Anal fissure

Advancements in Rectal Drug Delivery Systems: Clinical Trials, and Patents Perspective

The rectal route is an effective route for the local and systemic delivery of active pharmaceutical ingredients. The environment of the rectum is relatively constant with low enzymatic activity and is favorable for drugs having poor oral absorption, extensive first-pass metabolism, gastric irritation, stability issues in the gastric environment, localized activity, and for drugs that cannot be administered by other routes. The present review addresses the rectal physiology, rectal diseases, and pharmaceutical factors influencing rectal delivery of drugs and discusses different rectal drug delivery systems including suppositories, suspensions, microspheres, nanoparticles, liposomes, tablets, and hydrogels. Clinical trials on various rectal drug delivery systems are presented in tabular form. Applications of different novel drug delivery carriers viz. nanoparticles, liposomes, solid lipid nanoparticles, microspheres, transferosomes, nano-niosomes, and nanomicelles have been discussed and demonstrated for their potential use in rectal administration. Various opportunities and challenges for rectal delivery including recent advancements and patented formulations for rectal drug delivery have also been included.

The Efficacy of Sitz Baths as Compared to Lateral Internal Sphincterotomy in Patients with Anal Fissures: A Systematic Review

An anal fissure is a common condition that affects patients of all ages. Its clinical presentation is a sharp pain on defecation with or without blood. It is treated by conservative or surgical means. This study aims to assess the efficacy of a sitz bath as compared to lateral internal sphincterotomy in the treatment of anal fissures. The search strategy used keywords related to the topic of study. Three databases were used: PubMed, Google Scholar, and Science Direct. A total of 551 articles were screened. A quality assessment check was done on the articles leaving 11 articles. Four aspects of sitz bath outcomes were evaluated in the articles. In terms of analgesia, articles showed conflicting evidence. However, the overall evidence supports the use of sitz baths for their analgesic properties. In terms of healing, most articles had similar recovery rates of around 80%. Much of the research supported the use of sitz baths as the primary treatment to heal acute fissures. When compared to lateral internal sphincterotomy, the recovery rates of lateral internal sphincterotomy are superior to those of conservative treatment, including sitz baths. However, studies showed incontinence as a side effect of lateral internal sphincterotomy, and no studies reported side effects from the sitz baths. To conclude, the results of the articles support the use of sitz baths to treat anal fissures. Sitz baths have been found to have analgesic properties, as well as a good healing time. But, compared to lateral internal sphincterotomy, there is a significant difference in the healing rate at the end stage of treatment, lateral internal sphincterotomy is found to be superior. With regards to the side effects, none have been reported from using a sitz bath.

Health and quality of life among a cohort of patients having lateral internal sphincterotomy for anal fissures

AIM

The aim of this study is to report changes in health-related quality of life attributable to lateral internal sphincterotomy for treatment of anal fissure. There is very little evidence on whether the overall health-related quality of life of patients is detrimentally affected by the condition, or which aspects of self-perceived health status improve after lateral internal sphincterotomy. This study will articulate which aspects of health tend to improve and guide postoperative expectations appropriately. Knowledge gained from this study may also identify gaps in an individual patient's episode of care.

METHOD

Patients were prospectively identified when they consented to surgical treatment of their anal fissure and were contacted by phone to participate. Participants completed a number of patient-reported outcomes preoperatively and 6 months postoperatively. Faecal incontinence-related quality of life, pain and depression were measured at both time points. The severity of faecal incontinence was measured at both times.

RESULTS

Participants reported high levels of pain preoperatively. Postoperatively, improvement in pain exceeded the threshold of clinical relevance (P < 0.01). Thirty-five per cent of participants reported significant effects of faecal incontinence preoperatively, while 26% did so postoperatively. Participants with multiple comorbidities were more likely to report faecal incontinence postoperatively than preoperatively.

CONCLUSION

This study reports that lateral internal sphincterotomy improved pain symptoms without adverse effects on continence. Not all domains of health-related quality of life were similarly positively affected by anal fissure repair.

Hemorrhoid Energy Therapy for Treatment of Deep Chronic Anal Fissures

Energy therapy is a well-known, minimally invasive treatment for internal hemorrhoids. This treatment has not yet been studied in anal fissures refractory to medical therapy. Anal fissures, such as hemorrhoids, can disrupt the quality of life for patients. Currently, nonsurgical treatments available for anal fissures are only supportive measures. Definitive for chronic anal fissures refractory to medical therapy is internal sphincterotomy. This treatment has chances of relapse and a risk of anal incontinence. We propose the use of hemorrhoid energy therapy with bipolar cautery as a safer, less invasive, and effective therapy for recurrent anal fissures refractory to conservative management.

Perianal Crohn's disease: challenges and solutions

Perianal Crohn’s disease affects a significant number of patients with Crohn’s disease and is associated with poor quality of life. The nature of the disease, compounded by presentation of various disease severities, has made the treatment of perianal Crohn’s disease difficult. The field continues to evolve with the use of both historical and contemporary solutions to address the challenges associated with it. The goal of this article is to review current literature regarding medical and surgical treatment, as well as the future directions of therapy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Fissure in ano is a very common disorder of the anorectal region. Internal sphincter hypertonia with decreased relaxation coupled with mucosal ischemia of posterior anal canal are the major pathologies in chronic anal fissure (CAF). Though lateral internal sphincterotomy (LIS) remains the gold standard of treatment for the disease, it is accompanied by the potential complication of incontinence to both flatus and faecal matter. The aim of our study was to explore the role of topical diltiazem as an effective and a safe alternative to sphincterotomy for chronic anal fissure. Ninety patients with CAF were randomly assigned to group A and group B, with 45 patients each. Group A patients received 2 % diltiazem topical application, twice daily, and group B patients underwent LIS. All the patients were reviewed at first, fourth and sixth week after initiation of treatment. Visual analogue scores for pain and healing of fissure by visual inspection were recorded and compared. In group A, 71 % had complete healing of fissure at 6 weeks, with fair amount of pain relief (mean VAS-3.38), and in group B, 96 % showed healing of fissure, with excellent pain relief (mean VAS-1.87). Headache and flushing were noted in two patients in group A while no patients in group B developed incontinence. We conclude that LIS is more effective than topical diltiazem in the treatment of CAF. Topical diltiazem may be employed as an initial conservative treatment option before considering the surgical alternative.

Dermal Flap Advancement Combined with Conservative Sphincterotomy in the Treatment of Chronic Anal Fissure

Lateral internal sphincterotomy (LIS) is considered the surgical treatment of choice for chronic anal fissure (CAF). Flap techniques for fissure coverage have the advantage of primary wound healing, potentially providing better functional results and faster pain relief. The standard surgical strategy for CAF consisting of conventional LIS (CLIS) up tothe dentate line was modified by “tailoring” the LIS to the apex of the CAF, but never greater than 1 cm, and by advancing a dermal flap for coverage of the CAF (LIS + flap) after fissurectomy. Thirty consecutive patients who underwent “LIS + flap” were compared with 32 patients who had been previously treated by CLIS. A modified, trapezoidlike Y-V flap from perianal skin was advanced into the CAF base. Pain at the first postoperative day, pain at defecation during the first week, postoperative use of analgesics, and time for patients’ pain relief were significantly less at the “LIS + flap” group ( P < 0.01). Objective healing was achieved faster ( P < 0.01) and soiling episodes were less ( P < 0.05) after “LIS + flap.” The addition of a dermal flap after “conservative” LIS resulted in better healing and significantly less postoperative discomfort than the isolated application of CLIS.

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

BACKGROUND

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

OBJECTIVE

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

PATIENTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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