The longer term results of internal anal sphincterotomy for anal fissure

The Long-term Effect of Standardized Anal Dilatation for Chronic Anal Fissure on Anal Continence

PURPOSE

For the past several decades, internal anal sphincterotomy has generally been considered to be the standard operation for an anal fissure. However, wound complications inherent in this operation forced surgeons to look for an alternative form of treatment. The aim of our study was to evaluate the long-term outcome of anal dilatation for chronic anal fissure, especially possible negative impact on anal sphincter function.

METHODS

The study was approved by the local Institutional Review Board and given a waiver of written consent. A phone call survey was undertaken among a group of consecutive patients who had an anal dilatation by standardized technique for chronic anal fissure for the period between 2000 and 2016. The survey included medical, obstetrical and surgical-related data, Wexner fecal incontinence score, recurrence of the anal fissure, and the need for additional medical intervention. Five hundred 48 patients were identified after limitations of age, concomitant pathology, and procedures that were applied to the hospital computerized database. Eighty-five patients (group A) agreed to participate in the survey and 463 patients did not.

RESULTS

There were no differences between groups in demographic information and medical records data; therefore, group A may well represent a satisfactory sample of the whole group. The interval between the procedure and the survey was 6.8 ± 2.7 years. The Wexner incontinence score was 0 in 94% of patients.

CONCLUSION

Anal dilatation, performed in a systematic and standardized way, has a successful outcome with no complications and has no clear long-term negative impact on anal sphincter function.

[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.

Anal Fissure

Anal fissure (fissure-in-ano) is a very common anorectal condition. The exact etiology of this condition is debated; however, there is a clear association with elevated internal anal sphincter pressures. Though hard bowel movements are implicated in fissure etiology, they are not universally present in patients with anal fissures. Half of all patients with fissures heal with nonoperative management such as high fiber diet, sitz baths, and pharmacological agents. When nonoperative management fails, surgical treatment with lateral internal sphincterotomy has a high success rate. In this chapter, we will review the symptoms, pathophysiology, and management of anal fissures.

Cost considerations in the treatment of anal fissures

Anal fissure is a split in the lining of the distal anal canal. Lateral internal sphincterotomy remains the gold standard for treatment of anal fissure. Although technique is simple and effective, a drawback of this surgical procedure is its potential to cause minor but some times permanent alteration in rectal continence. Conservative approaches (such as topical application of ointment or botulinum toxin injections) have been proposed in order to treat this condition without any risk of permanent injury of the internal anal sphincter. These treatments are effective in a large number of patients. Furthermore, with the ready availability of medical therapies to induce healing of anal fissure, the risk of a first-line surgical approach is difficult to justify. The conservative treatments have a lower cost than surgery. Moreover, evaluation of the actual costs of each therapeutic option is important especially in times of economic crisis and downsizing of health spending.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Subcutaneous lateral internal sphincterotomy (SLIS)--a safe technique for treatment of chronic anal fissure

OBJECTIVE

Subcutaneous lateral internal sphincterotomy (SLIS) is an effective treatment for fissure in ano but carries a definite risk of incontinence. The aim of this study was to assess the efficacy and complications of SLIS in patients with chronic fissure in ano.

MATERIALS AND METHODS

All patients presenting with a chronic anal fissure who underwent SLIS were entered into a prospective database. This is a review of these patients over 5 year's period (September 2002-2007). All operations were performed or directly supervised by a consultant colorectal surgeon. Short-term follow-up was at the first outpatient appointment (6 weeks postoperatively) and any impairment of continence was documented.

RESULTS

During the study period of 5 years, 96 patients underwent SLIS at our institution. Median patient age was 45 years (range 19-81). The median duration of symptoms was 65 days. No fissure failed to heal after SLIS. Minor complications were noted in five patients; 85% (82/96) attended the follow-up and out of these, 6% (5/82) reported early incontinence. One patient was incontinent to flatus, one to liquid and three to solid stool. After 12 weeks of follow-up, two patients were completely symptom free, one was incontinent to flatus and two were incontinent to liquid stool.

CONCLUSION

SLIS remains an effective treatment for chronic anal fissure. A small proportion of patients do suffer from faecal incontinence, which may be permanent in some cases. Careful patient selection and proper surgical training can reduce this risk.

Glyceryl trinitrate ointment (0.25%) and anal cryothermal dilators in the treatment of chronic anal fissures

INTRODUCTION

Chronic anal fissure is a common benign disorder; for this condition, lateral internal sphincterotomy is the "gold standard" of treatment. Alternative medical treatments have not proven to be as effective as left lateral internal sphincterotomy.

AIM

This randomized trial was designed to compare the use of 0.25% glyceryl trinitrate ointment and anal cryothermal dilators with the use of 0.4% glyceryl trinitrate ointment alone in the treatment of chronic anal fissures.

METHODS

Between 1 June 2006 and 31 December 2007, 60 consecutive patients who were suffering from chronic anal fissures were randomized into two groups. The patients in group A (n = 30) were treated with 0.25% glyceryl trinitrate ointment and anal cryothermal dilators twice daily, and those in group B (n = 30) were treated with 0.4% glyceryl trinitrate ointment alone twice daily. The treatment was administered to the patients in each group for 6 weeks, and all patients were examined 7 weeks after the start of the trial.

RESULTS

Prior to treatment, the symptoms and the measurements of anal pressure were similar in both groups. At 7 weeks, the maximum resting pressure was significantly lower in group A (P < 0.05), in which 86.6% of the patients were asymptomatic in comparison with 73.3% of the patients in group B. After 1 year of follow-up, 25 patients (83.3%) in group A and 18 patients (60%) in group B presented no recurrence of symptoms (P < 0.05)

CONCLUSIONS

Treatment of chronic anal fissures with 0.25% glyceryl trinitrate ointment and anal cryothermal dilators was more effective than the administration of 0.4% glyceryl trinitrate ointment alone.

Randomized, prospective trial comparing 0.25 percent glycerin trinitrate ointment and anal cryothermal dilators only with 0.25 percent glycerin trinitrate ointment and only with anal cryothermal dilators in the treatment of chronic anal fissure: a two-year follow-up

PURPOSE

The objective of this study was to compare the efficacy of 0.25 percent glycerin trinitrate ointment in association with cryothermal anal dilators with 0.25 percent glycerin trinitrate ointment only and cryothermal anal dilators only.

METHODS

A total of 48 patients suffering from chronic anal fissure were enrolled in this prospective, randomized study between January 2002 and December 2003: Group A, 16 patients were treated with 0.25 percent glycerin trinitrate ointment and also used cryothermal anal dilators; Group B, 16 patients were treated with 0.25 percent glycerin trinitrate ointment only; Group C, 16 patients were treated with cryothermal anal dilator use only. All patients in each group followed the specified treatment protocol for six weeks.

RESULTS

After seven weeks of treatment, the symptoms complained of were resolved in 15 patients (93.7 percent) in Group A, 12 patients (75 percent) in Group B, and 12 patients (78 percent) in Group C. After two years of follow-up, 14 patients (87.5 percent) in Group A, 9 patients (56.2 percent) in Group B, and 10 patients (62.5 percent) in Group C presented no recurrence of symptoms. No patient in any group reported serious side effects of the treatment proposed, and treatment did not have to be withdrawn in any of the randomized patients. No episodes of anal incontinence of gas or feces were recorded in the patients who had used the anal dilators.

CONCLUSIONS

The combined treatment for chronic anal fissure proved to be efficacious, safe, and with statistically significant better results than the other treatments analyzed.

Sphincterolysis: a novel approach towards chronic anal fissure

BACKGROUND AND AIMS

The surgical approach in chronic anal fissure is often found associated with disturbed anal continence as well as recurrence. This report describes the author's approach of 'sphincterolysis' or fragmentation of the fibers of the internal sphincter on the left lateral anal wall.

PATIENTS AND METHODS

132 patients with chronic anal fissures were treated with this technique. Pre- and postoperative anal manometry was recorded. The postoperative course and early and 1-year follow-up results were recorded.

RESULTS

Early complications included ecchymosis, hematoma, and pain. Fissure healing and relief of symptoms observed in 97% of patients. A transient, variable degree of incontinence occurred in 23 patients and persistent incontinence to flatus and soiling in 5.

CONCLUSION

Internal anal sphincterolysis is a safe, effective procedure for the treatment of chronic anal fissure.

Controlled lateral sphincterotomy for chronic anal fissure

PURPOSE

This study assessed the usefulness of "controlled" lateral sphincterotomy for chronic anal fissures.

METHODS

Of 225 patients with chronic anal fissure, 110 underwent traditional sphincterotomy to the level of the dentate line, and 115 underwent controlled sphincterotomy in three steps according to the degree of anal stenosis. In Step 1, the internal sphincter was divided to the proximal level of the fissure. If the anal canal was still stenosed, the division was extended to the level of the dentate line in Step 2. Step 3 was a bilateral internal sphincterotomy. The anal stenosis was evaluated under anesthesia using a new conical calibrator scaled in 1-mm diameter increments. Forty adults without anorectal disease were examined as controls. In a telephone follow-up, 102 patients in the traditional sphincterotomy group and 106 patients in the controlled sphincterotomy group responded.

RESULTS

The normal group measured 34.6 +/- 1.4 mm (mean +/- standard deviation). Confounding effects of age, gender, body weight, and height were not significant. Based on the anal caliber measured in the normal group, anal stenosis is present with values of 31 mm and below (mean--2SD of the control value). Of 115 patients in the controlled sphincterotomy group, 90 (78 percent) underwent sphincterotomy below the level of the dentate line, 18 (16 percent) underwent sphincterotomy to the level of the dentate line, and 7 (6 percent) underwent bilateral sphincterotomy. None had incontinence of feces or leakage of stool. Ten of 102 patients (10 percent) in the traditional sphincterotomy group and 2 of 106 patients (2 percent) in the controlled sphincterotomy group complained of minor incontinence, such as gas incontinence, minor staining, or urgency (P = 0.017). There was one recurrence in the traditional sphincterotomy group.

CONCLUSION

Controlled lateral sphincterotomy could be a way of overcoming the risk of incontinence with lateral internal sphincterotomy for chronic anal fissure.

Chronic anal fissure

BACKGROUND

The treatment of chronic anal fissure has shifted in recent years from surgical to medical.

METHODS

A Medline search of studies relevant to modern management of chronic anal fissure was undertaken.

RESULTS

Traditional surgery that permanently weakens the internal sphincter is associated with a risk of incontinence. Medical therapies temporarily relax the internal sphincter and pose no such danger, but their limited efficacy has led to displacement rather than replacement of traditional surgery. Emerging medical therapies promise continued improvement and new sphincter-sparing surgery may render traditional surgery redundant.

CONCLUSION

First-line use of medical therapy cures most chronic anal fissures cheaply and conveniently. The few non-responders can be targeted for sphincter assessment before traditional surgery. If the initial good results of new sphincter-sparing surgery are confirmed, it may be possible to avoid any risk of incontinence, while achieving high rates of fissure healing.

Treatment of anal fissure with glyceryl trinitrate in patients referred for surgical management

BACKGROUND

A number of recent studies indicate that anal fissure may be treated by applying glyceryl trinitrate (GTN) ointment. The present study aims to determine the effectiveness and patient acceptability of GTN treatment for patients referred to a consultant surgeon.

METHODS

A prospective study of 65 consecutive patients referred to one surgeon (ALP) over a 12-month period was undertaken. All patients were offered 0.2% GTN ointment to be applied intra-anally four times daily for 4 weeks. Informed consent was obtained and review planned for 4 weeks.

RESULTS

Fourteen patients declined treatment and nine of the 14 (64%) subsequently underwent lateral sphincterotomy. Twelve of the 51 patients (18.5%) who accepted treatment could not complete it due to headache or persisting severe anal pain. Thirty-nine of the 51 patients (77%) were able to complete 4 weeks of treatment. Twenty-two of the 39 reported an improvement in symptoms. A total of 22 patients (43%) who started GTN treatment subsequently underwent lateral sphincterotomy.

CONCLUSIONS

Evidence from the present study suggests that GTN ointment has a place in the management of referred patients with severe and/or chronic anal fissure, but sphincterotomy remains an important treatment option for the majority.

Controlled digital anal dilatation under total neuromuscular blockade for chronic anal fissure: a justifiable procedure

BACKGROUND

There is widespread antipathy to digital dilatation of the anus (DDA) for medically resistant anal fissure. A retrospective study was therefore undertaken to test the validity of the criticism of this technique.

METHODS

Some 273 patients who underwent DDA for fissure between November 1982 and July 1997 were sent a questionnaire and/or telephoned. Those with impaired control were offered investigation. In addition, routine clinic follow-up data were scrutinized in the 302 available notes of the 307 patients who had undergone DDA for fissure to determine its efficacy.

RESULTS

Some 241 patients (88.3 per cent) were contacted successfully a median of 7.8 years after operation. Follow-up records showed the fissure to have healed in 89.1 per cent of 302 patients. No patient was rendered incontinent. Fifteen patients indicated persistently impaired control in the questionnaire, nine (3.8 per cent) as a result of the DDA and six preceding it. All 23 patients who had experienced either temporary or permanent impairment, whether or not pre-existing, were invited to attend for ultrasonography and manometric measurements, of whom 18 accepted. No sphincteric fragmentation was seen, and resting and squeeze pressures did not differ from normal.

CONCLUSION

A single DDA appears to heal 89 per cent of chronic anal fissures. Consequent impairment of control is infrequent and minor if the procedure is performed carefully and with the patient paralysed.

Anorectal pain and irritation: anal fissure, levator syndrome, proctalgia fugax, and pruritus ani

Anal fissures, proctalgia fugax, levator ani syndrome, and pruritus ani are common causes of anorectal pain and irritation. The clinician who obtains a thorough history and performs a complete examination can accurately diagnose these disorders. Ancillary tests seldom are helpful and rarely are necessary. Most patients suffering from these conditions readily respond to conservative therapy provided in the primary care practitioner's office.

Tailored lateral sphincterotomy for anal fissure

PURPOSE

Most surgical texts describe the length of division of the internal sphincter during closed lateral sphincterotomy as "to just above the dentate line," resulting in significant rates of incontinence. This study reviews our experience using a "tailored" lateral sphincterotomy by selecting the height of sphincter to be divided with the aim of preserving more sphincter.

METHODS

From 1976 to March 1996, the files of 440 patients who had sphincterotomies were reviewed by an independent research assistant. After exclusions, a residual group of 352 patients had undergone tailored left lateral sphincterotomy for chronic anal fissure that had failed conservative treatment or for acute anal fissure requiring surgical intervention.

RESULTS

A total of 287 patients from the group who had tailored left lateral sphincterotomy returned for review (81.5 percent). Of these, four complained of imperfect control of flatus (1.4 percent), one of minor staining (0.35 percent), and two of urgency (0.7 percent). None had incontinence of feces or leakage of stool. Five patients had repeat sphincterotomies, four for recurrence and one for a persistent fissure.

CONCLUSION

The technique of tailored lateral sphincterotomy is safe, effective, and preserves more anal sphincter. It might be argued that a controlled trial comparing tailored sphincterotomy with the standard height of incision (with preprocedure and postprocedure manometry) should be performed, but the clinically significant reduction in incontinence rates using the tailored approach would seem to support its use.