Management of complicated chronic anal fissures with high-dose circumferential chemodenervation (HDCC) of the internal anal sphincter

Belgian consensus guideline on the management of anal fissures

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.

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.

Use of Botulinum Toxin Injections for the Treatment of Chronic Anal Fissure: Results From an American Society of Colon and Rectal Surgeons Survey

BACKGROUND

Chronic anal fissure (CAF) is commonly treated by colorectal surgeons. Pharmacological treatment is considered first-line therapy. An alternative treatment modality is chemical sphincterotomy with injection of botulinum toxin (BT). However, there is a lack of a consensus on the BT administration procedure among colorectal surgeons.

METHODS

A national survey approved by the American Society of Colon and Rectal Surgeons (ASCRS) Executive Council was sent to all members. An eight-question survey was sent via ASCRS email correspondence between December 2019 and February 2020. Questions were derived from available meta-analyses and expert opinions on BT use in CAF patients and included topics such as BT dose, injection technique, and concomitant therapies. The survey was voluntary and anonymous, and all ASCRS members were eligible to complete it. Responses were recorded and analyzed via an online survey platform.

RESULTS

216 ASCRS members responded to the survey and 90% inject 50-100U of BT. Most procedures are performed under MAC anesthesia (56%). A majority of respondents (64%) inject into the internal sphincter and a majority (53%) inject into 4 quadrants in the anal canal circumference. Some respondents perform concomitant manual dilatation (34%) or fissurectomy (38%). Concomitant topical muscle relaxing agents are not used uniformly among respondents.

DISCUSSION

Injection of BT for CAF is used commonly by colorectal surgeons. There is consensus on BT dosage, administration site, technique, and the use of monitored anesthesia care.

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.

Botulinum toxin as a treatment for short bowel syndrome in rats

Purpose:

The denervation of the intestine with benzalkonium chloride (BAC) reduces mortality and improves weight gain in rats with short bowel syndrome (SBS). Nevertheless, translating these promising findings from bench to bedside is not feasible because BAC promotes peritonitis and irreversible denervation which may be followed by an uncontrolled dilatation of the viscera. The use of botulinum toxin (BT) instead of BAC to achieve the denervation of the remaining small intestine in SBS could be an interesting option because it leads to a mild and transient denervation of the intestine.

Methods:

Here we evaluated the effects of the ileal denervation with BT in rats with SBS by verifying the body weight variation and intestinal morphological parameters. Four groups with 6 animals each were submitted to enterectomy with an ileal injection of saline (group E) or BT (group EBT). Control groups were submitted to simulated surgery with an ileal injection of BT (group BT) or saline (group C - control).

Results:

We observed that the treatment of the remaining ileum with BT completely reversed the weight loss associated to extensive small bowel resection.

Conclusion:

This may provide a new promising approach to the surgical treatment of SBS.

Treatment of chronic anal fissure: Is open lateral internal sphincterotomy (LIS) a safe and adequate option?

BACKGROUND

Anal fissure which is defined as a longitudinal tear in anoderm under the dentate line is one of the most common benign diseases of anorectal area, and due to the severe pain during the defecation and emotional stress that it causes may reduce people's quality of life. There are several treatment methods such as medical substances and surgical procedures. In this retrospective study, we aimed to evaluate the safe and adequate option of lateral internal sphincterotomy (LIS) in chronic anal fissure treatment.

METHODS

This study is a retrospective study in which 417 patients who were treated for chronic anal fissure were included.

RESULTS

Of 417 patients included in the study, 228 (54.7%) were female and the mean ± SD age was 36.1 ± 8.96 years (ranging from 17 to 73 years). Major complaints of patients; pain, bleeding, constipation, pruritus, perianal discharge. Recurrence occurred in 15 patients (3.6%) (12 males, three females) and eight patients (1.9%) developed incontinence (four with gas, four with soiling and seven females, one male). The complaints of all patients with gas incontinence and a patient with fluid incontinence regressed, whereas three patients had permanent fluid incontinence.

CONCLUSION

LIS is still the gold standard for the treatment of chronic anal fissure when the physicians would like to avoid recurrence and obtain the best pain relief.

Bilateral versus unilateral botulinum toxin injections for chronic anal fissure: a randomised trial

BACKGROUND

Botulinum toxin injected into the internal anal sphincter is used in the treatment of chronic anal fissure but there is no standardised technique for its administration. This randomised single centre trial compares bilateral (either side of fissure) to unilateral injection.

METHODS

Participants were randomised to receive bilateral (50 + 50 units) or unilateral (100 units) Dysport® injections into the internal anal sphincter in an outpatient setting. Injection-related pain assessed by visual analogue scale was the primary outcome measure. Secondary outcomes were healing rate, fissure pain, incontinence, and global health scores.

RESULTS

Between October 2008 and April 2012, 100 patients with chronic anal fissure were randomised to receive bilateral or unilateral injections. Injection-related pain was comparable in both groups. There was no difference in healing rate. Initially, there was greater improvement in fissure pain in the bilateral group but at 1 year the unilateral group showed greater improvement. Cleveland Clinic Incontinence score was lower in the unilateral group in the early post-treatment period and global health assessment (EuroQol EQ-VAS) was higher in the unilateral group at 1 year.

CONCLUSIONS

Injection-related pain was similar in bilateral and unilateral injection groups. Unilateral injection was as effective as bilateral injections in healing and improving fissure pain without any deterioration in continence.

Chronic anal fissures: Open lateral internal sphincterotomy result; a case series study

Introduction

Anal fissure are defined as a tear in the skin of the anal canal distal to dentate line. Although still there are controversies about the exact management, lateral sphincterotomy is promising. The aim of this series is to present the outcome of lateral sphincterotomy for internal anal sphincter in term of patient satisfaction and complication.

Patient and methods

A prospective single cohort study, 190 patients, who were undergone lateral sphincterotomy for internal anal sphincter from 2010 to 2014, were analyzed. The operation was performed as a day case procedure. The median duration of follow up was 5 years (ranging from 3 to 6). The data were analyzed using the Statistical Package for Social sciences (SPSS) version 22. Descriptive statistic was used to describe findings.

Results

Forty three males (22.6%) and 147 females (77.4%) with a mean ± SD of age of 31.19 ± 7.78 years. Constipation was reported in 152 (80%) patients, bleeding in 131 (68.6%) cases, and pain in 142 (74.7%) patients. The median duration of the disease was 20 months (ranging from 1 to 30 months). Post-operatively, patient satisfaction was high (98.4%) with only 3 cases (1.6%) of recurrence.

Conclusion: lateral sphincterotomy for internal anal sphincter, along, is the procedure of choice for management of CAF because it is effective and it can cure the disease in nearly all patients with good patient satisfaction.

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Anal fissures are defined as a tear in the skin of the anal canal distal to dentate line.

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There are several modalities of management of anal fissure including anal dilatation and sphinerotomy.

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The current study analyze the outcome of lateral sphenerotomy along in the management of chronic anal fissure.

Long-term outcomes of Botulinum toxin in the treatment of chronic anal fissure: 5 years of follow-up

BACKGROUND

Chronic anal fissure is a frequent and disabling disease, often affecting young adults. Botulinum toxin and lateral internal sphincterotomy are the main therapeutic options for refractory cases. Botulinum toxin is minimally invasive and safer compared with surgery, which carries a difficult post-operative recovery and fecal incontinence risk. The long-term efficacy of Botulinum toxin is not well known.

OBJECTIVE

The aim of this study was to evaluate the long-term efficacy and safety of Botulinum toxin in the treatment of chronic anal fissure.

METHODS

This was a retrospective study at a single center, including patients treated with Botulinum toxin from 2005 to 2010, followed over at least a period of 5 years. All patients were treated with injection of 25U of Botulinum toxin in the intersphincteric groove. The response was registered as complete, partial, refractory and relapse.

RESULTS

Botulinum toxin was administered to 126 patients, 69.8% (n = 88) were followed over a period of 5 years. After 3 months, 46.6% (n = 41) had complete response, 23.9% (n = 21) had partial response and 29.5% (n = 26) were refractory. Relapse was observed in 1.2% (n = 1) at 6 months, 11.4% (n = 10) at 1 year, 2.3% (n = 2) at 3 years; no relapse at 5 years. The overall success rate was 64.8% at 5 years of follow-up. Botulinum toxin was well tolerated by all patients and there were no complications.

CONCLUSION

The use of Botulinum toxin to treat patients with chronic anal fissure was safe and effective in long-term follow-up.