Lateral internal sphincterotomy is superior to topical nitroglycerin for healing chronic anal fissure and does not compromise long-term fecal continence: six-year follow-up of a multicenter, randomized, controlled trial

Tailored lateral internal sphincterotomy (T-LIS) for chronic anal fissure by LigaSure Small Jaws©: a comparison with other non-conservative treatments for anal fissures

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).

Comparing closed versus open lateral internal sphincterotomy for management of chronic anal fissure: systematic review and meta-analysis of randomised control trials

Chronic anal fissure is one of the most common benign anorectal health conditions, causing significant morbidity, quality of life, and economic loss. Eight randomized controlled trials with a total population size of 1035 were eligible for analysis. Seven studies included both males and female, while one only included females. The majority of randomized controlled trials involved female dominance [54.9% (43.5-66.3)] and posterior midline location [86.1% (95% CI 81.5-90.8%)]. This meta-analysis of randomised control trials found that overall postoperative healing was 90.2%, recurrent anal fissure was 3.7%, and postoperative incontinence was 8.9% after LIS. Even though there was no statistically significant difference, closed lateral internal sphincterotomy (LIS) had higher rates of recurrent anal fissure (RR = 1.73 (95% CI 0.86-3.47, p = 0.90, I2 = 0%) and lower rates of postoperative incontinence rate (RR = 0.60 (95% CI 0.37-0.96, p = 0.76, I2-0) as compared with open LIS. We recommended that closed lateral internal sphincterotomy (LIS) is a safe and effective surgical treatment option for chronic anal fissures.

The Italian Unitary Society of Colon-proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of anal fissure

INTRODUCTION

The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colon-Proctologia) on the diagnosis and management of anal fissure, with the purpose to guide every physician in the choice of the best treatment option, according with the available literature.

METHODS

A panel of experts was designed and charged by the Board of the SIUCP to develop key-questions on the main topics covering the management of anal fissure and to performe an accurate search on each topic in different databanks, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in different rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to the PICO criteria, and the statements developed adopting the GRADE methodology.

CONCLUSIONS

In patients with acute anal fissure the medical therapy with dietary and behavioral norms is indicated. In the chronic phase of disease, the conservative treatment with topical 0.3% nifedipine plus 1.5% lidocaine or nitrates may represent the first-line therapy, eventually associated with ointments with film-forming, anti-inflammatory and healing properties such as Propionibacterium extract gel. In case of first-line treatment failure, the surgical strategy (internal sphincterotomy or fissurectomy with flap), may be guided by the clinical findings, eventually supported by endoanal ultrasound and anal manometry.

A systematic review and network meta-analysis comparing treatments for anal fissure

BACKGROUND

There are multiple treatments for anal fissures. These range from medical treatment to surgical procedures, such as sphincterotomy. The aim of this study was to compare the relative clinical outcomes and effectiveness of interventional treatments for anal fissure.

METHODS

Randomized controlled trials were identified by means of a PRISMA-compliant systematic review using the Medline, EMBASE, and CENTRAL databases. Inclusion criteria were randomized controlled trials comparing treatments for anal fissure. A Bayesian network meta-analysis was performed using BUGSnet package in R. Outcomes of interest were healing (6-8-, 10-16-, and >16-week follow-up), symptom recurrence, pain (measured on a visual analog scale), and fecal or flatus incontinence. PROPSERO Registration: CRD42021229615.

RESULTS

Sixty-nine randomized controlled trials were included in the analysis. Lateral sphincterotomy remains the treatment with the highest odds of healing compared to botulinum toxin and medical therapy at all follow-up time points. There was no significant difference in healing between botulinum toxin and medical therapy at any time point. Advancement flap showed similar effectiveness compared to lateral sphincterotomy. Medical treatment and botulinum toxin had the highest pain scores at follow-up. Sphincterotomy had the highest odds of fecal and flatus incontinence.

CONCLUSION

Lateral sphincterotomy had the highest rates of healing and should be considered as the definitive treatment after failed initial therapy with botulinum toxin or medical treatment. Botulinum toxin was equally effective compared to medical treatment. Advancement flap shows similar effectiveness compared to lateral sphincterotomy, but more studies are needed to evaluate its efficacy.

ACG Clinical Guidelines: Management of Benign Anorectal Disorders

Benign anorectal disorders of structure and function are common in clinical practice. These guidelines summarize the preferred approach to the evaluation and management of defecation disorders, proctalgia syndromes, hemorrhoids, anal fissures, and fecal incontinence in adults and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations Assessment, Development and Evaluation process. When the evidence was not appropriate for Grading of Recommendations Assessment, Development and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.

Safety and effectiveness of saving sphincter procedure in the treatment of chronic anal fissure in female patients

INTRODUCTION

Lateral internal sphincterotomy (LIS) is still the approach of choice for the treatment of chronic anal fissure (CAF) regardless to the internal anal sphincter tone but it is burdened by high risk post-operative faecal incontinence (FI). In female patient there are some anatomical and functional differences of the sphinteric system which make them more at risk of FI and vaginal birth could cause sphinteric lesions affecting the anal continence function. The aim of our study is to evaluate the results of saving sphincter procedure as treatment for female patients affected by CAF.

METHODS

We studied 110 female patients affected by CAF undergone fissurectomy and anoplasty with V-Y cutaneous flap advancement associating pharmacological sphincterotomy in patients with hypertonic IAS. The follow up was at least for 2 years. The goals were patient's complete healing, the evaluation of FI, recurrence rate and manometry parameters.

RESULTS

All wounds healed within 40 days after surgery. We recorded 8 cases of recurrences 6 healed with medical therapy and 2 with dilatation. We recorded 2 "de novo" temporary and low grade post-operative cases of FI. Post-operative value of MRP were unmodified in patient with normotonic IAS but significantly lower at 12 months follow up as compared with the pre-operative ones in patients with hypertonic IAS; after 24 months from surgery MRP values were within the normal range.

CONCLUSION

The fissurectomy and anoplasty with V-Y cutaneous flap alone or in association with a pharmacological sphincterotomy in patients with hypertonic IAS may represent an effective approach for the treatment of CAF in female patients.

Modified open posterior internal sphincterotomy with sliding skin graft for chronic anal fissure and anal stenosis: Low recurrence rate and no serious faecal incontinence postoperative complication

AIM

Lateral internal sphincterotomy (LIS) remains a standard for chronic anal fissure even though other surgical techniques have shown high efficacy. Faecal incontinence is a well-documented complication of LIS. We devised modified open posterior internal sphincterotomy (m-OPIS) with sliding skin graft (SSG), which is a combined procedure of OPIS and anal advancement flap. The aim of this study is to evaluate m-OPIS+SSG.

METHODS

This was a retrospective, observational, single-arm study. m-OPIS+SSG was performed for chronic anal fissure and anal stenosis. m-OPIS involved incision of the internal sphincter muscle at the posterior midline until four fingers could be passed. The incision wound was closed by anastomosis of the anoderm and skin. Then, an arcuate skin incision was created and the skin graft was advanced into the anal canal. Follow-up was conducted by clinical consultation and telephone interview. Faecal continence was assessed by Cleveland Clinic Faecal Incontinence (CCFI) score.

RESULTS

m-OPIS+SSG was performed in 143 patients. The mean patient age was 50±16 years. The success and overall recurrence rates after m-OPIS+SSG were 99% and 0.7%, respectively, with a median follow-up period of 16.3 years. One patient developed incontinence with liquid stools once during the 6-month period. None of the other patients suffered permanent faecal incontinence postoperatively. The postoperative CCFI score was 0.5±0.9.

CONCLUSIONS

We consider m-OPIS+SSG as one of the efficacious options of procedure for chronic anal fissure and anal stenosis, owing to its high success rate, low recurrence rate and no postoperative complication of serious faecal incontinence.

The Efficacy and Morbidity of Different Surgical Treatment Techniques for Chronic Anal Fissure: An Academic Colorectal Experience

Up to 40 per cent of chronic fissures will fail to heal with medical treatment alone. Open (OLIS) and closed (CLIS) lateral internal sphincterotomies are considered by many to be the treatment of choice for chronic anal fissures (CAF). The aim of this study was to compare the efficacy and clinical outcomes of different surgical techniques for treatment of CAF. We performed a retrospective chart review of 387 patients with CAF who underwent surgical intervention performed by colorectal surgeons between 2006 and 2012 at Greenville Hospital System. Of 387 patients, 199 underwent OLIS, 124 CLIS, and 64 patients underwent fissurectomy alone (FE). We investigated the effect of the surgical technique on time of healing, rate of flatus incontinence, wound infection, recurrence, and the need for additional intervention. There was no statistically significant difference among patients undergoing OLIS, CLIS, and FE in demographic characteristic, time of healing, rate of wound infections, and fecal continence, or recurrence rate. Comparison of a combined lateral internal sphincterotomy (LIS) group with FE showed that there is similar time of healing ( P = 0.58), no statistical difference in flatus incontinence rate ( P = 0.61), urinary retention ( P = 1.0), fissure recurrence ( P = 0.11), and prolonged healing ( P = 0.2). Patients in FE group more likely required additional treatment to complete wound healing ( P = 0.02). LIS is a safe and effective technique for treatment of CAF. Although there was no difference in complications rate and healing time, patients in the FE group required additional surgical or medical treatment more frequently to achieve complete healing.

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.

Treatment of anal fissure: a survey of surgical practice in Australia and New Zealand

AIM

The aim was to determine whether or not the clinical management of anal fissure in Australia and New Zealand accords with published guidelines.

METHODS

A comprehensive survey based on common clinical scenarios was distributed to 206 colorectal surgeons in Australia and New Zealand.

RESULTS

The response rate was 44% (91 surgeons). For 19 topic areas, only seven (37%) reached consensus (defined as > 70% majority opinion). Of these, six (86%) agreed with guideline recommendations. Twelve (63%) topic areas demonstrated community equipoise (defined as less than or equal to 70% majority opinion), of which five (42%) agreed with guideline recommendations and seven (58%) disagreed with guidelines. Of the seven topics that disagreed with guidelines, three were based on moderate quality evidence (first line management of acute anal fissure in a young patient, fissure healing and faecal incontinence rates following anocutaneous flap) and four were based on low quality evidence (length of sphincter division during a lateral sphincterotomy in women, management of chronic low-pressure anal fissures postpartum, fissure healing rate following anoplasty with botulinum toxin or sphincterotomy and faecal incontinence rates following repeat sphincterotomy for recurrence). Consensus and/or agreement with guidelines were more prevalent in management when medical therapy failed.

CONCLUSION

While areas of consensus mostly agreed with guideline recommendations, there remain many areas of community equipoise which warrant further research.

Are we following an algorithm for managing chronic anal fissure? A completed audit cycle

BACKGROUND

Anal fissure is one of the commonest proctological diseases with considerable national variation in sequential treatment. We aimed to audit our compliance of chronic anal fissure (CAF) management with national guidance provided by the Association of Coloproctology of Great Britain and Ireland (ACPGBI).

METHODS

We retrospectively audited patients presenting to outpatient clinics with CAF over a 6-month period. Using electronic patient records, notes and clinic letters, we compared their management with ACPGBI algorithm. A prospective re-audit was then performed.

RESULTS

Forty-one patients were included in the analysis (59% male). Sixty-eight percent (n = 28/41) of patients were appropriately started on conservative dietary therapy, of whom only 7.1% (n = 2/28) had treatment success. Eighty-nine percent (n = 25/28) were then appropriately treated with either topical diltiazem 2% or GTN 0.4%. Overall, 43.9% (n = 18/41) of all patients' entire management strategy adhered to the ACPGBI guidelines. In total, 48.8% (n = 20/41) patients had surgical treatment (excluding Botox), of which only 15% (n = 3/20) had undergone ACPGBI-compliant management. After local dissemination of results and education, the re-audit of 20 patients showed significant improvement in adherence to the guidelines (43.9% vs. 95%; P = 0.0001).

CONCLUSIONS

Topical creams were the most successful treatments (50%; n = 9/18) in ACPGBI-compliant strategies. Importantly, these data suggests that compliance with the ACPGBI algorithm leads to healing without surgery in 83.3% (n = 15/18) of patients, compared to 26.1% (n = 6/23) with non-compliant methods (P = 0.0004). This highlights the benefit of early conservative and medical management of CAF, before attempting surgery.

Randomised Prospective Controlled Trial of Topical 2 % Diltiazem Versus Lateral Internal Sphincterotomy for the Treatment of Chronic Fissure in Ano

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.

Cost considerations in the treatment of anal fissures

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.

Spasmolysis therapy after Milligan-Morgan haemorrhoidectomy

Pain after hemorrhoid surgery is the most common postoperative complication, significantly influencing patients' quality of life. Severe postoperative pain may still occur and continues to be the major concern of patients who are unwilling to undergo the surgery. Anal sphincter hypertonicity has been identified as a major influencing factor for increased pain after surgery. Since persistent internal anal sphincter spasm is a major factor responsible for the genesis of pain, relieving internal anal sphincter spasm is considered to be an effective method to ease the pain. Currently, multiple treatments have been used to manage pain after haemorrhoidal surgery, including sphincterotomy, botulinum toxin, glyceryl trinitrate, and calcium channel blockers. Haemorrhoidectomy coupled with spasmolysis therapy can significantly reduce the incidence of postoperative complications and improve the quality of life.

Long-term continence disturbance after lateral internal sphincterotomy for chronic anal fissure: a systematic review and meta-analysis

AIM

A systematic review was carried out to analyse continence at 2 years or more after lateral internal sphincterotomy (LIS) for chronic anal fissure (CAF).

METHOD

PubMed, MEDLINE, Scopus, Embase, Ovid, SCI, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar were used to search the literature from 1969-2012 for studies reporting a follow-up of more than 2 years after LIS for CAF. The primary outcome parameter analysed was continence. The secondary outcome parameters included success rate, recurrence, incidence of postoperative abscess and fistula formation and patient satisfaction.

RESULTS

Of 324 studies screened, 22 (n = 4512) were included. The mean follow-up period ranged from 24-124 months. The overall continence disturbance rate was 14% (95% CI 0.09-0.2). Weighted analysis showed flatus incontinence in 9% (95% CI 0.04-0.16), soilage/seepage in 6% (95% CI 0.03-0.1), accidental defaecation in 0.91% (95% CI 0.003-0.02), incontinence to liquid stool in 0.67% (95% CI 0.001-0.02) and incontinence to solid stool in 0.83% (95% CI 0.003-0.02) of patients.

CONCLUSION

The long-term risk of continence disturbance after lateral internal sphincterotomy is significant. Randomized controlled trials with a long follow-up are needed to substantiate these findings and to redefine its role in the treatment of chronic anal fissure.

Comparative study of conventional lateral internal sphincterotomy, V-Y anoplasty, and tailored lateral internal sphincterotomy with V-Y anoplasty in the treatment of chronic anal fissure

BACKGROUND

Lateral internal sphincterotomy has been proven highly effective in curing anal fissure but with a high incidence of postoperative incontinence.

OBJECTIVE

We compared conventional lateral internal sphincterotomy, V-Y advancement flap, and combined tailored lateral internal sphincterotomy with V-Y advancement flap in treating anal fissure.

PATIENTS

Consecutive patients treated for anal fissure at our colorectal unit were evaluated for inclusion. Participants were randomly allocated to receive conventional sphincterotomy (GI), V-Y advancement flap (GII), or combined tailored lateral sphincterotomy with V-Y advancement l flap (GIII).

MAIN OUTCOME MEASURES

The primary outcome measure was the incontinence rate; secondary outcomes included healing rate, operative time, anal manometery, and recurrence rate.

RESULTS

One hundred fifty patients with chronic anal fissure were randomized. Healing rate after 1 year was 84% in GI, 48% in GII, and 94% in GIII, respectively (P = 0.001). The recurrence rate was 4% in G1, 22% in GII, and 2% in GIII (P = 0.01). Incontinence rate was 14% in GI, 0% in GII, and 2% in GIII (P = 0.03).

CONCLUSION

Although all three procedures are simple and easy to perform, tailored lateral internal sphincterotomy with V-YF appears to produce the greatest healing rate, with the fewest complications and less rate of recurrence.

Functional Outcomes and Quality of Life after Anorectal Surgery

There is a paucity of information examining quality of life (QOL) and functional results after anorectal surgery. We aim to prospectively evaluate postoperative QOL, pain, functional outcomes, and satisfaction for a large cohort of patients undergoing anorectal surgery. Data were prospectively accrued for consecutive patients undergoing anorectal operations from June 2009 to September 2010. Preoperative and postoperative electronic questionnaires were completed. QOL was evaluated by the European QOL index (EQ-5D) and functional results with the Fecal Incontinence Severity Index (FISI). Satisfaction was assessed: 1) Are you satisfied with surgery? 2) Would you recommend surgery to others? Responses were reported: 1 to 5 (1 = not at all; 5 = a lot). Pain was scored: 1 (no pain) to 10 (worst). One hundred ninety-five patients, 111 (56.9%) females, median age 44 years (range, 18 to 93 years), underwent anorectal surgery for abscess, condyloma, fissure, fistula, hemorrhoids, incontinence, pilonidal disease, pouch problems, tumors, and prolapse. Overall, pain improved significantly with improved QOL ( P = 0.03). This correlated with overall postoperative satisfaction (92.4%). A total of 87.7 per cent of patients would recommend their surgery to others. The FISI was similar pre- and postoperatively ( P = 0.18) and did not worsen postoperatively irrespective of surgical indication and procedure. Most patients were satisfied after anorectal surgery, which correlated with improved pain and QOL. Functional outcomes did not worsen. This will help counsel patients preoperatively and allay anxiety about postoperative function.

Five-year results of fissurectomy for chronic anal fissure: low recurrence rate and minimal effect on continence

AIM

The aim of the study was to determine the long-term outcome, recurrence rate and faecal incontinence score after fissurectomy for chronic anal fissure (CAF) not responding to conservative treatment.

METHOD

Fifty-three consecutive patients (29 women) who underwent fissurectomy for a medically resistant CAF between 1998 and 2005 were included in the study. At a minimum follow-up of 5 years a standardized questionnaire was sent to all patients, assessing recurrence, satisfaction with the operation (on a scale of 0-10) and faecal continence (Vaizey score, 0-24). The patients were compared with a control group of 50 healthy volunteers, matched for sex and age, who had never undergone anal surgery.

RESULTS

Forty-three (81%) patients (25 women) returned the questionnaire. The mean age was 40 (SD 12.1) years and median follow up was 8.2 (5.5-12.2) years. Five patients had a recurrent CAF (11.6%). Ninety per cent of patients would have consented to the operation again if necessary. The mean Vaizey score at follow-up was 2.5 (SD ± 4.2). The mean Vaizey score of the four patients who had had a previous lateral sphincterotomy was 3.8 and for the eight patients who had reported a continence disturbance before fissurectomy it was 8.3. The mean Vaizey score of the 31 patients who were continent before fissurectomy was 0.8 compared with 0.4 in the control group (P = 0.9).

CONCLUSION

At 5 years or more fissurectomy for medically resistant CAF is effective with a low recurrence rate and minimal influence on continence.

Efficacy of management algorithm for reducing need for sphincterotomy in chronic anal fissures

BACKGROUND

Lateral internal sphincterotomy is the most effective treatment for chronic anal fissure (CAF), but carries a risk of faecal incontinence. We aimed to analyse efficacy and acceptance of a treatment algorithm in reducing the rate of necessary sphincterotomies.

METHOD

Patients with CAF seen from 2001 to 2010 were retrospectively analysed. All patients were offered all steps of the algorithm nitroglycerine (NTG) → Botox (BTX) → surgery, unless symptoms or patient preference demanded a more aggressive treatment. Patients were followed up in clinic, and treatment was advanced if a step either failed or caused intolerable side effects.

RESULTS

Two hundred and nine patients were included in the analysis. Mean duration of symptoms was 25.6 months and mean follow up 16 months. One hundred and 41 patients started on NTG, 36 on BTX, and 31 went straight to surgery. One patient opted for no treatment. Symptoms persisted in 58 (41.1%) of 141 NTG patients. Forty-five (31.9% of NTG subset) were advanced to BTX and 13 (9.2% of subset) to surgery. Of the 81 (36 primary + 45 secondary) BTX patients (38.8% of the total), only 11 (13.6% of subset) required surgery. A total of 55 (31 primary + 24 secondary; 26.3%) patients needed surgery: two (3.6%) fissures did not heal, one patient developed an abscess, 14 (25.5%) had prolonged wound healing and two (3.6%) developed a recurrent fissure after the sphincterotomy had healed.

CONCLUSION

Our algorithm is effective in CAF and the majority of patients respond to conservative management. Only 26.3% of all patients require surgery, which is effective but also carries some temporary morbidity.

Effect of chronic anal fissure components on isosorbide dinitrate treatment

BACKGROUND

Chronic anal fissure is diagnosed in the presence of persistent symptoms: The classic triad includes a linear mucosal tear exposing the internal sphincter fibers, hypertrophied anal papilla, and a sentinel skin tag. Thus, chronic anal fissure can be divided into three components: the fissure itself; hypertrophied anal papilla; the sentinel skin tag. Not every chronic anal fissure has all three components; some have two components, and others present with only a persistent fissure. The success rate of medical treatment for chronic anal fissure is reported as 42-86 %. In this study, we intended to observe the effect of said components on healing with isosorbide dinitrate treatment.

METHODS

A total of 105 patients with chronic anal fissures were admitted and were divided into three groups. Patients in group I had a single component (only the fissure with a linear mucosal tear exposing the internal sphincter fibers); group II had two components (skin tag or hypertrophied papilla in addition to the fissure); group III had all three components (fissure, skin tag, hypertrophied papilla). Isosorbide dinitrate 0.25 % was applied three times a day.

RESULTS

The success rates in the study groups were 93, 74, and 64 %, respectively. The success rate was significantly higher for group I than for groups II and III.

CONCLUSIONS

Chronic anal fissure components should be considered when evaluating the success rates of studies reporting the results of various medical treatments. The number of components seems to be an important factor that affects the results of isosorbide dinitrate treatment.

Segmental internal sphincterotomy--a new technique for treatment of chronic anal fissure

OBJECTIVE

Lateral internal sphincterotomy is an effective treatment for fissure in ano but carries a definite risk of incontinence. In trial to avoid this complication, segmental lateral internal sphincterotomy was used to treat chronic anal fissures.

DESIGN

The lateral internal sphincterotomy was done in two parts and at different planes.

SETTING

This study was conducted in the General Surgery Department, Zagazig University Hospital, Egypt.

PATIENTS

This study was undertaken on 50 patients (43 men and seven women, with mean age of 37.3 years) with chronic fissure in ano from January 2009 to December 2010.

INTERVENTIONS

Under general or local anesthesia, lateral internal sphincterotomy was done in two segments under direct vision. Preoperative and postoperative anal manometry study was recorded.

MAIN OUTCOME MEASURES

Postoperative course with early and long-term results were recorded. Mean follow-up was 18.5 months (ranging from 6 to 24 months).

RESULTS

In 31 patients, the technique was done under general anesthesia and the remainder under local anesthesia. The fissures and anal wounds were healed within 4 weeks. Pain was significantly reduced in all patients at day 1 postoperative. Early complications included mild hematoma and urine retention in one male patient (2%). No transient or any persistent degree of incontinence occurred in these patients group.

CONCLUSION

Segmental lateral internal sphincterotomy is a safe, easy, and effective procedure and not associated with risk of incontinence for the treatment of chronic anal fissure.

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.

Dermal flap coverage for chronic anal fissure: lower incidence of anal incontinence compared to lateral internal sphincterotomy after long-term follow-up

PURPOSE

Internal sphincterotomy is considered the standard for treating anal fissure, but it is associated with a risk of impaired anal continence. This study aimed to conduct a long-term follow-up to compare postoperative anal continence using dermal flap coverage or lateral internal sphincterotomy for treatment of chronic anal fissure.

PATIENTS AND METHODS

Sixty patients with chronic anal fissure (male/female, 30:30; age range, 22-79 y) were treated by open lateral internal sphincterotomy (n = 30) or dermal flap coverage (n = 30) from 1997 to 2002. The postoperative course was evaluated using the clinical charts. A standardized questionnaire assessing complaints and anal continence was sent to the patients 70 to 94 months postoperatively and phone interviews were conducted.

RESULTS

Operations were performed with general anesthesia as short-stay hospital procedures. The chronic fissure wounds healed in both groups regardless of surgical technique. Symptoms of mild anal incontinence (ie, soiling, flatus) were present 3 months after operation in 6 of 30 (20.0%) patients with lateral internal sphincterotomy and in no patient with dermal flap coverage (P < .05); 70 to 94 months postoperatively, mild anal incontinence was present in 10 of 21 (47.6%) patients with lateral internal sphincterotomy and in 1 of 17 (5.8%) patients with dermal flap coverage (P < .05).

CONCLUSION

Long-term follow-up shows a very low incidence of mild anal incontinence after dermal flap coverage. We conclude from this study that the dermal flap procedure appears to be efficacious without an increased risk of incontinence and with results comparable to lateral internal sphincterotomy. The dermal flap procedure can be recommended for patients following failed conservative fissure treatment without the potential risk of anal incontinence.

Innovations in chronic anal fissure treatment: A systematic review

A chronic anal fissure is a common perianal condition. This review aims to evaluate both existing and new therapies in the treatment of chronic fissures. Pharmacological therapies such as glyceryl trinitrate (GTN), Diltiazem ointment and Botulinum toxin provide a relatively non-invasive option, but with higher recurrence rates. Lateral sphincterotomy remains the gold standard for treatment. Anal dilatation has no role in treatment. New therapies include perineal support devices, Gonyautoxin injection, fissurectomy, fissurotomy, sphincterolysis, and flap procedures. Further research is required comparing these new therapies with existing established therapies. This paper recommends initial pharmacological therapy with GTN or Diltiazem ointment with Botulinum toxin as a possible second line pharmacological therapy. Perineal support may offer a new dimension in improving healing rates. Lateral sphincterotomy should be offered if pharmacological therapy fails. New therapies are not suitable as first line treatments, though they can be considered if conventional treatment fails.

V-Y advancement flap as first-line treatment for all chronic anal fissures

INTRODUCTION

It was suggested that anal advancement flap be used to treat patients with chronic anal fissures that have failed medical management and have a low-pressure sphincter complex. We wished to assess anal advancement flap as a treatment for all chronic anal fissures.

METHODS

All patients with chronic anal fissures regardless of their previous management underwent V-Y advancement flap. Patient demographics, symptom duration, previous treatments, short-term postoperative outcome and long-term follow-up were recorded.

RESULTS

Fifty-four consecutive patients, median age 39 years (22-66), underwent a V-Y advancement flap over a 7-year period; 34 were men. Duration of symptoms ranged from 2 to 36 months with a median of 8 months. Forty-two patients (78%) had failed a previous therapy: glyceryl trinitrate (GTN) (25), GTN and diltiazem (16) and lateral sphincterotomy (one). Wound dehiscence occurred in three patients of which only one required a surgical intervention. On follow-up at 6 months, all but one patient had a healed wound and was asymptomatic.

CONCLUSIONS

We have shown excellent rates of healing of chronic anal fissures treated with a V-Y advancement flap regardless of sphincter pressures, previous treatment and symptom chronicity. These results show the technique can be applied to all chronic fissures with success and used as a primary therapy.

Subcutaneous internal lateral sphincterotomy (SILS) versus nitroglycerine ointment in anal fissure: a prospective study

AIM

To compare the results of subcutaneous internal lateral sphincterotomy under local anesthesia and nitroglycerin ointment treatments in acute and chronic anal fissures.

METHODS

This was a comparative, prospective study of 340 patients of acute and chronic anal fissure. The patients voluntarily opted either for the surgical procedure under local anesthesia, or the nitroglycerin treatment. All the patients were followed with regular checkups and complaints were documented.

RESULTS

Except for 1.75% patients having bleeding/hematoma formation, and with a dropout of 2.60% patients, no failure, recurrence or long term complications like incontinence, were observed in patients who underwent subcutaneous internal lateral sphincterotomy after a mean follow up of 28 months. With surgical treatment pain, bleeding per rectum and constipation showed significant improvement as compared to nitroglycerin treatment. Fissure healing was 100% in surgical group as compared to 56.90% in medical group (P=0.000, odds ratio=344.6). Nitroglycerin was equally effective in acute and chronic fissures (P=0.096).

CONCLUSION

Subcutaneous internal lateral sphincterotomy under local anesthesia is more curative, easy and safe, in the hands of a beginner as well as an experienced surgeon, with highest patient satisfaction, and should be considered as the first line of therapy in both chronic and resistant/recurrent acute anal fissures.

Relaxation by beta 3-adrenoceptor agonists of the isolated human internal anal sphincter

AIMS

In this study, responses of beta(3)-adrenoceptor agonists were examined on human isolated internal anal sphincter (IAS) in order to explore their relaxant effects on hypertonicity of IAS.

MAIN METHODS

The relaxant efficacy (E(max)) and potency (-logIC(50)) of BRL37344 and SR58611A, beta(3)-adrenoceptor agonists, were examined in contracted IAS muscle strips. The presence of beta(3)-adrenoceptors, and changes in intracellular calcium and cyclic nucleotide levels in IAS muscle were tested by Western blotting, epifluorescence microscopy and enzyme immunoassay, respectively.

KEY FINDINGS

BRL37344 and SR58611A relaxed contracted IAS muscle (E(max)=27+/-3% and 35+/-3%; -logIC(50)=6.26+/-0.24 and 4.87+/-0.13; respectively). These relaxant responses were blocked by SR59230A, a selective beta(3)-antagonist but not by beta(1)/beta(2)-selective antagonists, neuronal inhibitor or inhibition of nitric oxide synthase. The E(max) of beta(3)-agonists was similar to that of beta(2)-selective agonists but smaller than that of isoprenaline (nonselective agonist) or beta(1)-selective agonists. BRL37344 (100 microM) increased cAMP (1.5-fold) without cGMP change, and depressed intracellular calcium signal. beta(3)-Adrenoceptor expression was smaller than that of beta(1)- and beta(2)-adrenoceptors.

SIGNIFICANCE

This is the first study demonstrating the presence of beta(3)-adrenoceptor in human IAS muscle and beta(3)-mediated relaxation of augmented sphincter tone. However, direct beta(3)-relaxation appears smaller than that obtained for nonselective agonists which may limit their potential use in the treatment of anorectal hypertonicity disorders.

Botulinum Toxin A with Fissurectomy is a Viable Alternative to Lateral Internal Sphincterotomy for Chronic Anal Fissure

Lateral internal sphincterotomy (LIS) is the gold standard surgical treatment for anal fissure. However, it carries potential complications, including fecal incontinence. The goal of this retrospective study was to compare the outcome of botulinum toxin A injection coupled with fissurectomy ([BTX + FIS) versus LIS. There were 59 patients who underwent BTX + FIS or LIS over a 5-year period. LIS was performed in the standard fashion without fissurectomy. BTX + FIS entailed internal sphincter injection with 80 units of botulinum toxin A coupled with fissurectomy. Forty patients underwent LIS and 19 had BTX + FIS. The choice of operation was based on the patient's preference. Primary healing rate was 90 and 74 per cent in the LIS and BTX + FIS groups, respectively ( P = 0.13). The complication rate was 10 per cent in the LIS vs 0 per cent in the BTX + FIS groups ( P = 0.29). Complications of LIS included anal sepsis in one patient and flatal and/or fecal incontinence in three patients. During a mean follow up of 19 months; recurrence rate was 0 and 5 per cent in the LIS and BTX+FIS groups, respectively ( P = 0.32). The results of this study demonstrate that BTX + FIS is a viable alternative to LIS for patients with chronic anal fissure and should be considered as an alternative first-line surgical therapy.

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.

Idiopathic hypertensive anal canal: a place of internal sphincterotomy

BACKGROUND

Hypertensive anal canal is frequently known to be associated with the presence of anal fissure. Based on clinical experience, we hypothesized that idiopathic anal sphincter hypertonia was a condition equivalent to anal fissure, and therefore, it could be treated the same way.

PATIENT AND METHODS

Sixty-three patients complaining of anal pain without any anal pathology and ten healthy volunteers were examined. All patients underwent clinical evaluation, neurological examination, anorectal manometry, and measurement of pudendal nerve terminal motor latency. All patients with hypertensive anal canal were randomized into three groups. Group I (surgical group) underwent closed lateral sphincterotomy (LS), group II using nitroglycerine ointment (GTN), and group III received injection of botulinum toxin in internal sphincter. Post-procedures data were recorded at follow-up period.

RESULTS

The mean resting anal pressure (MRAP) was significantly higher in the patient group (114.6 +/- 7.4 mmHg) than control group (72.5 +/- 6.6 mmHg, P < 0.001). Anal pain is the main presenting symptoms aggravated by defecation and not relived by analgesics or local anesthetics. After LS, pain visual analogue scale decreased significantly at follow-up period than after chemical sphincterotomy using GTN or BTX (P = 0.001). There was a significant decrease in MRAP postoperatively from 114.6 +/- 7.4 to 70.8 +/- 5.5 mmHg than after using GTN or BTX (P = 0.03).

CONCLUSION

Idiopathic hypertensive anal canal is a fact and already exists presented by anal pain aggravated by defecation. It can be managed safely by closed lateral sphincterotomy, but chemical sphincterotomy had a minor role in its management.

What every gastroenterologist needs to know about common anorectal disorders

Anorectal complaints are very common and are caused by a variety of mostly benign anorectal disorders. Many anorectal conditions may be successfully treated by primary care physicians in the outpatient setting, but patients tend not to seek medical attention due to embarrassment or fear of cancer. As a result, patients frequently present with advanced disease after experiencing significant decreases in quality of life. A number of patients with anorectal complaints are referred to gastroenterologists. However, gastroenterologists’ knowledge and experience in approaching these conditions may not be sufficient. This article can serve as a guide to gastroenterologists to recognize, evaluate, and manage medically or non-surgically common benign anorectal disorders, and to identify when surgical referrals are most prudent. A review of the current literature is performed to evaluate comprehensive clinical pearls and management guidelines for each topic. Topics reviewed include hemorrhoids, anal fissures, anorectal fistulas and abscesses, and pruritus ani.

Simple cutaneous advancement flap anoplasty for resistant chronic anal fissure: a prospective study

BACKGROUND

A proportion of patients with chronic anal fissure have persistent symptoms and pathology despite optimum conservative therapies. Lateral anal sphincterotomy, the standard surgical treatment, is associated with functional compromise in a minority of patients. Sphincter-sparing anoplasty has been advocated as an alternative procedure for those with "low pressure" sphincters. The aim of this study was to determine the efficacy of simple cutaneous advancement flap anoplasty (SCAFA) when applied to consecutive patients with chronic anal fissure irrespective of anal tone and the patient's gender.

METHOD

This was a prospective outcome study of 51 consecutive patients treated with SCAFA over a 6.5-year period.

RESULTS

Surgery was well tolerated. There were three (5.9%) early flap dehiscences, all of which were treated with repeat SCAFA, and one of those three patients remained symptomatic at 2 months. All fissures healed in the short term. Three other patients subsequently developed fissures at sites remote from the original pathology. Continence was unaffected by the procedure.

CONCLUSIONS

Simple cutaneous advancement flap anoplasty should be considered as a first-line surgical treatment of chronic anal fissure, irrespective of patient gender and anal tone.

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.