage 7, 60316, Frankfurt am Main, Germany.
| | - Katrin Suchan
- Centrum Coloproctologie, Klinik Maingau Vom Roten Kreuz, Eschenheimer Anlage 7, 60316, Frankfurt am Main, Germany
| | - Knut Voelke
- Centrum Coloproctologie, Klinik Maingau Vom Roten Kreuz, Eschenheimer Anlage 7, 60316, Frankfurt am Main, Germany
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Sungurtekin U, Ozgen U, Sungurtekin H. "Prospective, Randomized, Controlled Trial of Ultra-modified Internal Sphincterotomy vs Closed Lateral Internal Sphincterotomy for Chronic Fissure-in-Ano". Am Surg 2021; 88:2388-2396. [PMID: 33861669 DOI: 10.1177/00031348211011104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Currently, the lateral internal sphincterotomy is the treatment of choice for a chronic anal fissure (CAF). However, the length of the internal sphincter incision varies, due to lack of standardization. Insufficient length increases the risk of recurrence. To compare a new ultra-modified internal sphincterotomy (UMIS) to the closed lateral internal sphincterotomy (CLIS) for treating CAF, based on internal anal sphincter function and postoperative complications. The primary endpoint was continence after UMIS. The secondary outcomes were CAF healing complications, visual analog scale pain scores, and sphincter pressures. METHODS This was a prospective, randomized, controlled trial (block randomization method). 200 patients with CAFs were randomly assigned to receive either UMIS (n = 100) or the closed lateral internal sphincterotomy (CLIS) (n = 100). Follow-up was 2 years. RESULTS: All (100%) patients in both groups showed clinical improvement at 1 month post-surgery. Recurrences were accompanied by deteriorations in Cleveland Clinic Florida Fecal Incontinence scores at 12 months and 2 years (P < .05). The groups showed significant differences in fissure healing rates and pain scores. After 1 and 2 years, incontinence rates were significantly higher, and patient satisfaction scores were significantly lower in the CLIS group than the UMIS group (P < .05). CONCLUSION UMIS provided a faster healing rate and fewer side effects than the CLIS for treating CAFs. These results might lead to a standardized treatment among surgeons.
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Affiliation(s)
- Ugur Sungurtekin
- Department of General Surgery, Division of Colon & Rectal Surgery, 64052Pamukkale University School of Medicine, Denizli, Turkey
| | - Utku Ozgen
- Department of General Surgery, Division of Colon & Rectal Surgery, 64052Pamukkale University School of Medicine, Denizli, Turkey
| | - Hulya Sungurtekin
- Department of Anesthesiology & Critical Care, 64052Pamukkale University School of Medicine, Denizli, Turkey
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Chiarello MM, Cariati M, Brisinda G. Botulinum toxin versus other therapies for treatment of chronic anal fissure. COLOPROCTOLOGY 2020; 42:457-463. [DOI: 10.1007/s00053-020-00497-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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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Hancke E, Suchan K, Völke K. Anokutaner Advancement-Flap zur sphinkterschonenden chirurgischen Therapie der chronischen Analfissur. COLOPROCTOLOGY 2020. [DOI: 10.1007/s00053-020-00449-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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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; 14:511-525. [PMID: 24867398 DOI: 10.1586/14737167.2014.924398] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [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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