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Roelandt P, Bislenghi G, Coremans G, De Looze D, Denis MA, De Schepper H, Dewint P, Geldof J, Gijsen I, Komen N, Ruymbeke H, Stijns J, Surmont M, Van de Putte D, Van den Broeck S, Van Geluwe B, Wyndaele J. Belgian consensus guideline on the management of anal fissures. Acta Gastroenterol Belg 2024; 87:304-321. [PMID: 39210763 DOI: 10.51821/87.2.11787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Introduction Acute and chronic anal fissures are common proctological problems that lead to relatively high morbidity and frequent contacts with health care professionals. Multiple treatment options, both topical and surgical, are available, therefore evidence-based guidance is preferred. Methods A Delphi consensus process was used to review the literature and create relevant statements on the treatment of anal fissures. These statements were discussed and modulated until sufficient agreement was reached. These guidelines were based on the published literature up to January 2023. Results Anal fissures occur equally in both sexes, mostly between the second and fourth decades of life. Diagnosis can be made based on cardinal symptoms and clinical examination. In case of insufficient relief with conservative treatment options, pharmacological sphincter relaxation is preferred. After 6-8 weeks of topical treatment, surgical options can be explored. Both lateral internal sphincterotomy as well as fissurectomy are well-established surgical techniques, both with specific benefits and risks. Conclusions The current guidelines for the management of anal fissures include recommendations for the clinical evaluation of anal fissures, and their conservative, topical and surgical management.
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Affiliation(s)
- P Roelandt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Diseases (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - G Bislenghi
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - G Coremans
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - D De Looze
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Ghent, Belgium
| | - M A Denis
- Department of Gastroenterology and Hepatology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - H De Schepper
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium
| | - P Dewint
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium
- Department of Gastroenterology and Hepatology, Maria Middelares Hospital, Ghent, Belgium
| | - J Geldof
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Ghent, Belgium
| | - I Gijsen
- Department of Gastroenterology and Hepatology, Noorderhart Hospital, Pelt, Belgium
| | - N Komen
- Department of Abdominal Surgery, Antwerp University Hospital, Edegem, Belgium
- Antwerp RESURG Group, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - H Ruymbeke
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Ghent, Belgium
- Department of Gastroenterology, VITAZ, Sint-Niklaas, Belgium
| | - J Stijns
- Department of Abdominal Surgery, University Hospital Brussels, Brussels, Belgium
| | - M Surmont
- Department of Gastroenterology and Hepatology, University Hospital Brussels, Brussels, Belgium
| | - D Van de Putte
- Department of Gastro-intestinal Surgery, University Hospital Ghent, Ghent, Belgium
| | - S Van den Broeck
- Department of Abdominal Surgery, Antwerp University Hospital, Edegem, Belgium
| | - B Van Geluwe
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Abdominal Surgery, General Hospital Groeninge, Kortrijk, Belgium
| | - J Wyndaele
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
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Brillantino A, Renzi A, Talento P, Iacobellis F, Brusciano L, Monaco L, Izzo D, Giordano A, Pinto M, Fantini C, Gasparrini M, Schiano Di Visconte M, Milazzo F, Ferreri G, Braini A, Cocozza U, Pezzatini M, Gianfreda V, Di Leo A, Landolfi V, Favetta U, Agradi S, Marino G, Varriale M, Mongardini M, Pagano CEFA, Contul RB, Gallese N, Ucchino G, D'Ambra M, Rizzato R, Sarzo G, Masci B, Da Pozzo F, Ascanelli S, Foroni F, Palumbo A, Liguori P, Pezzolla A, Marano L, Capomagi A, Cudazzo E, Babic F, Geremia C, Bussotti A, Cicconi M, Di Sarno A, Mongardini FM, Brescia A, Lenisa L, Mistrangelo M, Sotelo MLS, Vicenzo L, Longo A, Docimo L. The Italian Unitary Society of Colon-proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of anal fissure. BMC Surg 2023; 23:311. [PMID: 37833715 PMCID: PMC10576345 DOI: 10.1186/s12893-023-02223-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 10/06/2023] [Indexed: 10/15/2023] Open
Abstract
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.
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Affiliation(s)
- Antonio Brillantino
- Deparment of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, Naples, 80131, Italy.
| | - Adolfo Renzi
- "Buonconsiglio-Fatebenefratelli" Hospital, Naples, Italy
| | - Pasquale Talento
- Department of Surgery, Pelvic Floor Center, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Francesca Iacobellis
- Department of General and Emergency Radiology, "A. Cardarelli" Hospital, Naples, Italy
| | - Luigi Brusciano
- Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Luigi Monaco
- "Pineta Grande" Hospital, "Villa Esther" Clinic, Avellino, Italy
| | - Domenico Izzo
- Department of General and Emergency Surgery, AORN dei Colli Monaldi-Cotugno-CTO, CTO Hospital, Naples, Italy
| | - Alfredo Giordano
- Department of General and Emergency Surgery, University of Salerno, Hospital of Mercato San Severino, Salerno, Italy
| | | | - Corrado Fantini
- Department of Surgery, "Dei Pellegrini" Hospital, ASL Napoli 1, Naples, Italy
| | | | - Michele Schiano Di Visconte
- Department of General Surgery, Colorectal and Pelvic Floor Diseases Center, "Santa Maria Dei Battuti" Hospital, Conegliano, TV, Italy
| | - Francesca Milazzo
- Department of Surgery, Pelvic Floor Center, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Giovanni Ferreri
- Department of Surgery, Pelvic Floor Center, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Andrea Braini
- Department of General Surgery, Azienda Sanitaria Friuli Occidentale (ASFO), Pordenone, Italy
| | - Umberto Cocozza
- Department of General Surgery, "S. Maria Degli Angeli" Hospital, Putignano (Bari), Italy
| | | | - Valeria Gianfreda
- Unit of Colonproctologic and Pelvic Surgery, "M.G. Vannini" Hospital, Rome, Italy
| | - Alberto Di Leo
- Department of General and Minivasive Surgery, "San Camillo" Hospital, Trento, Italy
| | - Vincenzo Landolfi
- Department of General and Specalist Surgery, AORN "S.G. Moscati", Avellino, Italy
| | - Umberto Favetta
- Unit of Proctology and Pelvic Surgery, "Città di Pavia" Clinic, Pavia, Italy
| | - Sergio Agradi
- Humanitas Gavazzeni/Castelli Bergamo, Bergamo, Italy
| | - Giovanni Marino
- Department of General Surgery, "Santa Marta e Santa Venera" Hospital of Acireale, Catania, Italy
| | - Massimilano Varriale
- Department of General and Emergency Surgery, "Sandro Pertini" Hospital, Asl Roma 2, Rome, Italy
| | | | | | | | - Nando Gallese
- Unit of Proctologic Surgery, "Sant'Antonio" Clinic, Cagliari, Italy
| | | | - Michele D'Ambra
- Department of General and Oncologic-Minivasive Surgery, "Federico II" University, Naples, Italy
| | - Roberto Rizzato
- Department of General Surgery, Hospital of Conegliano AULSS 2, Marca Trevigiana, Treviso, Italy
| | - Giacomo Sarzo
- Department of General Surgery, University of Padova, "Sant'Antonio" Hospital, Padova, Italy
| | | | - Francesca Da Pozzo
- Department of Surgery, "Santa Maria dei battuti" Hospital, San Vito al Tagliamento, Pordenone, Italy
| | - Simona Ascanelli
- Department of Surgery, University Hospital of Ferrara, Ferrara, Italy
| | - Fabrizio Foroni
- Deparment of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, Naples, 80131, Italy
| | - Alessio Palumbo
- Deparment of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, Naples, 80131, Italy
| | | | | | - Luigi Marano
- Academy of Applied Medical and Social Sciences - AMiSNS: Akademia Medycznych i Spolecznych Nauk Stosowanych, Elbląg, Poland
| | | | - Eugenio Cudazzo
- Department of Surgery, Pelvic Floor Center, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Francesca Babic
- Department of Surgery, Hospital of Cattinara, ASUGI Trieste, Trieste, Italy
| | - Carmelo Geremia
- Unit of Proctology and Pelvic Surgery, "Città di Pavia" Clinic, Pavia, Italy
| | | | - Mario Cicconi
- Department of General Surgery, "Sant'Omero-Val Vibrata" Hospital, Teramo, Italy
| | | | - Federico Maria Mongardini
- Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Antonio Brescia
- Department of Oncologic Colorectal Surgery, University Hospital S. Andrea, "La Sapienza" University, Rome, Italy
| | - Leonardo Lenisa
- Department of Surgery, Humanitas San Pio X, Surgery Unit, Pelvic Floor Centre, Milano, Italy
| | | | | | - Luciano Vicenzo
- Deparment of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, Naples, 80131, Italy
| | | | - Ludovico Docimo
- Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
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Maternini M, Guttadauro A, Avella P, Buondonno A, Mascagni D, Milito G, Stuto A, Renzi A, Rennis M, Bottini C, Quarto G, Nudo R, Del Re L, Amato B, Gabrielli F. Collagen treatment of complex anorectal fistula: 3 years follow-up. Open Med (Wars) 2023; 18:20220553. [PMID: 37465352 PMCID: PMC10350888 DOI: 10.1515/med-2022-0553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 05/16/2022] [Accepted: 08/12/2022] [Indexed: 07/20/2023] Open
Abstract
Fistula in ano is a common anorectal disease in adults. Currently, surgery remains the definitive therapeutic approach, but in some cases, it can lead to serious complications as faecal or gas incontinence. Therefore, sphincter sparing treatments should be considered for complex fistulas. One of the sphincteric preserving treatment is the filling with a dermal extract commonly called "collagen glue" as Salvecoll-E® gel. This is a multicentric, prospective, observational study on the use of Salvecoll-E® gel in treatment of complex anal fistulas. We treated 70 patients from May 2016 to May 2017. In the first phase, we debrided the fistula tract using a loose seton kept for 4-6 weeks. In the second phase, the seton was removed and the fistula tract was filled with Salvecoll-E® gel. In this article, we report results at 36 months of follow-up. Fifty patients (71.4%) had completely healed fistula within 36 months of follow-up. Twenty-eight patients (28.2%) had recurrences. Among these failures, 65% were within 6 months. All low transphincteric fistulas healed. Recurrences occurred only in median and high transphincteric fistulas. No patient had a worsening of continence status measured with Cleveland Clinic Florida Incontinence Severity score. Salvecoll-E® gel is a recent finding among sphincter-sparing treatments. In this study, we demonstrate that it is a safe option in the treatment of complex fistulas. Final results are satisfactory and in line with the best results published in literature among mini-invasive treatments.
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Affiliation(s)
- Matteo Maternini
- General Surgery Department, Istituti clinici Zucchi of Monza, University of Milano-Bicocca, 20126, Milan, Italy
| | - Angelo Guttadauro
- General Surgery Department, Istituti clinici Zucchi of Monza, University of Milano-Bicocca, 20126, Milan, Italy
| | - Pasquale Avella
- Department of Medicine and Health Sciences “V. Tiberio,” University of Molise, Via Francesco De Sanctis 1, 86100, Campobasso, Italy
| | - Antonio Buondonno
- Department of Medicine and Health Sciences “V. Tiberio,” University of Molise, Via Francesco De Sanctis 1, 86100, Campobasso, Italy
| | - Domenico Mascagni
- General Surgery Department, Policlinico Umberto I, University La Sapienza of Rome, 00161, Rome, Italy
| | - Giovanni Milito
- General Surgery Department, University Hospital of Roma “Tor Vergata,”00133, Rome, Italy
| | - Angelo Stuto
- General Surgery Department, IRCCS Policlinico San Donato of Milano, 20097, Milan, Italy
| | - Adolfo Renzi
- General Surgery Department, Clinica Villa Delle Querce, 80136, Naples, Italy
| | - Maria Rennis
- General Surgery Department, Ospedale San Gerardo di Monza, University of Milano-Bicocca, 20900, Milan, Italy
| | - Corrado Bottini
- General Surgery Department, Hospital of Gallarate, 21013, Varese, Italy
| | - Gennaro Quarto
- Department of Clinical Medicine and Surgery, University of Naples “Federico II,”Via S. Pansini, 5, 80131Naples, Italy
| | - Raffaele Nudo
- General Surgery Department, Casa di Cura Fabia Mater, 00171, Rome, Italy
| | - Luca Del Re
- General Surgery Department, Ospedale Multimedica San Giuseppe of Milano, 20123, MilanItaly
| | - Bruno Amato
- Department of Public Health, University of Naples “Federico II,”Via S. Pansini, 5, 80131Naples, Italy
| | - Francesco Gabrielli
- General Surgery Department, Istituti clinici Zucchi of Monza, University of Milano-Bicocca, 20126, Milan, Italy
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