Anal Fissure

The efficacy of diltiazem, glyceryl trinitrate, nifedipine, minoxidil, and lidocaine for the medical management of anal fissure: a systematic review and network meta-analysis of randomized controlled trials

PURPOSE

Anal fissure (AF) is a common anorectal condition causing pain, bleeding, and other perianal discomfort. This study conducts a network meta-analysis (NMA) to compare the efficacy and side effect profiles of pharmacological treatments for AF, including diltiazem (DTZ), glyceryl trinitrate (GTN), nifedipine (ND), minoxidil (MD), and lidocaine (LC).

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review and NMA were performed. Randomized controlled trials (RCTs) comparing non-surgical treatments for AF were sourced from PubMed, Cochrane Library, Embase, and Medline. The primary outcome was AF healing, with secondary outcomes including recurrence rates, pain reduction (visual analog scale), and adverse effects. Statistical analysis utilized odds ratios and surface under the cumulative ranking values for treatment ranking.

RESULTS

Twenty-two RCTs involving a total of 1770 participants were included in the analysis. ND demonstrated the highest healing rate, followed by DTZ and MD. LC exhibited the lowest healing rate. DTZ had the lowest recurrence rate and was the most effective in pain reduction, whereas LC had the highest recurrence rate and was the least effective in alleviating pain. The incidence of adverse effects with MD was relatively low, second only to LC, while GTN had the highest rate of adverse effects.

CONCLUSION

ND had the highest healing rate and should be considered as a first-line non-surgical treatment for AFs. Given the elevated incidence of adverse reactions associated with nitroglycerin, its use should be avoided in order to minimize the risk of significant toxicities and side effects. Additionally, because of its outstanding analgesic properties, DTZ is recommended as the preferred option for patients with heightened sensitivity to pain, but more studies are needed to evaluate its efficacy.

Chili pepper consumption and duration of fissure symptoms onset are associated with perianal fistula development among patients with anal fissure: a case-control study

BACKGROUND

Perianal fistula is one of the complications of deepened anal fissure. The present case-control study aimed to assess the risk factors of fissure-associated fistulas due to the limited available evidence.

METHODS

Patients with fissure-associated fistulas were considered as case, and patients with anal fissure who were undergoing medical treatment without any previous anorectal surgeries were considered as control group. Data were collected through medical records or by directly contacting patients. Risk factors of fissure-associated fistulas were assessed using a multivariable logistic regression analysis.

RESULTS

The current study included 119 patients, consisting of 54 cases and 65 controls. There were no significant differences between the groups in terms of demographic characteristics. Our analyses revealed that chili pepper consumption (odds ratio [OR] = 2.96, 95% confidence interval [CI]: 1.06-8.31, P-value = 0.039) and the duration of fissure symptoms (OR = 1.03, 95% CI: 1.00-1.05, P-value = 0.035) were associated with perianal fistula in patients with fissure, after adjusting for age and sex as potential covariates.

CONCLUSIONS

An independent association was found between chili pepper consumption as well as the duration of fissure symptoms onset with an increased odds of perianal fistula in patients with fissures. Therefore, limiting chili consumption and early management of fissure symptoms are recommended.

Anal fissures in COVID-19 survivors: Incidence, risk factors, and outcomes

Objectives

In spite of COVID-19's typical presentation in the form of fever, cough, myalgia, and pneumonia, other gastrointestinal manifestations have been reported. Among the COVID-19 survivors, anal fissure has been documented. The aim of this study was to report the incidence of anal fissure among those patients, its possible risk factors and outcome.

Material and Methods

This is a retrospective cross-sectional study which was conducted on COVID-19 patients' who were diagnosed with anal fissure. Those who survived and were discharged home safely were contacted to pick up whether they suffered from any symptoms suggesting anal fissure, to identify the risk factors of anal fissure and their outcomes.

Results

A total of 176 COVID-19 patients were enrolled in this study. The incidence of anal fissure among all patients was 36.9%. Patients were categorized into two groups; fissure and non-fissure groups. No significant difference was noted in the demographic data apart from age, which was younger in the fissure group. The majority of anal fissures resolved spontaneously after patients recovered from the COVID-19 symptoms with no specific treatment (43.1%).

Conclusion

Anal fissure is quite a common problem in COVID-19 patients. Young and middle-aged patients are more vulnerable to develop anal fissure after COVID-19 infection.

High-Intensity Laser Therapy - An Option for Managing the Pain in Anal Fissures

Introduction: Anal fissures (AFs) are a prevalent pathology. Although internal lateral sphincterotomy is still the gold-standard surgery for treating chronic AFs, this procedure is associated with a considerable risk of anal incontinence. This study describes an alternative and minimally invasive technique for treating AFs using photobiomodulation and a high-power diode laser-fissure treatment (LFT) and highlights initial results pertaining to pain. Methods: This retrospective study focused on 38 patients treated with LFT on an outpatient basis at three different hospitals in different states of Brazil (Santa Catarina, Paraná, and São Paulo). The objective was to evaluate the effects of LFT treatment on AF patient pain following the procedure. The Friedman test was used to identify the effects of LFT treatment over time (D0, D7, D15, D30, and D60) on postoperative pain intensity using the visual analogue scale (VAS). Complications and incontinence rates were also analyzed. Results: Roughly two-thirds of the patients (66%; n=25) were male. The median age of the cohort was 49. Constipation was described by 32% of the patients, 13% were smokers, and 21% had recently used opioids. In 92% of the cases, the AF was localized posteriorly. Skin tags were present in 27% of the cases, and 26% had recently undergone a previous orificial surgery. A significant reduction in pain was observed over time in the intensity of postoperative pain measured by the VAS. Prior to surgery (D0), the patients' mean VAS score was 4.1; it progressively decreased to 0.1 on the 60th postoperative day (P<0.05). There was no significant change in fecal continence at the end of the 60-day follow-up period. Minor complications occurred in 7.9% of the patients (2.6% hemorrhoidal thrombosis, 2.6% skin tag, and 2.6% "failure"). Conclusion: Our results suggest that treating AFs with laser therapy results in a significant reduction in pain intensity over time without interfering with anal continence.

Is chemodenervation with incobotulinumtoxinA an alternative to invasive chronic anal fissure treatments?

BACKGROUND

Botulinum toxin type A is currently strongly recommended for the treatment of anal fissures (AFs). However, there is still no consensus on dosage or injection technique. This study provides further efficacy and safety evidence in a 2-year follow-up.

METHOD

Prospective, open-label, single-arm, single-center study carried out in adult patients with AFs non-responsive to previous treatments. Patients were treated with incobotulinumtoxinA (incoBoNT/A) injected in both laterals and posterior intersphincteric groove. Healing rate at 2 years was the primary endpoint. Secondary endpoints included internal anal sphincter pressures, incontinence, and safety.

RESULTS

A total of 49 patients were treated with a mean incoBoNT/A dose of 40.5 U (spread across three locations). Healing rate at 2 years was 83.9% with a 24.5% of recurrence throughout the study. Only 7 patients (14.3%) reported adverse events (AEs) that were mild and temporary. Mean reduction in anal resting pressure was -9.1 mmHg at 3 months (p = 0.001). Mean reduction in voluntary squeeze pressure was -27.5 mmHg at 3 months (p < 0.001). Mean pain perception measured with a visual analog scale decreased by -6.5 points at 2 years (p < 0.001). There was an incontinence increase at 1 month of 1.3 points (p = 0.006), but baseline values were restored at 6 months.

CONCLUSION

We present results that support the use of incoBoNT/A as a second line for AFs that do not respond to ointment therapy. IncoBoNT/A injection is a less invasive treatment that should be considered before surgery due to its efficacy and its safety which includes no permanent impairment.

TRIAL REGISTRATION

ISRCTN90354265; Registered on 16th February 2024. Retrospectively registered.

Botulinum toxin injection for chronic anal fissure: a prospective controlled study with long follow-up

BACKGROUND

Botulinum toxin is an effective therapeutic option for chronic anal fissure. However, there is no evidence about treatment standardization and long-term follow-up. We aimed to evaluate the short- and long-term efficacy and safety of botulinum toxin compared to close lateral internal sphincterotomy, with a 5-year follow-up.

METHODS

This was a prospective, controlled, single-center study conducted at University Hospital of Ferrara, Ferrara, Italy. The primary outcome was fissure healing at 1 month. Secondary outcomes were Quality-of-Life (QoL) at 1 month and after 5 years, and fissure recurrence at 6 months and 5 years.

RESULTS

A total of 59 patients received botulinum toxin injection (Botox), and 32 underwent lateral internal sphincterotomy. At 1 month after treatments, postoperative pain decreased faster and significantly more in the Botox group (30 vs. 60 mm; P<0.001); fissure re-epithelization was observed in 59.4% of the surgical group compared to 25.4% of Botox (P=0.0001). Anal sphincter pressures decreased more in surgical group (P=0.044), although severe anal incontinence was present only in this subset (6.2%; P=0.041). Compared to surgery, patients who received Botox had higher satisfaction rates (P<0.001). Fissure recurrence at 6 months was more common in Botox than surgical group (16.9% vs. 3.2%, respectively; P=0.053). The overall healing rate improved in all patients and persisted at 12 months and 5 years in both groups with overall high patient satisfaction despite mild anal incontinence in 21.8% in the surgery group (P<0.05).

CONCLUSIONS

Botox, rather than surgery, should be considered the first-line treatment for chronic anal fissure.

Management of Hemorrhoids and Anal Fissures

Hemorrhoids and anal fissures are two of the most common benign anorectal diseases. Despite their high prevalence, diagnostic accuracy of benign anorectal disease is suboptimal at 70% for surgeons, especially for hemorrhoidal diseases. Once the diagnosis is correctly made, numerous medical and surgical treatment options are available, each with different rates of success and complications. In this article, the authors review each step of patient management, with emphasis on evidence-based treatment options for hemorrhoids and anal fissures. The article discusses the pathophysiology, diagnosis, medical management, and procedures for hemorrhoids followed by a detailed overview on the management of anal fissures.

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.

Constipation: A Pristine Universal Pediatric Health Delinquent

Constipation suffered by children is a global public health problem. Functional constipation (FC) brings about deteriorating effects in the children's lives who suffer from it. The risk factors for the development of constipation include the consumption of a diet low in fiber and high in calories (such as the consumption of fast food), a sedentary lifestyle with a lack of exercise, a family history of constipation, and emotional and psychological stress endured by children in their families. It is one of the most common causes of stomachaches in children. FC may lead to fecal incontinence (FI), anal fissures, recurrent urinary tract infections (RUTI), and enuresis in children. Severe constipation may result in stool becoming rock-hard and inflexible in the rectum, which is clinically identified as fecal impaction. It is imperative to perform clinical evaluation and treatment, including pharmacological (the use of stimulant and osmotic laxatives) and non-pharmacological (education, changes in diet, intervention to promote positive behavior and address any emotional issues, toilet training, and physiotherapy for the pelvic floor) interventions. In the case of refractory patients, neuromodulation, the irrigation of the anal canal, and surgical management may be needed. It is essential to lead a healthy, stress-free lifestyle with plenty of exercise and a balanced diet rich in fiber (such as fruits and vegetables) so children can have regular bowel habits and thrive.

Surgeons' practice and preferences for the anal fissure treatment: results from an international survey

The best nonoperative or operative anal fissure (AF) treatment is not yet established, and several options have been proposed. Aim is to report the surgeons' practice for the AF treatment. Thirty-four multiple-choice questions were developed. Seven questions were about to participants' demographics and, 27 questions about their clinical practice. Based on the specialty (general surgeon and colorectal surgeon), obtained data were divided and compared between two groups. Five-hundred surgeons were included (321 general and 179 colorectal surgeons). For both groups, duration of symptoms for at least 6 weeks is the most important factor for AF diagnosis (30.6%). Type of AF (acute vs chronic) is the most important factor which guide the therapeutic plan (44.4%). The first treatment of choice for acute AF is ointment application for both groups (59.6%). For the treatment of chronic AF, this data is confirmed by colorectal surgeons (57%), but not by the general surgeons who prefer the lateral internal sphincterotomy (LIS) (31.8%) (p = 0.0001). Botulin toxin injection is most performed by colorectal surgeons (58.7%) in comparison to general surgeons (20.9%) (p = 0.0001). Anal flap is mostly performed by colorectal surgeons (37.4%) in comparison to general surgeons (28.3%) (p = 0.0001). Fissurectomy alone is statistically significantly most performed by general surgeons in comparison to colorectal surgeons (57.9% and 43.6%, respectively) (p = 0.0020). This analysis provides useful information about the clinical practice for the management of a debated topic such as AF treatment. Shared guidelines and consensus especially focused on operative management are required to standardize the treatment and to improve postoperative results.

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.

Long-term Efficacy and Safety of Controlled Manual Anal Dilatation in the Treatment of Chronic Anal Fissures: A Single-center Observational Study

Objectives

Conventional anal dilatation for anal fissures has long been abandoned because of the high incidence of anal incontinence. However, less invasive and more precise dilation techniques have been developed that have shown high healing and low incontinence rates. This study aimed to evaluate the efficacy and safety of controlled anal dilatation (CAD) using a standardized maximum anal diameter.

Methods

This study included 523 patients who underwent CAD for chronic anal fissures between January 2010 and December 2014. CAD was performed under sacral epidural anesthesia. The index fingers of both hands were placed in the anus and dilated evenly in various directions. CAD was completed when the anus was dilated to the sixth scale (35 mm in diameter) using a caliber ruler.

Results

The mean anal scale size expanded from 3.1 to 5.8 (p<0.001). Non-healing was observed in nine patients (1.7%) at 1 month postoperatively, six of whom underwent additional CAD. The mean maximal anal resting pressure (mmHg) decreased from 90.2 to 79.7 at three months postoperatively (p<0.001). Postoperative complications were observed in 11 (2.1%) patients, of whom three patients with thrombosed hemorrhoids underwent resection. None of the patients complained of anal incontinence during the mean follow-up period of 16.6 months. The cumulative recurrence-free rates at three and five years were 87.9% and 69.2%, respectively.

Conclusions

CAD is technically simple and safe and can achieve reasonable long-term outcomes. Thus, CAD appears to be the preferred procedure for patients with chronic anal fissures who do not respond to conservative treatments.

The Assessment of Marcaine Versus Meperidine for Spinal Anesthesia in Anorectal Surgery: A Randomized Clinical Trial

Background

Spinal anesthesia (SA) for the surgical management of chronic anal fissures is favored by surgeons as it provides an early return to daily activities; however, the agents applied for SA to achieve the best outcomes with minimized adverse effects are a matter of debate.

Objectives

This study aimed to assess the utility of Marcaine versus meperidine for SA induction of anoderm surgery.

Methods

This randomized clinical trial (RCT) was conducted on 138 patients with chronic anal fissures who were candidates for surgical management in 2020. The patients were randomly assigned to two groups of SA using 2.5 mL of hyperbaric Marcaine 0.5% (n = 69) or 1 mg/kg of meperidine (n = 69). Pain severity (measured via Numerical Rating Scale (NRS)), anal sphincter tone manometry (measured at baseline and the end of the sphincterotomy), and drug-related adverse effects were compared between the groups.

Results

Both agents led to significant pain relief within 24 hours after SA (P < 0.05); nevertheless, pain severity was remarkably lower in meperidine-treated patients in different measurements performed during the first 24 hours after SA (P < 0.05). The sphincteric tone significantly decreased in both groups (P < 0.001), while the postoperative tone was significantly less in the Marcaine-treated patients (65.22 ± 3.02 versus 46.04 ± 1.97, P < 0.001). The two groups did not differ regarding the adverse effects (P > 0.05).

Conclusions

Meperidine for SA in anal fissure surgical management was relatively superior to Marcaine, as postoperative pain control was remarkably better achieved with meperidine. However, anal sphincter tone reached a normal range in Marcaine-treated cases, and the average tone in those anesthetized with meperidine was slightly above the normal limits.

Mucosal vs. cutaneous advancement flaps for the treatment of chronic anal fissures: a randomized clinical trial

PURPOSE

The aim of this study was to compare two surgical treatment methods for chronic anal fissures (CAF), mucosal advancement flap anoplasty (MAFA) and cutaneous advancement flap anoplasty (CAFA).

METHODS

A randomized, blinded clinical trial was conducted on patients with CAF refractory to medical treatment referred to a tertiary-level hospital between January 2021 and December 2022. The patients were assigned to two groups by block randomization and were compared in terms of outcome, pain reduction, and complications.

RESULTS

There were 30 patients (male to female ratio 2:3, median age 42 years [range 25-59 years]). Both techniques reduced anal pain significantly (p = 0.001); however, there were no significant differences between MAFA and CAFA groups in recurrence, duration of healing, postoperative pain, and postoperative bleeding. No patient suffered from fecal incontinence (Wexner score = 0) or flap necrosis postoperatively. Only two patients in the MAFA group (1 and 3 months after surgery) and one patient in the CAFA group (2 months after surgery) had recurrence (total recurrence rate = 10%, healing rate = 90%). All of the patients were satisfied with their surgical results.

CONCLUSION

Mucosal and cutaneous anal advancement flap techniques are effective and comparable surgical procedures for the treatment of chronic anal fissures with minimal complications, fast healing process, and minimal postoperative pain and complications.

CLINICAL TRIAL ID

IRCT20120129008861N4 ( www.irct.ir ).

Platelet-rich plasma improves acute and chronic anal fissure, a randomized control trial

Anal fissure is one of the most prevalent diagnosis in patients with anorectal symptoms. Depending on the chronicity, treatment choices vary, from topical and conservative management to operative ones. PRP is a blood-derived product with a three to five-fold platelet count and can be used for restorative purposes. The objective of this study is to assess the therapeutic effect of intralesional PRP in acute and chronic anal fissures and comparing it with the classic topical approach. We included 94 patients with acute and chronic anal fissures and divided them into intervention and control groups. Control patients were treated only with topical compounds, and the intervention group received one dose of intralesional autologous PRP plus the same classic treatment. We assessed patients 2 weeks, 1 month, and 6 months later. The mean pain score in the intervention group was significantly lower than control groups in all visits (p-value <0.001). During the follow-ups, the bleeding rate was significantly lower in the intervention group, so in the sixth month, the bleeding was 4% in the intervention group against 32% of the control (p-value <0.001). The healing rate assessed by examination was 96% in the intervention group against 66% in the control in the sixth month (p-value <0.001). Although there may be no significant difference in healing rate between groups in the acute anal fissure, the PRP group is significantly superior in the chronic setting. We concluded that in anal fissure treatment, PRP plus topical products are significantly superior to alone topical treatment.

The Value of Injection Therapy with Botulinum Toxin in Pain Treatment of Primary Chronic Anal Fissures Compared to Anal Dilation, and Local Nifedipine in Combination with Lidocaine

Introduction: Anal fissure is a longitudinal tear of the mucosa of the anal canal extending from the outer anal orifice in the direction of the dentate line of the inner anal opening. Fissures are divided into primary and secondary, and acute or chronic. Besides minimal rectal bleeding, itching and soiling, primary chronic anal fissures (PCAF) manifest with anal pain as theirs main determinant. It is described as the most troubling symptom. Aim: To compare the effect of injection therapy with botulinum toxin A (ITBT) vs. anal dilation (AD), and local nifedipine with lidocaine (LNL) in pain treatment of PCAF. Materials and Methods: This controlled retrospective prospective longitudinal study covered 94 patients, divided in 3 groups. The first was treated with ITBT, the second with AD and third using LNL (31, 33 and 30 patients respectively). Clostridium botulinum toxin A was used, dissolved with saline to concentration of 200 U/ml. The solution was applied to both sides of PCAF at dose of 40U. Modified technique of AD was done using 3 fingers of a single hand, progressively introduced into the anal canal, followed by gradual lateral distraction during 1 min. LNL therapy was conducted using nifedipine (0.3%) with lidocaine (1.5%) ointment, applied twice daily for 3 weeks. To measure pain, a visual analog scale (VAS) was used. The follow-up period was 12 weeks with checkup at week 4. Results: The median age of participants was 46.6±13.9 years (50 males vs. 44 females). The type of therapy had a significantly different effect on pain at week 4 (p=0.0003). Severe pain was present in only 2 ITBT patients, 16 AD, and 6 LNL patients. Post hoc analyses showed different pain disappearance time by week 12 (p <0.0001). The mean time was shortest in ITBT group (6.1±1.5 weeks). Anal pain intensity significantly differed among the 3 groups (Fisher exact, p=0.002). Namely, 71% in ITBT group rated the pain as weakest (VAS score 1) compared to 18.2% in AD and 30% of patients in LNL group. The overall pain reduction significance was in favor of ITBT, due to the differences between the ITBT and AD groups (p=0.00024) and ITBT compared to LNL group (p=0.018). Conclusion: ITBT is superior to AD and LNL in reducing pain in PCAF.

A Pilot, Prospective, Randomized-Controlled Study to Evaluate the Efficacy and Safety of Arsha Hita™ in the Treatment of Anal Fissures

Introduction Anal fissures are tears in the anal canal that cause pain, bleeding, and spasms. They can be treated with non-operative options such as sitz baths, local anesthetics, topical nitrates, oral fiber, and calcium channel blockers, but some patients require surgery. Topical nitrates have side effects such as severe headaches, while topical calcium channel blockers can cause itching. There is a need to explore alternative treatments with fewer side effects. This proof-of-concept pilot study aimed to compare the efficacy and safety of a combination of Arsha Hita™ tablets and ointment (Shree Dhootapapeshwar Limited, Mumbai Maharastra, India) (test treatment) with a combination of lidocaine 1.5% w/w + nifedipine 0.3% w/w cream for local application and Isabgol powder (6 g) orally as an active comparator (standard treatment), which is the standard treatment of anal fissures as per the Association of Colon and Rectal Surgeons of India (ACRSI) guidelines. Methodology This study was a single-center, prospective, randomized-controlled study conducted in Karnataka, India. Participants were screened for anal fissures and randomized to receive either standard treatment (Group A) or test treatment (Group B) for 14 days, and were re-evaluated after two, four, and six weeks. The study assessed signs and symptoms related to anal fissures, such as pain post-defecation on Visual Analog Scale (VAS), bleeding per anus grading, wound healing grade, stool consistency, and stool frequency. Compliance, inter-current illness, and concomitant therapy were noted at each visit. The study used independent sample t-tests to compare variables at baseline and chi-square or Fisher's exact tests to compare the number/proportion of participants achieving primary and secondary endpoints. Mann-Whitney U test was used to compare median composite scores at baseline and Visit 4, and Friedman's two-way analysis of variance was used to compare median composite scores across the four visits (p < 0.05 was considered significant). Descriptive analysis was used to assess VAS, bleeding, and healing grades. Results The study included 53 participants with anal fissures, of which 25 out of 27 allocated in Group A (two drop-outs) received standard treatment, and all 26 allocated in Group B received Arsha Hita treatment. At the end of the study, 11 participants in Group B achieved a 90% reduction in composite scores compared to only three patients in Group A (p<0.05). Both groups showed improvement in pain on defecation, severity of bleeding, healing of anal fissure wound, and participant's and physician's global impression score. Group B had significantly better results in terms of VAS score, resolution of per-anal bleeding, and physician's global impression score (p<0.05). There were no adverse events in either group during the six-week treatment period. Conclusion The pilot study provides evidence that the combination of Arsha Hita tablets and Arsha Hita ointment may be more effective and safer for treating anal fissures than the standard treatment. The test treatment group experienced greater pain relief, complete resolution of per-anal bleeding, and better global impression scores than the standard treatment group. These findings suggest the need for further research through larger, randomized controlled trials to determine the efficacy and safety of Arsha Hita in treating anal fissures.

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.

Pelvic floor physical therapy in the treatment of chronic anal fissure (PAF trial): quality of life outcome

BACKGROUND

Chronic anal fissure is one of the most common anorectal diseases and is associated with reduced quality of life. The aim of this study was to investigate the effects of pelvic floor physical therapy on quality of life in patients with chronic anal fissure using the Short-Form 36 Health Survey (RAND-36).

METHODS

Adult patients, with chronic anal fissure and concomitant pelvic floor dysfunction, such as dyssynergia and increased pelvic floor muscle tone, were recruited at the Proctos Clinic in the Netherlands, between December 2018 and July 2021 and randomly assigned to an intervention group, receiving 8 weeks of pelvic floor physical therapy or assigned to a control group receiving postponed pelvic floor physical therapy (PAF trial). Quality of life and pain ratings were outcomes of the study and were measured at 8- and 20-week follow-up.

RESULTS

One hundred patients (50 women and 50 men, median age 44.6 years [range 19-68 years]), completed the RAND-36 questionnaire and visual analog (VAS) pain scale score at admission. A significant improvement was found at 20-week follow-up in all domains of the RAND-36; physical functioning, pain, health change (p < 0.001); physical role, vitality, general health, social functioning, emotional role, mental health (p < 0.05). VAS pain was significantly reduced at 8 weeks (mean estimated difference 1.98; 95% CI 1.55-2.42, p < 0.001) and remained significant at 20-week follow-up (p < 0.001). The difference between the groups as regards change in the mean pain intensity scores at 8 weeks was 2.48 (95% CI - 3.20 to - 1.75; p < 0.001). Compared to the reference values of the general Dutch population, the patients in our study with a chronic anal fissure and pelvic floor dysfunction reported an impaired quality of life in 8 of 9 domains of the RAND-36. After treatment, significant lower scores were found in 2 out of 9 domains.

CONCLUSIONS

The results of this study provide evidence that treatment by pelvic floor physical therapy improves quality of life and reduces pain, making it an important tool in management of chronic anal fissure and concomitant pelvic floor dysfunction.

Pelvic floor physical therapy in patients with chronic anal fissure: a randomized controlled trial

Background

A chronic anal fissure is a common, painful condition with great impact on daily life. The exact pathogenesis has not been fully elucidated and treatment varies. A large percentage of patients experience pelvic floor dysfunction (dyssynergia and increased pelvic floor muscle tone). The aim of our study was to investigate the effect of pelvic floor physical therapy in patients with chronic anal fissure.

Methods

Between December 2018 and July 2021, at the Proctos Clinic in the Netherlands, patients with chronic anal fissure and pelvic floor dysfunction were randomly assigned to an intervention group, receiving 8 weeks of pelvic floor physical therapy including electromyographic biofeedback or assigned to a control group receiving postponed pelvic floor physical therapy. The primary outcome was muscle tone at rest during electromyographic registration of the pelvic floor before and after pelvic floor physical therapy. Secondary outcomes contained healing of the fissure, pain ratings, improvement of pelvic floor function, and complaint reduction measured with a proctology-specific patient-reported outcome measurement. Endpoints were measured at 8- and 20-week follow-up.

Results

One hundred forty patients were included in the study, 68 men (48.6%) and 72 women (51.4%) with a mean age of 44.5 ± 11.1 (range 19–79) years. Mean resting electromyographic values of the pelvic floor in the intervention group significantly improved from pre- to post-treatment (p < 0.001) and relative to controls (mean estimated difference between groups − 1.88 µV; 95% CI, − 2.49 to − 1.27 (p < 0.001) at first follow-up and remained significant from baseline at 20-week follow-up (p < 0.001). The intervention group performed better compared to the control group on all secondary outcomes, i.e., healing of the fissure (55.7% of the patients vs 21.4% in control, pain ratings (p < 0.001), diminished dyssynergia (p < 0.001), complaint reduction (p < 0.001), and decrease of pelvic floor muscle tone (p < 0.05) at first follow-up.

Conclusions

The findings of this study provide strong evidence that pelvic floor physical therapy is effective in patients with chronic anal fissure and pelvic floor dysfunction and supports its recommendation as adjuvant treatment besides regular conservative treatment.

Treatment of anal fissures: Results from a national survey on French practice

BACKGROUND

Treatment of an anal fissure (AF) is based on medical treatment (nonoperative therapies) and surgical procedures. However, the choice of treatment and its role in therapeutic strategy vary from one country to another, and to date, no standard French recommendation is currently available. Our aim was to assess French practices in the treatment of AFs.

METHODS

A national survey of members of the French National Society of Colo-Proctology (SNFCP) was carried out using an online questionnaire (1) to evaluate French practice and (2) to compare them with guidelines of other societies.

RESULTS

Two hundred responses were obtained among the 300 registered members, representing a participation rate of 67%. Members of the SNFCP agree with all scientific societies on the importance of first-line medical treatment, with surgery proposed as a second-line treatment in the case of the failure of well-conducted medical treatment. However, calcium channel blockers and topical nitrates as first-line treatment are rarely prescribed in France. Priority is therefore given to "simple" topical healing products and oral analgesics on demand. Similarly, surgical management differs since LIS is the "gold standard" in most guidelines, whereas in France, despite the data in the literature, fissurectomy is the first-line treatment.

CONCLUSIONS

Our study indicated the fissure treatment discrepancies of France with other countries concerning the usage of topical treatments and the choice of first-line surgical treatments that is currently considered a "French exception".

A Pain in the Butt: Hemorrhoids, Fissures, Fistulas, and Other Anorectal Syndromes

Painful and bothersome anorectal syndromes can be a diagnostic and therapeutic challenge for clinicians because structural and functional abnormalities may often coexist and require a multidisciplinary approach to management. Although it is often difficult to attribute all of a patient's anorectal symptoms to a singular disorder with definitive intervention and cure, improving quality of life, treating coexistent conditions such as functional constipation and/or defecation disorders, addressing psychological comorbidities if present, and confirming there is no evidence of inflammatory or malignant conditions are top priorities.

Scanner-Assisted CO2 Laser Fissurectomy: A Pilot Study

Introduction: Surgery for chronic anal fissure is challenging for every proctologist. Solving the pain by guaranteeing rapid and effective healing is the objective, but what is the price to pay today in functional terms? Though this result is nowadays partially achievable through interventions that include the execution of an internal sphincterotomy among the procedures, it is necessary to underline the high rate of patients who can present faecal incontinence. The aim of this study is to explore the effectiveness of scanner-assisted CO₂ laser fissurectomy.

Methods: From April 2021 to September 2021, all consecutive patients who affected by chronic anal fissure suitable for surgery, meeting the inclusion and exclusion criteria, were evaluated. All planned data were recorded before surgery, then at 24 h, 1 week, and 1 month follow-up. A scanner-assisted CO₂ laser was used in this study to achieve a smooth and dried wound with a minimal tissue thermal damage, to ensure good postsurgical pain control, rapid and functional, elastic and stable healing, and to prevent potential relapses. Paracetamol 1 g every 8 h was prescribed for the first 24 h and then continued according to each patient's need. Ketorolac 15 mg was prescribed as rescue.

Results: Mean pain intensity ≤3, considered as the principal endpoint, was recorded in 26 out of the 29 patients who enrolled in the study with a final success rate of 89.7% at 1-month follow-up. Pain and anal itching showed a statistically significant reduction while bleeding, burning, and maximum pain, and REALIS score showed a reduction too at the end of the follow-up period. Reepithelisation proved to be extremely fast and effective: 22 of 29 (75.9%) showed a complete healing and 5 showed a partial reepithelisation at 1-month follow-up.

Discussion: Outcomes of this study showed that it is undoubtedly necessary to change the surgical approach in case of anal fissure. The internal sphincterotomy procedure must be most of all questioned, where the availability of cutting-edge technological tools must be avoided and offered only in selected cases. Scanner-assisted CO₂ laser showed great results in terms of pain control and wound healing, secondary to an extremely precise ablation, vaporisation, and debridement procedures with minimal lateral thermal damage.

Pelvic floor physical therapy in the treatment of chronic anal fissure (PAF-study): Study protocol for a randomized controlled trial

BACKGROUND

Chronic anal fissure (CAF) is a common cause of severe anorectal pain with a high incidence rate. Currently, a wide range of treatment options are available with recurrence rates varying between 7 and 42%. Pelvic floor physical therapy (PFPT) is a treatment option for increased pelvic floor muscle tone and dyssynergia which often accompanies CAF. However, literature on this subject is scarce. The Pelvic Floor Anal Fissure (PAF)-study aims to determine the efficacy and effectiveness of PFPT on improvement on pelvic floor muscle tone and function, pain, healing of the fissure, quality of life and complaint reduction in patients with CAF.

METHODS

The PAF-study is a single-centre, two armed, randomized controlled trial. Patients with CAF and pelvic floor dysfunction are eligible for inclusion. Exclusion criteria include abscess, fistula, Crohn's disease, ulcerative colitis, anorectal malignancy, prior rectal radiation, and pregnancy. A total of 140 patients will be randomized for either PFPT or postponed treatment of PFPT.The primary outcome is tone at rest during electromyographic registration of the pelvic floor before and after therapy. Secondary outcomes consist of healing of the fissure, pain ratings, improvement of pelvic floor function, complaint reduction and quality of life. Primary and secondary endpoints are measured at 8 and 20 weeks and at 1-year follow-up.

DISCUSSION

Currently, there is a gap in treatment modalities between conservative management and surgery. This manuscript prescribes the rationale, design, and methodology of a randomized controlled trial investigating PFPT as a treatment option for patients with CAF.

Fissurectomy Versus Lateral Internal Sphincterotomy in the Treatment of Chronic Anal Fissure: A Randomized Control Trial

Introduction

An anal fissure is defined as a longitudinal split in the distal anoderm which extends from the anal verge to the dentate line. Fissures can be of primary or secondary type. The posterior midline is the most common location for primary fissures, while, anterior primary fissures, though rare, are more common in females. The cause of primary fissure is idiopathic. But secondary fissures are associated with other systemic diseases and can occur at an abnormal position anywhere in the anoderm. A high percentage of acute fissures heal spontaneously within three weeks with conservative medical management comprising of a high fiber diet, warm sitz bath, and topical analgesic with steroids. Secondary anal fissures will not heal in any form of treatment until the primary cause is addressed. These fissures often need surgical treatment. The lateral internal sphincterotomy (LIS) is one of the most practiced treatments for chronic anal fissure. Nonetheless, anal incontinence is one of the worrisome complications of LIS. Fissurectomy is one of the options among those techniques which address the issues with LIS. Some studies showed that patients with chronic fissures who are refractory to medical treatment responded well to fissurectomy. Hence, this study was conducted to compare the outcomes of fissurectomy and lateral internal sphincterotomy in the treatment of chronic anal fissure and compare recurrence and postoperative complications among both the procedures.

Methods

All consecutive patients attending the department of surgery with chronic fissure and age above 18 years were included in the study. All the included patients were randomized into two groups (fissurectomy and LIS) using the serially numbered opaque-sealed envelope (SNOSE) technique. The patients were discharged on the third day. The first visit was scheduled after two weeks and subsequent visits on the first and second months. Then the patients were followed up by telephonic conversation for the next six months. At the end of the follow-up, post-surgical complications were enquired, recorded, and interpreted.

Results

In the present study, out of a total of 87 patients, 80 patients were included in the study. Among all the patients, 16 patients (20%) developed retention of urine. Four patients in the LIS group showed retention of urine whereas in the fissurectomy group it was twelve. The difference was not statistically significant (p-value: 0.025). A total of 10 patients required catheterization postoperatively. More patients in the fissurectomy group developed incontinence to flatus (p-value: 0.02). Incontinence to liquid and solid was significantly higher in the fissurectomy group (p-value: 0.03 and 0.002, respectively).

Conclusion

In the present study, it was found that LIS was a better treatment option for chronic anal fissure than Fissurectomy. The postoperative complications were less in LIS than in fissurectomy. But the recurrence was higher in the LIS group while there was no recurrence in the fissurectomy group.

The role of percutaneous tibial nerve stimulation (PTNS) in the treatment of chronic anal fissure: a systematic review

PURPOSE

This study was designed to summarize the current evidence regarding the role of percutaneous tibial nerve stimulation (PTNS) in the treatment of chronic anal fissure (CAF).

METHODS

The present systematic review of the literature was conducted on the basis of the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The primary endpoint of our study was the CAF recurrence rate. Quality assessment was based on the RoB 2 tool and the Case Series Quality Checklist.

RESULTS

Overall, 5 studies and 102 patients were included. A considerably heterogeneity in the neuromodulation technique and setting was identified. The pooled recurrence rate was estimated at the level of 19% (16/84). Post-interventional pain and Wexner scores were considerably reduced. The 2-month healing rate was 72% (18/25), whereas 73.6% of patients were symptom-free at 6 months.

CONCLUSIONS

PTNS is an effective alternative for the non-operative management of CAF. Due to several limitations further larger and higher quality studies are required.

Lower gastrointestinal bleeding in pregnancy: Differential diagnosis, assessment and management

Rectal bleeding is a common symptom experienced by pregnant women. Although the majority of cases are attributable to benign conditions such as haemorrhoids and anal fissures, other more serious diagnoses such as inflammatory bowel disease and malignancy should not be overlooked. Most investigations are safe during pregnancy and these should not be withheld as significant implications on both fetal and maternal morbidity may result. In these cases, a multidisciplinary team approach is essential. This review explores the differential diagnosis, investigation and management of rectal bleeding during pregnancy.

Anorectal emergencies: WSES-AAST guidelines

Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

The REALISE score: a new statistically validated scoring system to assess the severity of anal fissures

BACKGROUND

Anal fissure (AF) is a common, painful disease that strongly affects patients' quality of life, however, no scoring system to assess the severity of AF is available in the literature. The aim of this study was to set up and validate a reliable scoring system to quantify the severity of AF, to be used in prospective trials comparing the efficacy and the outcomes of surgical or medical treatments.

METHODS

The study was conducted on patients with acute or chronic AF and a control group in a tertiary centre for coloproctology in June 2020-September 2020. Two researchers independently carried out a structured interviewer-led questionnaire at two different time points (T1/T2). The questionnaire consisted of five items selected according to the most commonly reported symptoms for AF: the item pain, was scored from 0 to 10 using a visual analogue scale, and quality of life, duration of pain, use of painkillers, and bleeding were scored from 1 to 5 using Likert-scale questions. The scoRing systEm for AnaL fIsSurE (REALISE) score was the sum of the points. Patients with AF and a control group of patients with haemorrhoids, anal fistula, or obstructed defecation syndrome entered the study. Main outcome measures were reliability, inter-/intraobserver agreement, and repeatability.

RESULTS

One hundred and fifty well-matched patients (75 with AF and 75 controls) were enrolled. A significant difference was found between the mean REALISE score for patients with AF and controls (p < 0.001). The two REALISE scores were highly correlated (r = 0.99). The coefficient of repeatability was 1.45 in T1 and 1.18 in T2.

CONCLUSIONS

The REALISE score may have an important role in the assessment and management of AF, in grading the severity of AF and comparing results of different treatments.

Management options for chronic anal fissure: a systematic review of randomised controlled trials

INTRODUCTION

Anal fissure is the most common cause of severe anorectal pain in adults, contributing significantly to coloproctology workloads. There are a wide variety of management options available, including topical nitrites, calcium channel blockers, botulinum toxin injection and sphincterotomy. The aim of this study was to review current options for the treatment of chronic anal fissure.

METHODS

A comprehensive search identifying randomized controlled trials comparing treatment options for anal fissure published between January 2000 and February 2020 was performed. The primary outcome assessed was healing at 8 weeks post commencing treatment. Secondary outcomes included recurrence, intolerance of treatment and complications.

RESULTS

A total of 2822 studies were identified. After removal of duplicates and non-relevant studies, we identified nine randomized controlled trials which met pre-defined criteria. There was a total of 775 patients. At 8 weeks, healing rates were 95.13% in those treated with sphincterotomy, 66.7% in the botulinum toxin group, 63.8% in the nitrate group, 52.3% for topical diltiazem and 50% for topical minoxidil. Recurrence was highest amongst those treated with botulinum toxin injection (41.7%) and lowest for sphincterotomy (6.9%). Although the absolute number is low, there was a risk of permanent incontinence with sphincterotomy.

CONCLUSION

This review of the randomized control data demonstrates that healing was significantly higher amongst those treated with sphincterotomy versus more conservative modalities. Topical nitrites had similar outcomes to botulinum toxin injection but were poorly tolerated in comparison to other treatments. The benefit of sphincterotomy was at a cost of increased complications, notably permanent incontinence.

Development and In vitro Evaluation of Nifedipine Gel Formulations for Anorectal Applications

Objective:

Current study focuses on the formulation and characterization of lipophilic and hydrophilic gel formulations of nifedipine to treat anal fissure via anodermal application.

Methods:

Lipophilic gels were prepared with Aerosil grades as gelling agents in bulk oils. Polyethylene glycols, hydroxypropyl methylcellulose, and Carbopol® 974P were used as gelling agents in water and propylene glycol for forming hydrophilic gels. The effect of repeated Freeze-Thaw Cycles (FT-C) on microstructures of the gels was investigated by examining viscosity, rheology and textural properties. Aerosil 200 containing lipophilic gels exhibited thixotropic behavior with plastic flow properties and higher viscosities.

Result:

Accordingly, their compressibility and adhesiveness increased. FT-C caused notable changes in microstructures and textural properties of the lipophilic gels excluding the formulation containing Aerosil 200-in-isopropyl myristate. Among the hydrophilic gels, the viscosity of Carbopol® 974P gels increased depending on the amount of polymer, triethanolamine and water; these gels featured plastic flow without thixotropic behavior. Their compressibility and adhesiveness were higher than other gel formulations with stable post-FT-C characteristics. The higher flux values of nifedipine were observed from water containing Carbopol® 974P gel.

Conclusion:

The results of the stability tests showed that the Carbopol® 974P gel had a longer shelf life than the Aerosil 200-in-isopropyl myristate gel.

[Chronic anal fissure: etiopathogenesis, diagnosis, treatment]

Etiology, epidemiology and pathophysiology of anal fissure are examined in the article in order to determine the most optimal treatment strategy. The authors concluded that the most effective treatment is combined approach using both minimally invasive surgery and various medicines for anal spasm reduction.

Potential combination topical therapy of anal fissure: development, evaluation, and clinical study†

To treat anal fissure, internal anal sphincterotomy may be associated with surgical risks and incidence of incontinence. Botulinum toxin injection into the anal sphincter is invasive and expensive. Headache and hypotension hindered topical treatment with glyceryl trinitrate. Greater patient compliance, potentiated efficacy, reduced side effects, and lower cost are the major advantages offered by the combination therapy. Therefore, combination topical gels of nifedipine (NIF), lidocaine hydrochloride (LDH) and betamethasone valerate (BMV) were prepared and evaluated regarding viscosity, pH, drug content, and in vitro release. Compatibility study of drug-drug and drug-excipient mixtures preceded the formulation. Stability study was performed. A prospective randomized clinical trial was conducted for six weeks to assess the efficacy of the optimized formula in the treatment of anal fissure either acute (AAF, 37 patients) or chronic (CAF, 34 patients) in comparison with three single drug market products. The compatibility was indicated except in case of LDH with each of poloxamer 407 (P407), methylparaben, and propylparaben as well as BMV with P407. The gels showed acceptable viscosity ranges, tolerated pH values, and drugs content limits complying with the pharmacopeial limit. The gel containing 10% Transcutol^® (F2) was selected as optimized formula due to the significant (p < 0.05) enhancement in NIF release. The recommended storage temperature was 8 °C. In comparison with the market products, the optimized gel can be represented as a potential combination therapy of acute and chronic anal fissures as suggested by significantly increased healing% and significantly reduced pain, bleeding, anal discharge and itching without side effects.

The Effect of Nonoperative Management of Chronic Anal Fissure and Hemorrhoid Disease on Bowel Function Patient-Reported Outcomes

BACKGROUND

Nonoperative management has been reported to decrease symptoms from common anorectal conditions such as chronic anal fissures and hemorrhoids. The effects of these interventions on bowel function are unknown.

OBJECTIVE

This study aims to perform a prospective evaluation of patient-reported outcomes of bowel function on nonoperative management for chronic anal fissures and hemorrhoid disease.

DESIGN

This is a prospective, observational study.

SETTINGS

Patient-reported outcome measures were collected from the clinical practice of the division of colon and rectal surgery at a tertiary colon and rectal surgery referral center.

INTERVENTION

All patients received standardized dietary counseling including fiber supplementation as well as toileting strategies. Those with chronic anal fissures were also prescribed topical calcium channel blockers. The Colorectal Functional Outcome questionnaire was administered at baseline and at first follow-up visit.

MAIN OUTCOME MEASURES

The primary outcomes measured were the mean change in patient-reported bowel function scores after nonoperative management for each disease and in aggregate.

RESULTS

A cohort of 64 patients was included, 37 patients (58%) with chronic anal fissure and 27 patients with hemorrhoid disease. Incontinence, social impact, stool-related aspects, and the global score were observed to have statistically significant improvement in the aggregate group. When analyzed by diagnosis, hemorrhoid disease demonstrated a statistically significant improvement in incontinence and stool-related aspects, whereas chronic anal fissure was associated with a statistically significant change in social impact, stool-related aspects, and the global score.

LIMITATIONS

This study was limited by the small cohort size and unclear patient adherence to medical management.

CONCLUSIONS

Nonoperative management of chronic anal fissures and hemorrhoid disease is associated with significant improvement in patient-reported outcome scores in several domains, suggesting that dietary counseling and medical therapy should be the first-line outpatient therapy for these diseases. See Video Abstract at http://links.lww.com/DCR/A726.

Management of Common Benign Anorectal Disease: What All Physicians Need to Know

Benign anorectal conditions produce anal pain, rectal bleeding, or discharge from the perianal region, which are highly prevalent symptoms in the general population. Hemorrhoidal disease, anal fissure, perianal abscess, proctalgia syndromes, and pruritus anii are the most common clinical disorders. Well-trained physicians, irrespective of their specialty, can treat most of these disorders and refer them to a specialist in proctology only when necessary. The aim of this review is to provide a practical guide to the management of benign anorectal disorders in terms of their initial management and the criteria for specialist referral.

Treatment algorithm for anal fissure. Consensus document of the Spanish Association of Coloproctology and the Coloproctology Division of the Spanish Association of Surgeons

The Spanish Association of Coloproctology and the Coloproctology Division of the Spanish Association of Surgeons propose this consensus document with a treatment algorithm for anal fissure that could be used for decision making. Non-surgical therapy and surgical treatment of anal fissure are explained, and the recommended algorithm is provided. The methodology used was: creation of a group of experts; search in PubMed, MEDLINE and the Cochrane Library for publications from the last 10 years about anal fissure; presentation at the 21st National Meeting of the Spanish Association of Coloproctology Foundation 2017 with voting for/against each conclusion by the attendees and review by the scientific committee of the Spanish Association of Coloproctology.

Botulinum toxin injection vs topical nitrates for chronic anal fissure: an updated systematic review and meta-analysis of randomized controlled trials

AIM

Chronic anal fissures (CAFs) are frequently encountered in coloproctology clinics. Chemical sphincterotomy with pharmacological agents is recommended as first-line therapy. Topical nitrates (TN) heal CAF effectively but recurrences are common. An alternative treatment modality is injection of botulinum toxin (BT) into the anal sphincter. We aimed to perform an updated systematic review and meta-analysis to compare the effectiveness of BT and TN in the management of CAF.

METHOD

PubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until March 2017. All randomized controlled trials (RCTs) that reported direct comparisons of BT and TN were included. Two independent reviewers performed methodological assessment and data extraction. Random effects models were used to calculate pooled effect size estimates.

RESULTS

Six RCTs describing 393 patients (194 BT, 199 TN) were included. There was significant heterogeneity among the trials. On random effects analysis there were no significant differences in incomplete fissure healing (OR = 0.47, 95% CI 0.13-1.68, P = 0.24) or recurrence (OR = 0.70, 95% CI 0.39-1.25, P = 0.22) between BT and TN, respectively. BT was associated with a higher rate of transient anal incontinence (OR = 2.53, 95% CI 0.98-6.57, P = 0.06) but significantly fewer total side effects (OR = 0.12, 95% CI 0.02-0.63, P = 0.01) and headache (OR = 0.10, 95% CI 0.02-0.60, P = 0.01) compared with TN.

CONCLUSION

BT is associated with fewer side effects than TN but there is no difference in fissure healing or recurrence. Patients need to be warned regarding the risk of transient anal incontinence associated with BT.

Anal advancement flap versus lateral internal sphincterotomy for chronic anal fissure- a systematic review and meta-analysis

BACKGROUND

Chronic anal fissures (CAF) are common and associated with reduced quality of life. Lateral internal sphincterotomy (LIS) is frequently carried out but carries a significant risk of anal incontinence. Anal advancement flap (AAF) has been advocated as an alternative, 'sphincter-preserving' procedure. We aimed to perform a systematic review and meta-analysis to compare the efficacy of both techniques in the treatment of CAF.

METHODS

The online databases of PubMed/Medline, CINAHL, EMBASE and Cochrane Central Register of Controlled Trials were searched from inception to January 2017. All studies that investigated and reported outcomes of LIS and AAF for treatment of CAF were included. The primary outcome measure was anal incontinence while secondary outcomes included unhealed fissure and wound complication rates. Random effects models were used to calculate pooled effect size estimates.

RESULTS

Four studies (2 randomized controlled trials and 2 retrospective studies) describing 300 patients (150 LIS, 150 AAF) fulfilled our inclusion criteria. There was significant clinical heterogeneity among the trials. On random effects analysis, AAF was associated with a significantly lower rate of anal incontinence compared to LIS (OR = 0.06, 95% CI = 0.01 to 0.36, p = .002). However, there were no statistically significant differences in unhealed fissure (OR = 2.21, 95% CI = 0.25 to 19.33, p = .47) or wound complication rates (OR = 1.41, 95% CI = 0.50 to 4.99 p = .51) between AAF and LIS.

CONCLUSIONS

AAF is associated with less incontinence, but similar wound complications as well as a similar rate of unhealed fissures compared to LIS. However, further well-executed, multi-centre randomized trials are required to provide stronger evidence.

Does the duration of symptoms of anal fissure impact its response to conservative treatment? A prospective cohort study

BACKGROUND

Conservative treatment is the first line of treatment for anal fissure. The current study aimed to evaluate the impact of symptom duration on the response of anal fissure to conservative treatment.

PATIENTS AND METHODS

This prospective study was conducted on sixty patients with acute or chronic anal fissure who were treated conservatively with bulking agents, Sitz baths, and topical glyceryl trinitrate (GTN) 0.2%. Pain and constipation were assessed prior to treatment and at 6 weeks after therapy using visual analogue scale (VAS) and Wexner constipation score. Adverse effects as headache and postural hypotension were also queried.

RESULTS

The mean pre-treatment VAS for acute fissure was significantly higher than chronic fissure (8.8 ± 0.96 Vs 5.8 ± 1.12), also the post-treatment VAS for acute fissure was significantly lower at 6 weeks of treatment (0.47 ± 0.8 Vs 2.5 ± 1.3). The baseline Wexner constipation score was comparable in both groups; however, at six weeks of treatment it declined more significantly in patients with acute fissure. Patients with acute fissure achieved significantly better healing than chronic fissure (80% Vs 40%). Healing rates decreased from 100% in patients with symptoms < one month to 33.3% in patients with symptoms >6 months.

CONCLUSION

Conservative treatment including topical GTN 0.2% significantly hastened healing and relieved pain and other symptoms of acute more than chronic anal fissure. Healing rates of anal fissure in response to conservative treatment showed remarkable decrease in proportion to the duration of complaint.

Oral versus topical calcium channel blockers for chronic anal fissure-a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Chemical sphincterotomy with pharmacological agents is recommended as first line therapy for chronic anal fissures (CAF). Calcium channel blockers (CCB) are associated with similar efficacy but fewer side effects compared to nitrates. However, the optimal formulation (oral versus topical) is unknown. We aimed to perform a systematic review and meta-analysis to compare the effectiveness of oral and topical CCB in the treatment of CAF.

METHODS

PubMed and Embase online databases were searched for relevant articles. Two independent reviewers performed methodological assessment and data extraction. Random effects models were used to calculate pooled effect size estimates. A sensitivity analysis was also carried out.

RESULTS

Four randomized controlled trials describing 279 patients (138 in oral, 141 in topical group) were examined. There was significant heterogeneity among studies. On random effects analysis, topical CCB were associated with a significantly lower rate of unhealed fissure (21.3% vs. 38.4%; OR = 2.65, 95% CI = 1.50 to 4.69, p = 0.0008) when compared to oral therapy. However, there were no significant differences in fissure recurrence (5.4% vs. 5.5%; OR = 1.01, 95% CI = 0.31 to 3.33, p = 0.98) or side effects (15.6% vs. 39.1%; OR = 4.54, 95% CI = 0.46 to 44.3, p = 0.19) between topical and oral CCB. On sensitivity analysis, having excluded the most heavily biased trial, topical CCB were associated with significantly fewer side effects compared to oral therapy (4.3% vs. 38.0%; OR = 13.16, 95% CI = 5.05 to 34.3, p < 0.00001).

CONCLUSIONS

Topical CCB are associated with better healing and fewer side effects when compared to oral therapy but there is no difference in recurrence rates.

A Case Series of Anal Carcinoma Misdiagnosed as Idiopathic Chronic Anal Fissure

Chronic anal fissure is a linear ulcer in the anal canal that has not cicatrized for more than 8-12 weeks of treatment. Most anal fissures are idiopathic and are located in the posterior midline. Squamous cell carcinoma of the anus commonly presents as bleeding and anal pain. It may also present as a mass, nonhealing ulcer, itching, discharge, fecal incontinence and fistulae. Not uncommonly, small and early cancers are misdiagnosed as benign anorectal disorders like anal fissures or hemorrhoids. The clinical suspicion of squamous cell carcinoma of the anus is of paramount importance in patients with nonhealing anal fissures, fissures in atypical positions or with indurated or ulcerated anal tags and in patients with risk factors for the development of anal squamous intraepithelial lesions that are precursors of invasive anal squamous cell carcinoma. The authors present 3 cases of squamous cell carcinoma of the anus initially misdiagnosed as benign chronic anal fissure.