Pathophysiological aspects and clinical outcome of intra-anal application of isosorbide dinitrate in patients with chronic anal fissure

Enhanced Approach to Treating Chronic Anal Fissures: Fissurectomy with Vertical Non-full-thickness Midline Sphincterotomy and Mucosal Advancement Flap

Objectives

Lateral internal sphincterotomy is a conventional surgical intervention for chronic anal fissures, yet the potential for postoperative anal incontinence underscores the need for an alternative approach. This study aimed to evaluate the outcomes of patients with chronic fissures who underwent a combination of fissurectomy, vertical non-full thickness midline sphincterotomy (VNMS), and mucosal advancement flap (MAF), as a means of mitigating the risk of incontinence.

Methods

This retrospective analysis included forty-six consecutive patients with chronic anal fissures, unresponsive to topical diltiazem, who underwent fissurectomy combined with VNMS and MAF between April 2018 and May 2023. Primary outcome measures encompassed fissure healing rates. Continence was assessed using the Fecal Incontinence Severity Index (FISI), and manometric assessments were conducted before the procedure and three months postoperatively.

Results

With a median follow-up of 27 months, there were no postoperative complications, and the overall fissure healing rate reached 96% (44/46). At three months post-procedure, FISI scores were reduced to 0, with no instances of fecal soiling. Anal resting pressure exhibited a significant reduction at 3 months [pre-op: 133 (95% CI, 128-150) vs. 3 mo: 109 (95% CI, 100-117) cmH2O; p = 0.01]. Similarly, maximum anal squeeze pressure showed a significant decrease three months post-surgery [pre-op: 317 cmH2O (95% CI, 294-380) vs. 3 mo: 291 cmH2O (95% CI, 276-359), p = 0.03].

Conclusions

The combination of fissurectomy, VNMS, and MAF proved to be an effective approach for chronic anal fissures, yielding favorable medium-term outcomes without postoperative anal incontinence.

Analgesic injection of botulinum toxin in anal fissures is efficient and can be performed safely in patients actively receiving chemotherapy

PURPOSE

Injection of botulinum toxin into the internal anal sphincter is a well-documented intervention to reduce anal hypertonia in the treatment of anal fissures. In patients receiving chemotherapy, painful anal conditions are frequent, secondary to change in bowel habits and reduced immunity. However, injection of botulinum toxin is often not offered due to fear of complications.

METHODS

In this retrospective longitudinal observational study, performed in a tertiary hospital setting, we analysed patient characteristics, outcome and complication rates of botulinum toxin injection in patients actively receiving chemotherapy.

RESULTS

Twenty-six patients were treated with 20-50 IU botulinum toxin while actively receiving chemotherapy because of intractable pain and hypertonia. The fissure was located dorsally in 69% (n = 18) and ventrally in 19% (n = 5), while in 3 patients (12%), no fissure was documented. The majority of the patients (88%, n = 23) had complete (54%, n = 14) or partial (35%, n = 9) relief of pain. In three patients, additional anal pathology developed in the weeks following botulinum toxin injection: thrombosis of grade IV haemorrhoids, perianal haematoma and an intersphincteric abscess.

CONCLUSIONS

Injection of botulinum toxin in the anal sphincters is a safe and effective analgesic option in patients with anal fissure while actively receiving chemotherapy.

A Double-Blind Randomized Trial Comparing the Effectiveness and Safety of Nifedipine and Isosorbide Dinitrate in Chronic Anal Fissure

BACKGROUND

Chronic anal fissure is a common disease that is accompanied with pain and bleeding during defecation. Various surgical and non-surgical methods have been offered for the treatment of this condition. The aim of this randomised clinical study was to compare the effectiveness and safety of nifedipine and isosorbide dinitrate (ISDN) in the treatment of chronic anal fissure.

METHODS

This double-blind clinical trial study was performed on patients aged 20 to 60 years old in 2012 to 2013. The samples with a primary diagnosis of chronic anal fissure were enrolled from the patients admitted to public treatment at the educational Imam Ali Clinic, Shahrekord, Iran by researchers and general surgery specialists. The patients were randomised into two groups: nifedipine 0.3% (n = 35) or ISDN 0.2% (n = 35) applied three times a day for three weeks. The patients were examined on the 7th, 14th, and 21st days of treatment, and the symptoms including bleeding, pain, and healing status, as well as the side effects of the drugs, were assessed. Pain was evaluated using a visual analogue scale (VAS).

RESULTS

After 21 days of follow-up, complete healing was achieved in 77.1% (n = 27) of patients in the nifedipine group and 51.4% (n = 18) in the ISDN group (P = 0.05). The mean VAS of the pain on day 21 was 0.91 (SD 0.01) in the ISDN group and 0.45±0.78 in the nifedipine group, with a statistically significant difference (P = 0.038). The bleeding was similar in the two groups (P = 0.498).

CONCLUSION

In view of the findings on healing status and pain in the patients, nifedipine may be significantly more effective in the treatment of chronic anal fissure than ISDN.

In support of clinical case reports: a system of causality assessment

The usefulness of clinical research depends on an assessment of causality. This assessment determines what constitutes clinical evidence. Case reports are an example of evidence that is frequently overlooked because it is believed they cannot address causal links between treatment and outcomes. This may be a mistake. Clarity on the topic of causality and its assessment will be of benefit for researchers and clinicians. This article outlines an overall system of causality and causality assessment. The system proposed involves two dimensions: horizontal and vertical; each of these dimensions consists of three different types of causality and three corresponding types of causality assessment. Included in this system are diverse forms of case causality illustrated with examples from everyday life and clinical medicine. Assessing case causality can complement conventional clinical research in an era of personalized medicine.

Comparative study of glyceryl trinitrate ointment versus surgical management of chronic anal fissure

Chronic Anal Fissure (CAF) is common perineal condition and well-known painful entity. Standard surgical treatment even though available, may require long hospital stay and sometimes have worrying complications like anal incontinence. So non-surgical treatment, Glyceryl Trinitrate has been shown to be an effective for chronic anal fissure. It decreases anal tone and ultimately heals the anal fissure. The present study is the attempt to know the efficacy of 0.2% Glyceryl Trinitrate ointment in the treatment of chronic anal fissure and to compare the effectiveness of 0.2% Glyceryl Trinitrate ointment (GTN) versus fissurectomy with lateral internal sphincterotomy (LIS) and fissurectomy with posterior internal sphincterotomy (PIS) in the management of chronic anal fissure. This is a prospective comparative study of management of chronic anal fissure done in our hospital during the period of one and half year from October 2005 to March 2007. Thirty patients treated with 0.2% Glyceryl Trinitrate ointment and 30 patients treated with fissurectomy and lateral internal sphincterotomy and 30 patients treated with posterior internal sphincterotomy, for chronic anal fissure were selected for study. A single brand of 0.2% Glyceryl Trinitrate ointment (Nitrogesic) used for trial arm. Dose of administration was 1.5 cm to 2 cm in the anal canal with device provided by manufacturers of the proprietary preparation and applied twice a daily for 12 weeks. Patients were followed up for 12 weeks and thereafter evaluated for relief of symptoms in all three groups. Observations were recorded at 2 weeks; 6 weeks and 12 weeks of follow up period, regarding symptoms like pain and bleeding during defecation, healing of CAF and also for side effects like headache in GTN group and flatus, fecal incontinence in surgical groups. Data collected in proforma and analyzed. Study revealed CAF was more in male 59 patients (66%) than the female 31 patients (34%), the ratio being 1: 0.52. The maximum number of patients was encountered in the age group of 20 to 40 years with mean duration of age 34.14 years. In all three groups symptoms like pain, bleeding, constipation and sphincter spasm were present. Sentinel pile was present in 56% of the patients. Common site of fissure was found to be posterior in 94% of patients. Observations with respect to relief of pain, no bleeding and healing were recorded at 2, 6 and 12 weeks of duration. Lateral sphincterotomy remains effective but should be reserved for the patients who fail to respond to initial chemical sphincterotomy or GTN therapy. GTN is good alternative mode of therapy for patients who refuse surgery and prefer medical line of treatment.

Efficacy of management algorithm for reducing need for sphincterotomy in chronic anal fissures

BACKGROUND

Lateral internal sphincterotomy is the most effective treatment for chronic anal fissure (CAF), but carries a risk of faecal incontinence. We aimed to analyse efficacy and acceptance of a treatment algorithm in reducing the rate of necessary sphincterotomies.

METHOD

Patients with CAF seen from 2001 to 2010 were retrospectively analysed. All patients were offered all steps of the algorithm nitroglycerine (NTG) → Botox (BTX) → surgery, unless symptoms or patient preference demanded a more aggressive treatment. Patients were followed up in clinic, and treatment was advanced if a step either failed or caused intolerable side effects.

RESULTS

Two hundred and nine patients were included in the analysis. Mean duration of symptoms was 25.6 months and mean follow up 16 months. One hundred and 41 patients started on NTG, 36 on BTX, and 31 went straight to surgery. One patient opted for no treatment. Symptoms persisted in 58 (41.1%) of 141 NTG patients. Forty-five (31.9% of NTG subset) were advanced to BTX and 13 (9.2% of subset) to surgery. Of the 81 (36 primary + 45 secondary) BTX patients (38.8% of the total), only 11 (13.6% of subset) required surgery. A total of 55 (31 primary + 24 secondary; 26.3%) patients needed surgery: two (3.6%) fissures did not heal, one patient developed an abscess, 14 (25.5%) had prolonged wound healing and two (3.6%) developed a recurrent fissure after the sphincterotomy had healed.

CONCLUSION

Our algorithm is effective in CAF and the majority of patients respond to conservative management. Only 26.3% of all patients require surgery, which is effective but also carries some temporary morbidity.

Clinical judgement and the medical profession

OBJECTIVES

Clinical judgment is a central element of the medical profession, essential for the performance of the doctor, and potentially generating information also for other clinicians and for scientists and health care managers. The recently renewed interest in clinical judgement is primarily engaged with its role in communication, diagnosis and decision making. Beyond this issue, the present article highlights the interrelations between clinical judgement, therapy assessment and medical professionalism.

METHODS

Literature review and theory development.

RESULTS

The article presents different methodological approaches to causality assessment in clinical studies and in clinical judgement, and offers criteria for clinical single case causality. The article outlines models of medical professionalism such as technical rationality and practice epistemology, and characterizes features of professional expertise such as tacit knowledge, reflection in action, and gestalt cognition.

CONCLUSIONS

Consequences of a methodological and logistical advancement of clinical judgment are discussed, both in regard to medical progress and to the renewal of the cognitive basis of the medical profession.

A literature review on the role of chemical sphincterotomy after Milligan-Morgan hemorrhoidectomy

OBJECTIVE

A literature review of agents used to induce chemical sphincterotomy after hemorrhoidectomy.

METHODS

Electronic databases were searched from January 1935 to August 2010.

RESULTS

Two randomized controlled trials compared calcium channel blockers (Ca2) with placebo. Pain appeared to be less for up to 7 days, and its side-effect profile was comparable to the control group. Four randomized controlled trials examined the role of glyceryl trinitrate (GTN). GTN may be used up to 6 weeks to aid healing. Pain may be slightly less during its use and potentially offers less pain during defecation in the first 48 h. Its side-effect profile including headache appears comparable to placebo. Three randomized controlled trials investigated botulinum toxin A (BTX). BTX may be used to aid healing after hemorrhoidectomy. Pain may be less for up to a week after surgery. Its side-effect profile including incontinence to flatus appears comparable to placebo. It would be especially useful in cases where poor patient compliance is envisaged. Only one paper was found comparing BTX with GTN. BTX may be preferred over GTN due to better pain control and fewer side effects.

CONCLUSION

BTX, Ca2, and GTN may give effective pain relief for a week after hemorrhoidectomy. Their side-effect profiles are comparable to placebo.

Optimal treatment duration of glyceryl trinitrate for chronic anal fissure: results of a prospective randomized multicenter trial

Background

Chronic anal fissure (CAF) is a painful condition that is unlikely to resolve with conventional conservative management. Previous studies have reported that topical treatment of CAF with glyceryl trinitrate (GTN) reduces pain and promotes healing, but optimal treatment duration is unknown.

Methods

To assess the effect of different treatment durations on CAF, we designed a prospective randomized trial comparing 40 versus 80 days with twice daily topical 0.4% GTN treatment (Rectogesic^®, Prostrakan Group). Chronicity was defined by the presence of both morphological (fibrosis, skin tag, exposed sphincter, hypertrophied anal papilla) and time criteria (symptoms present for more than 2 months or pain of less duration but similar episodes in the past). A gravity score (1 = no visible sphincter; 2 = visible sphincter; 3 = visible sphincter and fibrosis) was used at baseline. Fissure healing, the primary endpoint of the study, maximum pain at defecation measured with VAS and maximum anal resting pressure were assessed at baseline and at 14, 28, 40 and 80 days. Data was gathered at the end of the assigned treatment.

Results

Of 188 patients with chronic fissure, 96 were randomized to the 40-day group and 92 to the 80-day group. Patients were well matched for sex, age, VAS and fissure score. There were 34 (19%) patients who did not complete treatment, 18 (10%) because of side effects. Of 154 patients who completed treatment, 90 (58%) had their fissures healed and 105 (68%) were pain free. There was no difference in healing or symptoms between the 40- and the 80-day group. There was no predictor of fissure healing. A low fissure gravity score correlated with increased resolution of pain (P < 0.05) and improvement of VAS score (P < 0.05) on both univariate and multivariate analysis. A lower baseline resting pressure was associated with better pain resolution on univariate analysis (P < 0.01). VAS at defecation and fissure healing significantly improved until 40 days (P < 0.001), while the difference between 40 and 80 days was not significant.

Conclusion

We found no benefits in treating CAF with topical GTN for 80 days compared to 40 days. Fissure healing and VAS improvement continue until 6 weeks of treatment but are unlikely thereafter.

Blinded randomized clinical trial of botulinum toxin versus isosorbide dinitrate ointment for treatment of anal fissure

BACKGROUND

Nitric oxide donors such as isosorbide dinitrate (ISDN) are considered the first choice of treatment for anal fissure. After reports of the successful treatment of such fissures with botulinum toxin, this randomized blinded trial compared botulinum toxin with ISDN in the treatment of chronic anal fissure.

METHODS

Patients were randomized to receive an injection of botulinum in the internal anal sphincter and a placebo ointment, or a placebo injection and ISDN ointment. The primary endpoint was macroscopic fissure healing after 4 months.

RESULTS

After 4 months macroscopic healing of the fissures was noted in 14 of 37 patients in the botulinum group and 21 of 36 in the ISDN group. Pain scores were lower among patients who received ISDN, although the difference was not significant. Side-effects were similar in the two groups.

CONCLUSION

In contrast with previous reports on botulinum toxin as a therapeutic agent for anal fissure, this study found no advantage over treatment with a nitric oxide donor as regards fissure healing and fissure-related pain.

The effect of glyceryl trinitrate ointment on posthemorrhoidectomy pain and wound healing: results of a randomized, double-blind, placebo-controlled study

PURPOSE

Spasm of the internal sphincter may be a source of anal pain and delayed healing after hemorrhoidectomy. This study assessed whether glyceryl trinitrate (GTN) ointment reduces pain and promotes wound healing after hemorrhoidectomy.

METHODS

A prospective, randomized, double-blind, placebo-controlled trial was conducted comparing effects of an ointment containing GTN (0.2 percent) vs. a placebo ointment. The study preparations were self-applied by the patient to the surgical site twice per day for two weeks after the hemorrhoidectomy. Pain was assessed with a visual analog scale, and 24-hour analgesic use was recorded on postoperative days 1, 3, and 7. Complete healing was defined as complete epithelialization and evaluated at the end of the third postoperative week.

RESULTS

Sixty-nine patients were randomly assigned to receive topical 0.2 percent GTN group or placebo. Data from 30 patients in each group were available for analyses. Patients in the GTN group experienced significantly less postoperative pain than those with placebo on days 1, 3, and 7 (P < 0.05). Use of prescribed analgesics (metamizole and acetaminophen) was significantly greater for the placebo group on days 1 and 3. Wound healing at the end of the third postoperative week was significantly greater with GTN compared with placebo (76.7 percent vs. 46.7 percent, P = 0.02).

CONCLUSIONS

Compared with placebo, perianal application of 0.2 percent GTN ointment significantly decreases postoperative pain after hemorrhoidectomy and reduces analgesic requirements in the immediate postoperative period. GTN ointment also achieves more rapid healing of wounds.

Botulinum toxin treatment for anal fissure

OBJECTIVES

To evaluate the effectiveness of Botulinum toxin injection in the treatment of anal fissure.

METHODS

38 patients (22 males, 16 females; mean age (SD) of 33.3 (8.3) years) who have presented to Surgical Outpatient Clinic at Al Ain Hospital, United Arab Emirates, with anal fissure in the period between June 2000 and September 2001 and treated with Botulinum toxin injection were retrospectively studied. They were followed up for at least 8 weeks to evaluate the effects of treatment.

RESULTS

Treatment with Botulinum toxin was effective in 89% of patients with chronic uncomplicated anal fissure. Two patients experienced minor incontinence in the form of a fecal soiling which disappeared later.

CONCLUSION

Botulinum toxin injection is an effective alternative for surgery for treatment of uncomplicated idiopathic anal fissure. Surgery should be offered to patients who do not improve with Botulinum toxin injection and to those with complicated anal fissure.

Neurochemical coding of the enteric nervous system in chagasic patients with megacolon

Neuronal destruction has been considered the hallmark of pathogenic mechanisms in chagasic megacolon. Characterization of neuropeptides in the enteric nervous system from chagasic patients with megacolon could elucidate some aspects of the development of this syndrome. In the present work we demonstrate the changes in expression of neuropeptides and neurochemical markers present in neuronal plexuses from the colons of chagasic patients with megacolon. Sections of frozen tissue samples were immunohistochemically labeled for anticalretinin, cChaT, substance P, VIP, NOS, and NPY. Immunoreactivity was observed using a confocal microscope. Our results demonstrate that in chagasic patients with megacolon, inhibitory motor neurons (VIP and NOS immunoreactive) are preferentially destroyed by Trypanosoma cruzi and/or the inflammatory process. These results suggest a selective destruction of enteric neurons in the colon of chagasic patients with megacolon, pointing to an important discovery in the mechanism of pathogenesis of Chagas' disease.

Efficacy and safety of botulinum toxin a injection compared with topical nitroglycerin ointment for the treatment of chronic anal fissure: a prospective randomized study

OBJECTIVES

To evaluate the efficacy and safety of botulinum toxin A injection compared with topical nitroglycerin ointment for the treatment of chronic anal fissure (CAF).

METHODS

Fifty outpatients with CAF were randomized to receive either a single botulinum toxin injection (30 IU Botox) or topical nitroglycerin ointment 0.2% b.i.d. for 2 wk. If the initial therapy failed, patients were assigned to the other treatment group for a further 2 wk. If CAF still showed no healing at wk 4, patients received combination therapy of botulinum toxin and nitroglycerin for 4 additional wk. Persisting CAF at wk 8 was treated according to the investigator's decision. Healing rates, symptoms, and side effects of the therapy were recorded at wk 2, 4, 8, 12, and 24 after randomization.

RESULTS

The group initially treated with nitroglycerin showed a higher healing rate of CAF (13 of 25, 52%) as compared with the botulinum toxin group (6 of 25, 24%) after the first 2 wk of therapy (p < 0.05). At the end of wk 4, CAF healed in three additional patients, all receiving nitroglycerin after initial botulinum toxin injection. Mild side effects occurred in 13 of 50 (26%) patients, all except one were on nitroglycerin.

CONCLUSIONS

Nitroglycerin ointment was superior to the more expensive and invasive botulinum toxin injection for initial healing of CAF, but was associated with more but mild side effects.

Controlled dose delivery in topical treatment of anal fissure: pilot study of a new paradigm

PURPOSE

Topical nitroglycerin has been widely used as a means for avoiding surgery in patients with anal fissure. However, nitroglycerin has not been universally accepted for this application because of inconsistency of efficacy and side effects. This study compares conventional digital application with precise intra-anal dosing of nitroglycerin using a specialized dose-delivery device and anal cannula.

METHODS

Twenty-six consecutive patients (13 males) with chronic anal fissure and no previous treatment were randomly allocated to receive 0.75 ml of 0.3 percent nitroglycerin ointment (2.25 mg nitroglycerin) t.i.d. intra-anal using the cannula (Group A) or perianally with the gloved finger (Group B). Nitroglycerin dosage was controlled in Group A by the dose-delivery device connected to the cannula and by single-dose preloaded syringes in Group B.

RESULTS

Anal manometry: pressure reduction after application of nitroglycerin was 47 +/- 18.6 in Group A and 20.7 +/- 13.4 percent in Group B (P < 0.01). Headaches were reported by 1 of 10 patients in Group A and 10 of 12 patients in Group B (P = 0.0027). Seven patients of Group B had to be crossed to intra-anal treatment as a result of intensity of headaches. Pain relief was noted by 8 of 10 and 9 of 12 patients in Groups A and B, respectively (P = 0.6). Sphincterotomy was required in only 13.6 percent of all patients.

CONCLUSIONS

Controlled intra-anal dosing of topical nitroglycerin produces a significantly greater reduction in sphincteric pressure and lower incidence of headaches than with perianal administration of the same dose of ointment. These results suggest a new paradigm for increasing safety and efficacy of dose-dependent prescription anal topical medications.

Toxine botulique et fissure anale chronique

Lateral internal sphincterotomy is widely used in the treatment of chronic anal fissure. However, it is associated with a high rate of irreversible incontinence. For this reason the botulinum toxin has become a medical means of reversible sphincterotomy. Indeed, this neurotoxin induces relaxation of the smooth internal anal sphincter lasting one to three months after one injection. We reviewed the published studies about the use of this technique in the management of chronic anal fissure. Healing occurred in more than 70% of fissures without irreversible incontinence. Although further studies are needed to determine the best modalities of administration, especially due to the remaining significant recurrence rate, this toxin may be a valuable treatment for chronic anal fissure in the future.

Serum Levels and Possible Haemodynamic Effects following Anorectal Application of an Ointment Containing Nifedipine and Lignocaine

OBJECTIVES

This study aimed to assess whether topical anorectal application of an ointment containing nifedipine (0.3% w/w) and lignocaine (lidocaine) [1.5% w/w] to healthy adult volunteers gives rise to pharmacologically relevant serum levels of the active ingredients and has any haemodynamic effects or side effects.

METHODS

A dose of 3g of the ointment was circumferentially applied inside the anus to 12 healthy volunteers every 12 hours for 7 days. Blood samples were collected at 0, 30, 60, 240, 480 and 720 minutes after the first application; in addition, blood samples were collected at days 1 and 7 after multiple applications. Serum concentrations of nifedipine, its main metabolites and lignocaine were determined by a new high-performance liquid chromatography method established for the purpose of the study. Volunteers' blood pressure, heart rate, ECG status and laboratory parameters were monitored throughout the study.

RESULTS

Topical application of the ointment to healthy volunteers did not produce therapeutically significant serum levels of the active ingredients and/or their active metabolites. Indeed, chromatographic signals of the active ingredients and/or nifedipine metabolites were only sporadically observed, below the quantification limits for the method, and consistent with therapeutically negligible concentrations. No serious local or systemic adverse events were observed throughout the study, and no subjects developed arrhythmias or significant ECG changes. Neither blood pressure nor mean heart rate varied significantly after application of a single dose. After multiple doses, mean systolic and diastolic blood pressure remained close to baseline levels for the duration of the study. The mean heart rate after multiple doses was about 5% below baseline level at days 1 and 7; however, these differences were not statistically significant.

CONCLUSION

This study demonstrates the safety of topical anorectal application of an ointment containing nifedipine (0.3% w/w) and lignocaine (1.5% w/w) to healthy volunteers.

Cost-saving effect of treatment algorithm for chronic anal fissure: a prospective analysis

Evidence-based medicine suggests that in the management of chronic anal fissure (CAF), lateral internal sphincterotomy (LIS) is far more effective than medical treatment in lowering the anal sphincter tone and curing the fissure. In the current study, we developed a treatment algorithm from topical nitroglycerin (NTG) to botulinum toxin type A (Botox [BTX]) to LIS and analyzed its cost benefit by calculating the effective and potential costs based on the treatment success and the rate of avoided surgeries. Patients presenting between November 2003 and December 2004 with CAF and symptoms for greater than 3 months were prospectively treated according to a treatment algorithm which started with (1) topical NTG, in case of failure (2) injection of BTX, thus limiting (3) surgery to those who failed both nonsurgical options or at any point chose the surgical approach. Based on the primary end points of fissure healing or surgery, we calculated the true cost (algorithm) and the potential incremental cost (BTX plus surgery or surgery in all patients, respectively). Sixty-seven patients with CAF (25 men and 42 women; median duration of symptoms, 16 weeks) were treated according to the algorithm. NTG alone was successful in fissure healing in 31 of 67 patients (46.2%). Two developed a recurrent fissure and then received BTX as part of the protocol. Of the 36 patients who failed NTG trial, 3 requested surgery; the others were treated with BTX, which was successful in 84.8%. Five patients (15.2%) failed BTX and subsequently required surgery. The overall surgery rate in the whole study group was 11.9%, whereas CAF healed in 88.1% of our patients with medical treatment alone. Cost for NTG is $10; for 100 units BTX, $528; and for outpatient surgery, $1119. The total cost for these 67 patients therefore was $33,252 ($290 for NTG, $20,580 for NTG plus BTX, $3,357 for NTG plus LIS, and $9,025 for NTG plus BTX plus LIS). If all patients had received BTX with a 15% failure rate, the total cost would have been $56,688 (70.3% cost increase). If all patients had undergone surgery as initial/only treatment, the total cost would have been $74,973 (125% cost increase). Our treatment algorithm for CAF with stepwise escalation can avoid surgery in 88% of the patients. It is highly cost-efficient and resulted in savings of 41% (compared with BTX plus LIS) and up to 70% (compared with surgery in all patients), respectively.

Cost-saving effect of treatment algorithm for chronic anal fissure: a prospective analysis

Evidence-based medicine suggests that in the management of chronic anal fissure (CAF), lateral internal sphincterotomy (LIS) is far more effective than medical treatment in lowering the anal sphincter tone and curing the fissure. In the current study, we developed a treatment algorithm from topical nitroglycerin (NTG) to botulinum toxin type A (Botox [BTX]) to LIS and analyzed its cost benefit by calculating the effective and potential costs based on the treatment success and the rate of avoided surgeries. Patients presenting between November 2003 and December 2004 with CAF and symptoms for greater than 3 months were prospectively treated according to a treatment algorithm which started with (1) topical NTG, in case of failure (2) injection of BTX, thus limiting (3) surgery to those who failed both nonsurgical options or at any point chose the surgical approach. Based on the primary end points of fissure healing or surgery, we calculated the true cost (algorithm) and the potential incremental cost (BTX plus surgery or surgery in all patients, respectively). Sixty-seven patients with CAF (25 men and 42 women; median duration of symptoms, 16 weeks) were treated according to the algorithm. NTG alone was successful in fissure healing in 31 of 67 patients (46.2%). Two developed a recurrent fissure and then received BTX as part of the protocol. Of the 36 patients who failed NTG trial, 3 requested surgery; the others were treated with BTX, which was successful in 84.8%. Five patients (15.2%) failed BTX and subsequently required surgery. The overall surgery rate in the whole study group was 11.9%, whereas CAF healed in 88.1% of our patients with medical treatment alone. Cost for NTG is $10; for 100 units BTX, $528; and for outpatient surgery, $1119. The total cost for these 67 patients therefore was $33,252 ($290 for NTG, $20,580 for NTG plus BTX, $3,357 for NTG plus LIS, and $9,025 for NTG plus BTX plus LIS). If all patients had received BTX with a 15% failure rate, the total cost would have been $56,688 (70.3% cost increase). If all patients had undergone surgery as initial/only treatment, the total cost would have been $74,973 (125% cost increase). Our treatment algorithm for CAF with stepwise escalation can avoid surgery in 88% of the patients. It is highly cost-efficient and resulted in savings of 41% (compared with BTX plus LIS) and up to 70% (compared with surgery in all patients), respectively.

Topical nitroglycerin versus lateral internal sphincterotomy for chronic anal fissure: prospective, randomized trial

INTRODUCTION

Topical nitroglycerin (GTN) is one of the medical treatments of choice in chronic anal fissure. The present prospective, randomized, clinical trial was conducted to study the symptomatic relief, healing, and changes in the maximum anal resting pressure (MARP) in patients with chronic anal fissure comparing topical GTN and lateral sphincterotomy.

METHODS

Forty consecutive patients with chronic anal fissure were randomized for treatment with either topical GTN or internal sphincterotomy (20 patients in each group). Anal manometry was done before treatment in all patients, and 1 h after application of GTN or sphincterotomy. Patients were followed at 2-weekly intervals for 6 weeks for symptomatic relief and healing.

RESULTS

Both GTN and sphincterotomy brought about a highly significant, but comparable drop in the MARP after treatment (P < 0.0001 in both groups). Sphincterotomy relieved pain much earlier compared to GTN (70% vs 40% at 2 weeks, P = 0.0032); but after 4 weeks of treatment, pain relief in both groups was comparable. Healing in the sphincterotomy group was also earlier than with GTN (55% vs 0% at 2 weeks, P < 0.0001; and 85% vs 30% at 4 weeks, P < 0.0001); but after 6 weeks, healing in both groups was comparable. Sphincterotomy had a significant incidence of minor, short-term complications; it also required surgical expertise, theatre time, and day-care beds. Nitroglycerin is safe, with mild and tolerable side-effects of headache and local burning sensation.

CONCLUSION

Topical GTN should be the initial treatment in chronic anal fissure. Lateral sphincterotomy should be reserved for patients with severe disabling pain (because pain relief is much faster), and for patients not responding to at least 4 weeks of GTN therapy.

A randomized, prospective, double-blind, placebo-controlled trial of the effect of a calcium channel blocker ointment on pain after hemorrhoidectomy

PURPOSE

Spasm of the internal sphincter plays a role in hemorrhoidal disease and may be a source of anal pain after hemorrhoid surgery. We have evaluated the effects of topical diltiazem, a calcium channel blocker, in reducing pain after hemorrhoidectomy.

METHODS

After hemorrhoidectomy, 18 patients were randomly assigned to receive 2 percent diltiazem ointment (n = 9) or a placebo ointment (n = 9). Ointments were applied to the perianal region three times daily for seven days. Patients were prescribed hydrocodone bitartrate (Vicodin) to take as needed. The type and number of prescribed or nonprescribed medications taken during the postoperative period were recorded. Patients maintained a log to measure postoperative pain daily and perceived benefit of the ointment, using a Visual Analog Scale ranging from 0 to 10. Any postoperative morbidity noted during the follow-up period was recorded.

RESULTS

Patients using the diltiazem ointment had significantly less pain and greater benefit than those in the placebo group throughout the first postoperative week. Postoperative pain scores in the placebo group averaged 8.8 +/- 1.2 early and diminished to 5.2 +/- 1.7 at the end of one week, compared to the diltiazem group of 5.2 +/- 2.4 early and 2.3 +/- 1.2 at the end of one week (P < 0.001, both time periods). Perceived benefit in the placebo group averaged 2.7 +/- 1.2 vs. 5.6 +/- 1.4 in the diltiazem group (P < 0.001). Total and daily narcotic use was higher in the placebo group, but this was not statistically significant (P = 0.13). No differences in the frequency of use of nonsteroidal anti-inflammatory drugs and acetaminophen were seen between the two groups, and there were no differences in morbidity between the two groups.

CONCLUSIONS

Perianal application of 2 percent diltiazem ointment after hemorrhoidectomy significantly reduces postoperative pain and is perceived as beneficial, with no increase in associated morbidity. Patients using a placebo ointment tend to take more prescription narcotics for pain relief postoperatively, with a similar usage of nonsteroidal anti-inflammatory drugs and acetaminophen, although differences were not significant.

Treatment of chronic anal fissure by application of L-arginine gel: a phase II study in 15 patients

PURPOSE

Local application of exogenous nitric oxide donors, such as isosorbide dinitrate and glyceryl trinitrate, promotes fissure healing by reducing anal resting pressure and improving anodermal blood flow. The major drawback of these nitric oxide donors is headache. The overall incidence of this side effect is approximately 40 percent. Recently we have shown in healthy volunteers that L-arginine, being an intrinsic precursor of nitric oxide, reduces anal resting pressure without headache as a side effect. The aim of the present study was to evaluate the effect of L-arginine on anal resting pressure, anodermal blood flow, and fissure healing in patients with chronic anal fissure.

METHODS

Fifteen patients with a chronic anal fissure were included in the present study. Before entering the study 10 patients were unsuccessfully treated by local application of isosorbide dinitrate. Six of these patients experienced severe headache during treatment with isosorbide dinitrate. All patients were treated for at least 12 weeks by local application of a gel containing L-arginine 400 mg/ml five times a day. In patients with a persistent fissure, treatment was continued until 18 weeks. Anal manometry and laser Doppler flowmetry of the anoderm were performed before treatment, 20 minutes after local application of the first dose, and after 12 weeks of treatment. A visual analog scale was used to assess fissure-related pain and headache.

RESULTS

One patient dropped out after one day of treatment, and one was excluded because of violation of the study protocol. After 12 weeks of treatment complete fissure healing was observed in 3 of 13 (23 percent) patients, and after 18 weeks the healing rate was 8 of 13 (62 percent) patients. None of the 13 patients experienced typical nitric oxide-induced headache. The pressure recordings showed a significant reduction of maximum anal resting pressure (mean +/- SD): pretreatment 89 +/- 17 mmHg; 20 minutes after application of the first dose 67 +/- 17 mmHg; 12 weeks after treatment 74 +/- 14 mmHg (P < 0.005). Recordings of anodermal blood flow showed a significant increase in flow: pretreatment 0.36 +/- 0.25 volts; 20 minutes after application of the first dose 0.59 +/- 0.27; 12 weeks after treatment 0.64 +/- 0.33 (P < 0.005).

CONCLUSIONS

Local application of L-arginine promotes fissure healing without headache as a side effect, and L-arginine is effective even in patients not responding to isosorbide dinitrate treatment.

Randomized, prospective trial comparing 0.2 percent isosorbide dinitrate ointment with sphincterotomy in treatment of chronic anal fissure: a two-year follow-up

PURPOSE

The aim of this trial was to compare lateral internal sphincterotomy with local 0.2 percent isosorbide dinitrate in the treatment of chronic anal fissure to minimize surgical complications such as minor fecal incontinence.

METHODS

Fifty-four patients with chronic anal fissure were randomized in a prospective trial to either sphincterotomy or local 0.2 percent isosorbide dinitrate. All patients had anal function tests before and 5 weeks after treatment.

RESULTS

In the ointment group, 18 patients (67 percent) healed at 5 weeks and 24 (89 percent) healed at 10 weeks of treatment. Maximum resting anal pressure was reduced 30 percent. Eight patients (30 percent) had minor side effects. In the surgical group, 26 patients (96 percent) healed at 5 weeks and 100 percent healed at 10 weeks after treatment, with 33 percent reduction in maximum resting anal pressure. Forty-four percent of patients had minor fecal incontinence, which remained in 15 percent after 24 months follow-up. No statistical difference in maximum resting anal pressure was found between groups ( P = 0.16), but the percentage of healing at 5 weeks was greater in the surgical group ( P < 0.001).

CONCLUSIONS

Isosorbide dinitrate ointment must be considered as the first choice of treatment in patients with chronic anal fissure. Surgery should be indicated if chemical sphincterotomy fails.

Review article: the management of pelvic floor disorders

Anorectal disorders, such as faecal incontinence, defecation difficulty and conditions associated with anorectal pain, are commonly encountered in the practices of gastroenterologists, urogynaecologists and colorectal surgeons. The evaluation of these disorders has been very much improved by the development and wider availability of diagnostic tests, such as manometry, endo-anal ultrasound, static and dynamic pelvic magnetic resonance imaging and electromyography. After briefly reviewing the normal anatomy and physiology of the anorectum, the pathophysiology and diagnostic approaches to faecal incontinence, defecation disorders and functional anorectal pain are discussed. Until recently, the management of these disorders has been largely anecdotal. However, our therapeutic armamentarium has been expanded by pharmacological agents, such as nitrates, calcium channel blockers and botulinum toxin, as well as the development of novel techniques, such as sacral nerve stimulation. These and other pharmacological, behavioural and surgical approaches are reviewed with respect to the robustness of evidence to support their efficacy in patients with these disorders.

Anal fissure: the changing management of a surgical condition

BACKGROUND

Chronic anal fissure is a common benign disorder that causes severe, sharp anal pain during defaecation. Fissures are generally associated with raised resting anal pressures, and treatments are aimed at reduction of these pressures. Surgical sphincterotomy is very successful at healing fissures but is associated with significant morbidity. Much work has gone into the development of new pharmacological agents that can promote healing of chronic anal fissures by production of a reversible chemical sphincterotomy, with the aim of avoiding long-term problems of incontinence.

METHODS

We review these recent innovations that have largely replaced surgery as first line treatment for chronic anal fissure.

CONCLUSIONS

Despite there being initial success with many of these pharmacological agents in the treatment of patients with chronic anal fissures, there are still some concerns about their use. In particular, the occurrence of side effects limits their use, and, unfortunately, they are not always effective at healing fissures. However, despite these drawbacks they remain excellent first-line options in the treatment of chronic anal fissures, and surgery should be offered only to patients who fail these therapies.

Concepts in pathogenesis and treatment of chronic anal fissure--a review of the literature

OBJECTIVE

Chronic anal fissures are associated with a persistent hypertonia and spasm of the internal anal sphincter. Classic treatment is surgical sphincterotomy to reduce the anal tone and eliminate sphincteric spasm. However, concerns have been raised about the incidence of fecal incontinence after surgery. Therefore, pharmacological means to treat chronic anal fissures have been explored.

METHODS

We conducted a literature review on MEDLINE database.

RESULTS

All treatments address the anomaly of a high anal pressure. Several studies have investigated the effect of topical glyceryl trinitrate ointment. Healing rates range from 30% to 86%. Therapy is limited because of a high incidence of moderate to severe headaches in up to 84% of patients. Comparable results are observed after injection of botulinum toxin into the anal sphincter (43-96%). Minor incontinence for flatus and soiling has been reported in up to 12% of patients. Further pharmacological approaches including treatment via calcium channel blockade and treatment with alpha-adrenoceptor antagonists are still at a developmental stage.

CONCLUSIONS

Topical glyceryl trinitrate ointment and injection of botulinum toxin into the anal sphincter are advocated as the first-line treatment for chronic anal fissure. Lateral sphincterotomy should be offered to patients with relapse and therapeutic failure of prior pharmacological treatment.

Topical nifedipine with lidocaine ointment vs. active control for treatment of chronic anal fissure: results of a prospective, randomized, double-blind study

PURPOSE

Chronic anal fissure may be treated by chemical or surgical sphincterotomy. The aim of this study was to test the efficacy of local application of nifedipine and lidocaine ointment in healing chronic anal fissure.

METHODS

The study was performed according to a prospective, randomized, double-blind design. One hundred ten patients who gave informed consent were recruited. They received a clinical examination, a questionnaire to evaluate symptoms and pain, anorectal manometry, and anoscopy. Healing of anal fissure at Day 42 of therapy was defined as the primary efficacy variable of the study. Patients treated with nifedipine (n = 55) used topical 0.3 percent nifedipine and 1.5 percent lidocaine ointment every 12 hours for 6 weeks. The control group (n = 55) received topical 1.5 percent lidocaine and 1 percent hydrocortisone acetate ointment during therapy. Anal pressures were measured by recording resting and maximal voluntary contraction pressures at baseline and at Day 21. Long-term outcomes were determined after a median follow-up of 18 months.

RESULTS

Healing of chronic anal fissure was achieved after 6 weeks of therapy in 94.5 percent of the nifedipine-treated patients (P < 0.001) as opposed to 16.4 percent of the controls. Mean anal resting pressure decreased from a mean value +/- standard deviation of 47.2 +/- 14.6 to 42 +/- 12.4 mmHg in the nifedipine group. This represents a mean reduction of 11 percent (P = 0.002). Changes of maximal voluntary contraction in nifedipine-treated patients were not significant. No changes in mean anal resting pressure and maximal voluntary contraction were observed in the control group. We did not observe any systemic side effect in patients treated with nifedipine. After the blinding was removed, recurrence of the fissure was observed in 3 of 52 patients in the nifedipine group within 1 year of treatment, and 2 of these patients healed with an additional course of topical nifedipine and lidocaine ointment.

CONCLUSIONS

Our study clearly demonstrates that the therapeutic use of topical nifedipine and lidocaine ointment should be extended to the conservative treatment of chronic anal fissure.

A study to determine the nitroglycerin ointment dose and dosing interval that best promote the healing of chronic anal fissures

PURPOSE

The aim of this study was to determine the optimal dose and dosing interval of nitroglycerin ointment to heal chronic anal fissures.

METHOD

A randomized, double-blind study of intra-anally applied nitroglycerin ointment (Anogesic) was conducted in 17 centers in 304 patients with chronic anal fissures. The patients were randomly assigned to one of eight treatment regimens (0.0, 0.1, 0.2, 0.4 percent nitroglycerin ointment applied twice or three times per day), for up to eight weeks. A dose-measuring device standardized the delivery of 374 mg ointment. Healing of fissures (complete reepithelialization) was assessed by physical examination using an observer unaware of treatment allocation. The subjects assessed pain intensity daily by completing a diary containing a visual analog scale for average pain intensity for the day, the worst pain intensity for the day, and pain intensity at the last defecation.

RESULTS

There were no significant differences in fissure healing among any of the treatment groups; all groups, including placebo had a healing rate of approximately 50 percent. This rate of placebo response was inexplicably higher than previously reported in the literature. Treatment with 0.4 percent (1.5 mg) nitroglycerin ointment was associated with a significant (P < 0.0002) decrease in average pain intensity compared with vehicle as assessed by patients with a visual analog scale. The decreases were observed by Day 4 of treatment. At 8 weeks the magnitude of the difference between 0.4 percent nitroglycerin and control was a 21 percent reduction in average pain. Treatment was well tolerated, with only 3.29 percent of patients discontinuing treatment because of headache. Headaches were the primary adverse event and were dose related.

CONCLUSION

Nitroglycerin ointment did not alter healing but significantly and rapidly reduced the pain associated with chronic anal fissures.

Botulinum neurotoxin and other treatments for fissure-in-ano and pelvic floor disorders

BACKGROUND

The management of disorders of the lower gastrointestinal tract, such as chronic anal fissure and pelvic floor dysfunction, has undergone re-evaluation recently. To a large extent this is due to the advent of neurochemical treatments, such as botulinum neurotoxin injections and topical nitrate ointment.

METHODS AND RESULTS

This review presents, inter alia, current data on the use of botulinum neurotoxin to treat lower gastrointestinal tract diseases, such as chronic anal fissure for which it promotes healing and symptom relief in up to 70 per cent of cases. This agent has also been used selectively to weaken the external anal sphincter and puborectalis muscle in constipation and in Parkinson's disease. Symptomatic improvement can also be induced in anterior rectocele by botulinum neurotoxin injections.

CONCLUSION

Botulinum neurotoxin appears to be a safe therapy for anal fissure. It is more efficacious than nitrate application and does not require patient compliance to complete treatment. While it may also be a promising approach for the treatment of chronic constipation due to pelvic floor dysfunction, further investigation of its efficacy and safety in this role is needed before general usage can be advocated.

Randomized clinical trial assessing the side-effects of glyceryl trinitrate and diltiazem hydrochloride in the treatment of chronic anal fissure

INTRODUCTION

Glyceryl trinitrate (GTN) ointment (0 small middle dot2 per cent) has an efficacy of up to 68 per cent in healing chronic anal fissure, but with headache as a major side-effect. Diltiazem hydrochloride (DTZ) cream (2 per cent) is expected to have fewer side-effects.

METHODS

A prospective double-blind randomized two-centre trial requiring at least 26 patients in each group (alpha = 0.05, beta = 0.9) was instituted after approval of the local ethics committee, to compare the incidence of side-effects (primary endpoint) with 0.2 per cent GTN ointment and 2 per cent DTZ cream in the treatment of chronic anal fissure. Treatments were applied perianally, twice daily for 6-8 weeks. All patients gave written informed consent.

RESULTS

Both groups were comparable in patient demographics and clinical characteristics. Twelve patients violated the protocol, withdrew or did not attend follow-up. There were more side-effects with GTN (21 of 29 patients) than with DTZ (13 of 31) (relative risk (RR) 1.84 (95 per cent confidence interval (c.i.) 1.11 to 3.04), P = 0.01). In particular, more headaches occurred with GTN (17 of 29 patients) than with DTZ (eight of 31) (RR 2.06 (95 per cent c.i. 1.18 to 3.59), P = 0.01). There were no significant differences in healing and symptomatic improvement rates between patients receiving GTN (25 of 29) and DTZ (24 of 31).

DISCUSSION

DTZ cream caused substantially fewer headaches than GTN ointment. There was no significant difference in the healing or improvement of chronic anal fissure between the treatments. DTZ may be the preferred first-line treatment for chronic anal fissure.

Fissurectomy and isosorbide dinitrate for chronic fissure in ano not responding to conservative treatment

BACKGROUND

Although lateral sphincterotomy heals chronic fissure in ano in over 90 per cent of cases it is a surgical technique with inherent complications. To avoid such complications, chronic fissure in ano was treated by fissurectomy in this study. To enhance postoperative tissue perfusion allowing stable wound healing, fissurectomy was combined with temporary chemical sphincterotomy by a nitric oxide donor cream.

METHODS

Seventeen consecutive patients (ten women) with chronic fissure in ano not responding to conservative management underwent diathermy fissurectomy. After operation patients used a 1 per cent isosorbide dinitrate cream. Postoperative follow-up continued until wounds had healed, at which time anal endosonography was performed. A telephone inquiry into fissure recurrence and continence status was made.

RESULTS

Seventeen patients underwent fissurectomy, without postoperative complications. All wounds had healed within 10 weeks. No fissure recurrence was seen after a median follow-up of 29 months. Histopathology showed non-specific scar tissue without signs of internal anal sphincter fibrosis. Postoperative endosonography showed no evidence of new internal sphincter defects.

CONCLUSION

In the treatment of chronic anal fissure not responding to chemical sphincterotomy with nitric oxide donors, fissurectomy in combination with isosorbide dinitrate cream may be a sphincter-sparing surgical technique.

Topical mononitrate treatment in patients with anal fissure

AIM

To assess the efficacy and patient compliance of topical mononitrate hydrogel for the treatment of anal fissure.

MATERIALS AND METHODS

Nineteen patients with symptomatic chronic anal fissures were randomly allocated to receive either active (10 patients) or placebo (nine patients) gel treatment. Rectal administration of hydrogel containing 0.2% isosorbide-5-mononitrate was prescribed. Patients were instructed on its application to the anal canal twice daily for 3 weeks. A questionnaire was used to determine patient compliance with therapy. Anal manometry was performed before and after therapy.

RESULTS

At the end of therapy, the fissures were healed in 80% of actively treated patients compared with 22% of the control group. There was a mean reduction of 28% in mean resting anal pressure. Two actively treated patients (20%) suffered from mild headache relieved with oral analgesics and menthol lozenges. Faecal incontinence was not observed. There were no recurrences during at least 3 months of follow-up.

CONCLUSIONS

Topical mononitrate gel therapy of anal fissures is an effective and safe approach. In this study, the few cases of headache were rapidly relieved with oral analgesia and menthol lozenges.

Progress in the understanding and treatment of chronic anal fissure

BACKGROUND

Chronic anal fissure is a common and painful condition associated with internal anal sphincter hypertonia. Reduction of this hypertonia improves the local blood supply, encouraging fissure healing. Surgical sphincterotomy is very successful at healing these fissures but requires an operation with associated morbidity. Temporary reduction in sphincter tone can be achieved on an outpatient basis by applying a topical nitric oxide donor (for example, glyceryl trinitrate) or injecting botulinum toxin into the anal sphincter.

METHODS

A Medline database was used to perform a literature search for articles relating to the non-surgical treatment of chronic anal fissure.

RESULTS

Review of the literature shows botulinum toxin injection to be more effective at healing chronic anal fissures than topical glyceryl trinitrate. Topical isosorbide dinitrate has not been directly compared with either of these two agents but has a healing rate approaching that of botulinum toxin injection. The main side effect of botulinum toxin injection is temporary faecal incontinence in approximately 2% of cases, whereas topical nitrates cause headaches in 20%-100% of cases. No long term side effects were identified with any of the medical treatments.

CONCLUSION

Chemical sphincterotomy is an effective treatment for chronic anal fissure and has the advantages over surgical treatment of avoiding long term complications (notably incontinence) and not requiring hospitalisation.

Randomized, prospective, double-blind, placebo-controlled trial of effect of nitroglycerin ointment on pain after hemorrhoidectomy

PURPOSE

Fissure-in-ano is characterized by pain, bleeding, and internal anal sphincter hypertonicity. Spasm of the internal sphincter also plays a role in hemorrhoidal disease and may be a source of anal pain after hemorrhoid surgery. Inducing sphincter relaxation with a nitroglycerin ointment has shown promise in healing anal fissures and relieving symptoms of pain. Our study attempts to test the hypothesis that topical nitroglycerin applied to the perianal region is beneficial in reducing pain after hemorrhoidectomy.

METHODS

After hemorrhoidectomy 39 patients were randomly assigned to receive 0.2 percent nitroglycerin ointment (n = 19) or placebo (n = 20). Ointments were applied to the perianal region three times daily for seven days. Patients were prescribed hydrocodone bitartrate to take as needed. Visual analog scales were used to measure postoperative pain intensity and ointment benefits. Patients completed questionnaires to record medication morbidity and number of prescribed or nonprescribed medications taken.

RESULTS

Patients using nitroglycerin had less pain and greater benefit from ointment than those did in the placebo group, but differences were not significant. Narcotic use was higher in the placebo group when considered on a daily basis, but was statistically significant on the second postoperative day only (P < 0.05). Morbidity from ointment application was significantly higher in the nitroglycerin group (P < 0.002) and included a headache in 8 of 19 patients. Nonsteroidal anti-inflammatory drugs and acetaminophen were not prescribed, but were taken more frequently in nitroglycerin patients (P < 0.0003).

CONCLUSION

Perianal application of 0.2 percent nitroglycerin ointment after hemorrhoidectomy significantly reduced narcotic requirements on the second postoperative day. Headaches and a subsequent need for nonnarcotic medications may limit benefits of nitroglycerin.

The pharmacology of the internal anal sphincter and new treatments of ano-rectal disorders

Surgical options for faecal incontinence in the presence of intact sphincters are limited. Furthermore, in patients with fissures, lateral sphincterotomy reduces anal sphincter hypertonia but there has been concern about complications. A greater understanding of the basic pharmacology of the internal anal sphincter has led to the development of novel treatments for both these disorders. A Medline review was undertaken for internal anal sphincter pharmacology, anal fissures and faecal incontinence. This review is based on these articles and those found by further cross-referencing. Nitric oxide released from non-adrenergic non-cholinergic nerves is the main inhibitory agent in the internal anal sphincter. Relaxations are also mediated through beta-adrenoceptors and muscarinic receptors. Stimulation of alpha-receptors results in contraction. Calcium and its entry through L-type calcium channels is important for the maintenance of tone. Nitric oxide donors produce reductions in resting anal tone and heal fissures but are associated with side-effects. Muscarinic agents and calcium channel antagonists show promise as low side-effect alternatives. Botulinum toxin appears more efficacious than other agents in healing fissures. To date, alpha-receptor agonists have been disappointing at improving incontinence. Further understanding of the pharmacology of the internal anal sphincter may permit the development of new agents to selectively target the tissue with greater efficacy and fewer side-effects.

Glyceryl trinitrate vs. lateral sphincterotomy for chronic anal fissure: prospective, randomized trial

INTRODUCTION

Glyceryl trinitrate has been shown to be an effective treatment for chronic anal fissure. It decreases anal tone and ultimately heals anal fissures. The aim of this trial was to compare glyceryl trinitrate with lateral sphincterotomy (current standard treatment) as definitive management for chronic anal fissure.

METHODS

All patients with symptoms of chronic anal fissure were randomly assigned to one of two treatment arms. The glyceryl trinitrate group applied 0.2 percent paste to the perianal area three times a day for eight weeks. Patients in the lateral sphincterotomy group underwent surgery on the next available operating list. Patients were reviewed at two weekly intervals until the fissure healed.

RESULTS

Sixty-five patients were enrolled in the trial, with 31 in the lateral sphincterotomy group and 34 in the glyceryl trinitrate group. Five patients were excluded after randomization. Twenty of 33 (60.6 percent) glyceryl trinitrate patients had healed fissures in eight weeks compared with 26 of 27 (97 percent) in the sphincterotomy group (P = 0.001). Twelve patients in the glyceryl trinitrate group had little improvement in their symptoms and underwent lateral sphincterotomy. Poor tolerance and poor compliance with treatment were important factors in patients whose fissures did not heal with glyceryl trinitrate. Fissures healed significantly faster after sphincterotomy compared with glyceryl trinitrate treatment (P = 0.0001). Nine of the 20 patients whose fissures healed with glyceryl trinitrate paste subsequently had a recurrence of their fissures. There were no long-term complications from lateral sphincterotomy.

CONCLUSION

Glyceryl trinitrate paste heals the majority of chronic anal fissures. However, a significant minority have little improvement or develop side effects and require conventional surgical treatment. Poor compliance with prescribed treatment often contributes to nonhealing. In addition, some fissures which initially heal with glyceryl trinitrate paste recur and require further treatment. Glyceryl trinitrate treatment is labor intensive for patients and physicians and has not been shown to be superior to lateral sphincterotomy.

Treatment of anal fissures with topical nitroglycerin

Anal fissure is a painful condition that is caused by anodermal tearing after the passage of hard stool. Severe cases result in involuntary internal anal sphincter spasm and have traditionally been treated surgically with a lateral sphincterotomy. Investigators have demonstrated that nitric oxide causes relaxation of the smooth muscle of the anal canal, so topical nitroglycerin ointment preparations have recently been studied as an efficacious alternative to surgery. Despite the fact that there are a number of trials examining topical nitroglycerin for the treatment of anal fissures, there remains no consensus about concentrations, compositions and applications necessary to obtain good results. This review summarises current literature regarding topical nitroglycerin pharmacotherapy for anal fissure.

Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects

PURPOSE

Topical glyceryl trinitrate heals anal fissures, but a majority of patients experience headache. Topical gels of the calcium channel blocker diltiazem and the cholinomimetic bethanechol significantly lower anal sphincter pressure in volunteers. This study investigated the use of these two new pharmacologic agents in the treatment of patients with chronic anal fissure.

METHODS

Two studies were conducted, each involving 15 patients with chronic anal fissure. In each study patients underwent anal manometry and laser doppler flowmetry before treatment. They were treated with either 2 percent diltiazem gel or 0.1 percent bethanechol gel three times daily for eight weeks. Assessment every two weeks was by clinical examination, repeat anal manometry, and laser doppler flowmetry. Daily pain was assessed by linear analog charts.

RESULTS

Fissures healed in 10 of 15 (67 percent) patients treated with 2 percent diltiazem gel and in 9 (60 percent) patients treated with 0.1 percent bethanechol gel. There was no significant difference in the pretreatment maximum resting sphincter pressure (MRP) between responders and nonresponders in either group. There was significant reduction in the pain score after treatment with diltiazem (P = 0.002) and bethanechol (P = 0.005) compared with that before treatment. MRP was significantly lower after diltiazem (P = 0.0001) and bethanechol (P = 0.02) compared with pretreatment MRP. No headaches or side effects were reported.

CONCLUSIONS

Both topical diltiazem and bethanechol substantially reduce anal sphincter pressure and achieve fissure healing to a similar degree reported with topical nitrates, but without side effects.

Neuromyogenic properties of the internal anal sphincter: therapeutic rationale for anal fissures

Lateral sphincterotomy diminishes internal anal sphincter hypertonia and thereby reduces anal canal pressure. This improves anal mucosal blood flow and promotes the healing of anal fissures. However, sphincterotomy can be associated with long term disturbances of sphincter function. The optimal treatment for an anal fissure is to induce a temporary reduction of anal canal resting pressure to allow healing of the fissure without permanently disrupting normal sphincter function. Broader understanding of the intrinsic mechanisms controlling smooth muscle contraction has allowed pharmacological manipulation of anal sphincter tone. We performed an initial Medline literature search to identify all articles concerning "internal anal sphincter" and "anal fissures". This review is based on these articles and on additional publications obtained by manual cross referencing. Internal anal smooth muscle relaxation can be inhibited by stimulation of non-adrenergic non-cholinergic enteric neurones, parasympathetic muscarinic receptors, or sympathetic beta adrenoceptors, and by inhibition of calcium entry into the cell. Sphincter contraction depends on an increase in cytoplasmic calcium and is enhanced by sympathetic adrenergic stimulation. Currently, the most commonly used pharmacological agent in the treatment of anal fissures is topical glyceryl trinitrate, a nitric oxide donor. Alternative agents that exhibit a similar effect via membrane Ca2+ channels, muscarinic receptors, and alpha or beta adrenoceptors are also likely to have a therapeutic potential in treating anal fissures.

Manual dilatation of the anus-still widely practised in the West of Scotland

OBJECTIVE

Two main surgical options exist for the current treatment of chronic anal fissure: manual dilatation of the anus (MDA) and lateral internal sphincterotomy (LIS). The high incidence of incontinence after MDA is widely documented. One study carried out in the West of Scotland in 1992 showed that 49% of patients undergoing MDA subsequently suffered some degree of incontinence. This study was set up to determine the number of surgeons in the region who continue to use MDA in their clinical management of chronic anal fissure.

METHODS

All consultant and higher surgical trainees in General Surgery in the West of Scotland were circulated with a postal questionnaire in November 1996 requesting how long they had been in post and to state their current preferred treatment of choice for chronic anal fissure.

RESULTS

Almost half the consultant surgeons (47%) in the West of Scotland favour MDA as their treatment of choice and its utilization increases according to seniority. In contrast, registrars and junior consultants predominantly use LIS.

CONCLUSION

These data show a high incidence of MDA as the treatment of choice for chronic anal fissure amongst consultant surgeons in the West of Scotland. The implications of such a practice are discussed.

Treatment of chronic anal fissure with topical glyceryl trinitrate

PURPOSE

There has been an emerging trend to treat chronic anal fissures by pharmacologic means. In particular, by the topical application of glyceryl trinitrate. However, such treatment has failed to gain wide acceptance within our local surgical community. The aim of this study was to evaluate the efficacy and patient acceptance of topical glyceryl trinitrate in the management of chronic anal fissures.

METHODS

A retrospective review was conducted on a consecutive series of 31 patients who were diagnosed as having a chronic anal fissures and were managed by the topical application of 0.2 percent glyceryl trinitrate to the perianal region twice a day. All patients were commenced on a high-fiber diet, and they were reviewed every two weeks until healed or until surgery was required. Patients were subsequently contacted by a mailed questionnaire to determine compliance with therapy, resolution of symptoms, recurrence of symptoms after cessation of therapy, and side effects.

RESULTS

Of 31 patients, 27 completed the questionnaire. Only 67 percent (18/27) of patients complied with the treatment as prescribed, and just 56 percent (15/27) achieved complete resolution of their symptoms after three to ten weeks of therapy. Recurrence of symptoms developed in 27 percent (4/15) of these patients after a median follow-up of six months. Side effects were reported in 78 percent (21/27) of patients, and in ten percent (2/21) they were so severe that the patients ceased therapy.

CONCLUSION

In this study the treatment of chronic anal fissures with topical glyceryl trinitrate appeared less efficacious than previously reported. In addition, the study highlighted problems with patient compliance, healing rates, and side effects that are associated with this modality therapy.