Identifying the best therapy for chronic anal fissure

Depression in patients with anorectal fistulas and anal fissures: a propensity score-matched cohort study

PURPOSE

Anal fissures and anorectal fistulas are diseases often associated with significant pain and prolonged discomfort, resulting in a significantly reduced quality of life (QoL). They are not only a surgical problem but also have a profound psychosocial impact and influence on QoL. The aim of this study was to investigate the incidence of depression in patients with these pathologies and to highlight the need to address the psychosocial aspects of these diseases.

METHODS

Data from the Disease Analyzer database of approximately 3,000 general practitioners in Germany were retrospectively analyzed. The retrospective cohort study included patients aged ≥ 18 years diagnosed with anal fissure (n = 15,467) or anorectal fistula (n = 3,520) between January 2005 and December 2022 and propensity score matched individuals without these disorders (n = 94,935). The primary outcome was a diagnosis of depression within five years of the index date. Kaplan-Meier curves and Cox regression analyses were used to analyze the association between the two anorectal diseases and depression.

RESULTS

After 5 years of follow-up, 13.0% of patients with anal fissure and 12.3% of patients with anorectal fistula were diagnosed with depression, compared with 9.7-10.3% in the control group (p < 0.001). Cox regression analysis showed a significant association between both diseases and depression (anal fissure: HR: 1.31; 95% CI: 1.25-1.38; anorectal fistula: HR: 1.30; 95% CI: 1.17-1.44).

CONCLUSION

The results suggest that anal fissures or anorectal fistulas are significantly associated with a subsequent depression. This highlights the importance of multidisciplinary management that addresses both physical and psychosocial aspects to improve patient outcomes.

Comparative Analysis of Open and Closed Sphincterotomy for the Treatment of Chronic Anal Fissure: Safety and Efficacy Evaluation

BACKGROUND Chronic anal fissure is a common condition that causes pain and discomfort and has a significant impact on quality of life. When conservative management fails, surgical sphincterotomy can be successful. This retrospective study from a single center in Turkey included 188 patients with chronic anal fissures and aimed to compare outcomes from open and closed sphincterotomy. MATERIAL AND METHODS This retrospective study included 188 patients treated with lateral internal sphincterotomy (LIS) for chronic anal fissure between January 2015 and December 2021 in our hospital. Open LIS procedure was performed in 91 patients and closed LIS was performed in 97 patients. Demographic characteristics, postoperative complications, and recurrence were compared for these 2 methods. RESULTS Of the 188 patients included in the study, 47.9% were women and 52.1% were men. The mean age was 42.9 (20-84) years. In the open LIS group, recurrence occurred in 2 patients (2.19%), and no incontinence was observed. In the closed LIS group, recurrence occurred in 3 patients (3%; P=0.703), and incontinence developed in 5 patients (5.15%; P=0.035). CONCLUSIONS Comparing the 2 methods used in chronic anal fissure surgery, and considering the recurrence and risk of incontinence, the most feared outcome by the patient and surgeon, open LIS stands out as a superior technique, especially in young male patients.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusions

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL TRIAL ID

IRCT20120129008861N4 ( www.irct.ir ).

Benign Colorectal Disorders

Benign conditions of the colon and rectum are a heterogeneous group of conditions that range from inflammatory to infectious to pelvic floor health conditions that affect large segments of the US population. These conditions include diverticular disease, hemorrhoids, and anorectal lesions. The initial presentation of these very common conditions often occurs in the outpatient primary care setting, and most can be managed by the primary care clinician. This article will provide an overview on the prevalence, diagnosis, and management of some of the most common benign colorectal disorders; these are broadly divided into diverticular disease, hemorrhoids, and anorectal conditions.

Management of Chronic Anal Fissure with a Novel Topical Hemp-Herbal-Based Ointment: A Pilot Study

Introduction

Anal fissure (AF) is a common anorectal disease. Although several pharmacological treatments are available, many patients still require surgical interventions. In this study, we aimed to evaluate the efficacy of an ointment based on a multifunctional blend of herbal ingredients including hemp (ProctoFiz) for chronic AF.

Methods

A single-arm, questionnaire-based prospective study was conducted in a large tertiary center to evaluate the outcomes of patients suffering from chronic AF treated with topical ProctoFiz.

Results

Ninety-two patients were included in the study, 54 (58.7%) were females with a median age of 39 (range 17-78). 32 patients (34.7%) suffered from recurrent AF before enrolling in the study, and 5 patients (5.4%) underwent previous surgical interventions for AF. Three patients (3.2%) were lost to follow-up, leaving 89 patients for analysis. Eighty patients (89.9%) reported significant improvement of symptoms after 1 week using ProctoFiz, and 79 patients reported continued improvement after 1 month of treatment. The mean pain Visual Analog Score (VAS) declined by 6.6 points (8.9 vs. 2.3; 95% CI: 7.20 to -5.99, p < 0.0001) following 1 week of treatment, with continuous improvement to a mean of 0.64 after 1 month. Negative impact on quality of life significantly decreased from a mean of 8.8 to 0.38 following a month of treatment (p < 0.0001), with significant reduction in the number of patients suffering from bleeding following bowel movements (64.1-2.5%; p = 0.0001).

Conclusion

Hemp-based topical treatment of AF is feasible and significantly improves AF-correlated symptoms.

Endoscopic Ultrasound-Guided Botox Injection for Refractory Anal Fissure

Background: Anal fissures cause severe pain and can be difficult to treat. Medical therapy is initially used, followed by sigmoidoscopy-guided botox injections if the medical therapy is not successful. With this technique, however, it is not clear whether botox is injected into the muscle layer or submucosa. Aim: To evaluate the efficacy of EUS-guided botox injection directly into the internal sphincter. Methods: Consecutive patients with chronic anal fissure refractory to conventional endoscopic botulinum toxin type A injection were enrolled in the study. EUS was performed using a linear array echoendoscope, and a 25 G needle was used to inject botox. All patients were followed up at one- and two-month intervals. Results: Eight patients with chronic anal fissures were included in the study. Six patients had an excellent response to botox at the two-month interval using a visual analog pain scale, while one patient had a moderate response with a pain score reduction of 40%. One patient had no response. No complications were noted. An improvement in visual analog scale (pre-score > post-score) was statistically significant at the p < 0.01 level. Conclusion: EUS-guided botox injection into the internal sphincter appears to be a promising technique for patients with refractory anal fissure with pain.

Minimal Lateral Internal Sphincterotomy (LIS): Is It Enough to Cut Less Than the Conventional Tailored LIS?

Purpose

Anal fissure is a common anorectal condition, yet its pathogenesis remains unclear. Lateral internal sphincterotomy (LIS) is the gold standard treatment for chronic anal fissures that do not respond to conservative treatment; however, it has a risk of anal incontinence. We believe that fibrosis of the internal anal sphincter is an important factor in the pathogenesis of chronic anal fissure. In this study, we describe the minimal LIS method, a minimally invasive method where only the fibrotic portion of the internal anal sphincter is cut. We also describe the outcomes of this method.

Methods

We performed a retrospective review of 468 patients (270 male and 198 female) who underwent minimal LIS for chronic anal fissure in 2017 at Seoul Song Do Hospital. We analyzed the patients’ clinical characteristics, manometry data, complications, and outcomes of minimal LIS. The outcomes of the surgery were assessed via questionnaires during the postoperative outpatient visits, beginning 2 weeks postoperatively.

Results

The overall complication rate was 4.0% (19 patients). Delayed healing occurred in 14 patients (3.0%), perianal abscess was present in 3 patients (0.6%), and gas incontinence occurred in 2 patients (0.4%). All complications were improved with conservative treatment. Recurrence, defined as the recurrence of anal fissure more than 4 weeks after healing, was present in 6 patients (1.3%).

Conclusion

Minimal LIS is a safe and effective treatment option for patients with chronic anal fissure. Postoperative complications, especially incontinence and recurrence, are rare.

The comparison between the medical and the surgical management of chronic anal fissures

Introduction. Anal fissures can be defined as a tear or a break in the anoderm. Acute fissures do not exceed a 6 week-duration and can be seen as a simple tear in the anoderm along with edema, whereas chronic fissures are longer than 6 weeks. Aim. To compare the efficacy of the medical and surgical options for the treatment of chronic anal fissures and to recommend the appropriate option in terms of their symptomatic relief, healing of fissures and long-term effectiveness. Materials & Methods. A prospective observational study was conducted for a period of 2 years, that is, from October 2018 to October 2020, including a follow-up period of 2 months. A total of 72 patients with chronic anal fissures were included in the study and randomized into two groups, represented by the medical management group and the surgical management group (Lateral Internal Sphincterotomy (LIS)). Results. In the case of the 36 patients with CAF (chronic anal fissure) who underwent surgical management, all 36 (100%) patients had optimal healing of the fissure at 6 weeks. In the case of the 36 patients with CAF who underwent medical management, only 32 (89%) patients had optimal healing of the fissure at 6 weeks, whereas 4 patients failed to heal even after 2 months. Conclusions. Surgical management is the preferable method for chronic anal fissures in comparison to medical management. But the medical management has a role in acting as a bridge to surgical management in patients who are not fit for surgery or do not perceive surgery as an option at the time.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Dietary Modifications in Fissure-in-ano: A Qualitative Study Based on Persian Medicine

Background:

Anal fissure (AF) is a common disease associated with severe pain and reduced quality of life. Factors related to lifestyle, including diet and bowel habits, play a pivotal role in its pathogenesis. Most of the chronic fissures are not responsive to drugs and more likely to recur. Given the significance of diet in Persian medicine (PM), investigation on physiopathology and appropriate foods can be useful for decreases in AF symptoms and consequences.

Objective:

This study was intended to evaluate the role of diet in the formation and progression of AF from the perspective of PM.

Methods:

In this study, the most important resources of PM dating back to thousands of years were reviewed. All these textbooks contained a section on AF, its causes, and treatment. Further analysis was performed on these resources in comparison with databank and resources of modern medicine to develop a food-based strategy for AF management.

Results:

From the view of PM, the warmth and dryness of anus temperament accounted for AF. Both Persian and modern medicine identified constipation as another cause for AF. Therefore, avoidance from some foods and commercial baked goods was recommended. Both Persian and modern medicine forbad the following foods: potato, cabbage, cauliflower, pasta, beef, fish, and so forth. High fiber and oligo-antigen diets with some limitations have garnered more attention.

Conclusion:

An integrative approach is recommended employing both Persian and modern medicine for AF. There have been some evidence in this regard, however standardized clinical trials are required for future research.

Recovery from hemorrhoids and anal fissure without surgery

BACKGROUND/AIMS

An anal fissure (AF) is a linear tear in the distal anal canal and is one of the most common causes of anal pain. Hemorrhoidal disease (HD) is a symptomatic growth and distal displacement of normal anal cushions. Numerous studies have addressed the contributing factors of these conditions, yet the results remain controversial. In this study, we hypothesize that increasing patients' awareness of hidden risk factors could reduce the rate of HD and AF.

MATERIALS AND METHODS

A questionnaire-based controlled study was planned. After power analysis, patients with HD (n=60) and AF (n=60) were enrolled consecutively into the study group and compared with the control group (n=60) of healthy individuals. The survey was designed to assess the participants' toilet and dietary habits and anxiety risk. Odds ratios were calculated and a binary logistic regression model was constructed to identify associated factors.

RESULTS

Hard stools, spending more than 5 minutes in the toilet, frequent straining during defecation, and increased spice intake were more frequent in the patients with HD; and hard fecal consistency, time elapsed in toilet greater than 5 min, straining during defecation, and high anxiety risk were more frequent in the patients with AF as compared to the control group (p<0.05).

CONCLUSION

Possible associations were identified between habitual factors or conditions (i.e., fecal consistency, the time elapsed in the toilet, straining during defecation) and anxiety and benign anorectal diseases (i.e., HD and AF). Patients should be advised about these hidden threats.

Benign Anal Disease: Implementation of an Educational Program Across Specialties

BACKGROUND

Benign anal diseases, including hemorrhoids, fissures, abscesses, fistulas, and anal condylomata, affect 10%-15% of our population. Most patients seen by nonsurgical providers experience delayed treatment. We examined at our institution whether an educational session on anorectal diseases would benefit trainees from medical and surgical specialties.

MATERIALS AND METHODS

The study took place at Oregon Health & Science University, a primary institutional practice with 130 resident participants. An exploratory study using a 10-point pretest and posttest regarding these diseases was designed and administered to medical subspecialties, including general surgery (GS), emergency medicine, internal medicine, and family medicine, obstetrics/gynecology, and pediatric residents. Intervention was a 50-min presentation highlighting anatomy, history and physical findings, and disease treatment. The posttest was repeated after 6 mo to evaluate retention and overall satisfaction, and differences were evaluated.

RESULTS

With the exception of GS, posttest scores improved. Internal medicine improved most significantly. GS residents scored better on the pretest than other specialties; their posttest scores, however, declined. The survey demonstrated residents with prior education scored better on the pretest. PGY-1 and PGY-2 residents improved most on their posttest. On 6-mo retest, 17.6% of residents responded and posttest performance was 72%.

CONCLUSIONS

Nonsurgical residents have limited knowledge about benign anal diseases but demonstrate improvement after educational intervention. Surgery residents performed well, but demonstrate regression to the mean, common in test taking, but may also require a more advanced lecture. Formal institutional, regional, and national educational interventions are needed to improve the understanding of these diseases.

The association between body mass index and anal canal human papillomavirus prevalence and persistence: the HIM study

Background: While receptive anal sex is an established risk factor for anal human papillomavirus (HPV) infection and squamous cell carcinoma of the anus (SCCA), people with anal HPV infection and SCCA commonly report no lifetime receptive anal sex suggesting other factors may also increase risk for anal HPV infection and persistence. Given potential associations between obesity and conditions that may cause perianal or anal canal lesions, we hypothesized that body mass index (BMI) was associated with HPV infection. Methods: Genotyping for 36 HPV types was conducted on anal canal specimens from men, ages 18-70, from Brazil, Mexico, and the USA. Eligibility included no history of genital warts or HIV. Evaluable specimens were collected from 328 men having sex with men (MSM) and 1348 men having sex with women (MSW) who reported no lifetime receptive anal sex. Prevalence of anal HPV infection and six-month persistence by BMI were estimated in addition to adjusted prevalence ratios for the association between BMI and HPV infection. Results: Among MSW, obese men had a higher prevalence of HPV-16 in the anal canal (3.1%), compared to normal weight men (1.3%) although 95% CI overlapped. Among MSM, prevalence of HPV decreased with increasing BMI. A similar pattern was observed for persistence. After adjustment for confounders, obese MSW had 2.4 times higher odds of HPV-16 compared to normal weight men. Conclusions: BMI may be positively associated with anal HPV (especially HPV-16) among MSW and negatively associated with anal HPV among MSM which supports continued universal HPV vaccination programs.

Efficacy of a combination of herbal gel versus topical diltiazem (2%) in chronic anal fissure healing: a randomized doubleblind clinical trial

Introduction: Chronic anal fissure (CAF) is a common painful ailment that adversely affects quality of life. Nonsurgical treatments such as topical diltiazem are routinely administered to patients with CAF. However, diltiazem is associated with side effects such as headache and allergic reactions, which often lead to discontinuation of the treatment. The aim of this study was to determine the efficacy and safety of a topical Persian herbal remedy with analgesic, antiinflammatory and antiseptic properties versus topical diltiazem (2%) in CAF healing. Methods: In this randomized double-blind clinical trial, 70 patients with CAF were randomly divided into an intervention group receiving topical herbal medicine and control group receiving topical diltiazem (2%) for 6 weeks. Both groups were given lifestyle and dietary advice including adherence to a high-fiber diet, avoidance of spicy foods, use of a laxative (psyllium powder) in case of constipation, and taking sitz baths. Severity of pain, bleeding, and itching were measured at the first visit as well as the first, third, and sixth weeks of treatment. Wound healing and epithelialization were evaluated by anal examination. The treatment and follow-up period was 12 weeks; 6 weeks for assessing the effect of treatment and 6 weeks for examining treatment maintenance and evaluating the percentage of recurrence. Results: The herbal medicine caused significant reduction in pain compared with diltiazem (P < 0.001). The herbal medicine had a significant effect in terms of wound healing at the end of the period (P < 0.001). Recurrence rate was lower in the intervention group (32%) than the control group (56%), though this difference was not significant (P = 0.323) Conclusion: Findings of this clinical trial suggest a higher efficacy of the combination herbal remedy versus topical diltiazem 2% in the management of pain and wound associated with CAF.

Topical Minoxidil Versus Topical Diltiazem for Chemical Sphincterotomy of Chronic Anal Fissure: A Prospective, Randomized, Double-Blind, Clinical Trial

BACKGROUND

Anal fissure is a common anorectal problem causing severe pain and discomfort to the patients. Chemical sphincterotomy has emerged as a noninvasive alternative to the surgical methods of fissure treatment. The objective of this study was evaluation of the efficacy and the adverse effects of topically applied minoxidil in chemical sphincterotomy of chronic anal fissure in comparison with topical diltiazem.

METHODS

A total of 88 patients with chronic anal fissure aged between 15 and 65 years were included in this double-blind, randomized clinical trial and were randomly assigned to either 0.5% minoxidil cream or 2% diltiazem cream twice daily for 2 weeks. The pain intensity, bleeding, wound healing, itching, headache, dizziness, significant drop in blood pressure, allergy and fissure relapse were assessed on a monthly basis for 2 months.

RESULTS

Both diltiazem and minoxidil reduced the pain, bleeding and improved fissure healing with no significant difference. There were no between-groups differences in the frequencies of adverse effects, except for itching which was slightly higher with minoxidil during the first month. Allergy occurred in two patients in the minoxidil group, which was not severe and did not lead to discontinuation of the trial.

CONCLUSION

Topically administered minoxidil is of equal efficacy as diltiazem in the treatment of chronic anal fissure with low frequency of adverse effects. Thus, it can be considered as an agent for chemical sphincterotomy of anal fissure, but the itching at the beginning of the treatment can affect the adherence of the patient to treatment. Trial registration number IRCT2015041414483N6 (the full trial protocol could be accessed online at www.irct.ir ).

Lateral Anal Sphincterotomy for Chronic Anal Fissures- A Comparison of Outcomes and Complications under Local Anaesthesia Versus Spinal Anaesthesia

INTRODUCTION

Fissure-in-Ano is one of the common and most painful anorectal conditions encountered in surgical practice. Inspite of several conservative treatment options, surgical treatment in the form of Lateral Anal Spincterotomy (LAS) remains the gold standard of treatment for Chronic Anal Fissures (CAF). However, LAS is often done under spinal or general anaesthesia incurring huge treatment costs and hospital stay.

AIM

To study if LAS can be treated with Local Anaesthesia (LA) thereby, reducing the costs and the anaesthetic risk to patients with no significant change in the surgical ease or clinical outcome.

MATERIALS AND METHODS

A total of 79 patients with chronic fissure underwent randomized allocation to two treatment arms - The first to undergo LAS under LA and the second under Spinal Anaesthesia (SA). The primary outcome variables studied were complications like post-operative pain, infections, healing rate of fissure and incontinence rates. Secondary outcome variables studied were cost, hospital stay and need for additional anaesthetic.

RESULTS

A total of 79 patients underwent LAS procedure. A total of 42 patients had LA and 39 patients had SA. There was no statistically significant difference in the healing rate, pain, infection and incontinence rates between the two groups. Moreover, the LA group incurred lower cost, reduced hospital stay and reduced risk of anaesthesia.

CONCLUSIONS

LAS can be satisfactorily performed under local anaesthesia with no increased risk of pain or complications, and is best suited for resource-poor surgical settings.

Increased anal basal pressure in chronic anal fissures may be caused by overreaction of the anal-external sphincter continence reflex

Chronic anal fissure is a painful disorder caused by linear ulcers in the distal anal mucosa. Even though it counts as one of the most common benign anorectal disorders, its precise etiology and pathophysiology remains unclear. Current thinking is that anal fissures are caused by anal trauma and pain, which leads to internal anal sphincter hypertonia. Increased anal basal pressure leads to diminished anodermal blood flow and local ischemia, which delays healing and leads to chronic anal fissure. The current treatment of choice for chronic anal fissure is either lateral internal sphincterotomy or botulinum toxin injections. In contrast to current thinking, we hypothesize that the external, rather than the internal, anal sphincter is responsible for increased anal basal pressure in patients suffering from chronic anal fissure. We think that damage to the anal mucosa leads to hypersensitivity of the contact receptors of the anal-external sphincter continence reflex, resulting in overreaction of the reflex. Overreaction causes spasm of the external anal sphincter. This in turn leads to increased anal basal pressure, diminished anodermal blood flow, and ischemia. Ischemia, finally, prevents the anal fissure from healing. Our hypothesis is supported by two findings. The first concerned a chronic anal fissure patient with increased anal basal pressure (170mmHg) who had undergone lateral sphincterotomy. Directly after the operation, while the submucosal anesthetic was still active, basal anal pressure decreased to 80mmHg. Seven hours after the operation, when the anesthetic had completely worn off, basal anal pressure increased again to 125mmHg, even though the internal anal sphincter could no longer be responsible for the increase. Second, in contrast to previous studies, recent studies demonstrated that botulinum toxin influences external anal sphincter activity and, because it is a striated muscle relaxant, it seems reasonable to presume that it affects the striated external anal sphincter, rather than the smooth internal anal sphincter. If our hypothesis is proved correct, the treatment option of lateral internal sphincterotomy should be abandoned in patients suffering from chronic anal fissures, since it fails to eliminate the cause of high anal basal pressure. Additionally, lateral internal sphincterotomy may cause damage to the anal-external sphincter continence reflex, resulting in fecal incontinence. Instead, higher doses of botulinum toxin should be administered to those patients suffering from chronic anal fissure who appeared unresponsive to lower doses.

Time Trends, Clinical Characteristics, and Risk Factors of Chronic Anal Fissure Among a National Cohort of Patients with Inflammatory Bowel Disease

BACKGROUND

Chronic anal fissure (CAF) is a common problem that causes significant morbidity. Little is known about the risk factors of CAF among patients with inflammatory bowel disease (IBD).

AIM

To study the clinical characteristics and prevalence of CAF among a cohort of IBD patients.

METHODS

We performed a population-based study on IBD patients from the National Veterans Affairs administrative datasets from 1998 to 2011. IBD and AF were identified by ICD-9 diagnosis codes.

RESULTS

We identified 60,376 patients with IBD between the ages of 18-90 years, 94% males, 59% diagnosed with ulcerative colitis (UC), and 88% were Caucasians. The overall prevalence of CAF was 4% for both males and females. African Americans (AA) were two times more likely to have CAF compared to Caucasians (8 vs. 4%; OR 2.0, 95% CI 1.6-20.2, p = 0.0001) or Hispanics (8 vs. 4.8%; OR 2.1, 95% CI 1.4-25.2, p = 0.0001). The prevalence of CAF significantly dropped with age from 7% at age group 20-50 to 1.5% at 60-90 (p = 0.0001). CD patients were two times more likely to have CAF than UC patients (6 vs. 3%; OR 1.9, 95% CI 1.5-18.2, p = 0.0001). The initial diagnosis of CAF occurred within 14 years after the initial diagnosis of IBD in 74.5% patients.

CONCLUSIONS

CAF is more prevalent among IBD than what is reported in the general population and diagnosed after the diagnosis of IBD. CAF is more prevalent among patients with CD, younger patients, and AA. The current results lay the groundwork for further outcome studies relate to anal fissure such as utilization, hospitalization, and cost.

Anal fissure

An anal fissure is a common, mostly benign, condition that can be acute or chronic. The diagnosis is usually made on history and physical examination, but further investigations are sometimes necessary. Primary fissures are usually benign and located in the posterior or anterior position. Secondary fissures are lateral or multiple and often indicate a more serious underlying pathology. The management of primary anal fissures is generally non-operative and includes increased dietary fibre, sitz baths, topical ointments and botulinum toxin injections. If these treatments are ineffective the patient will need a surgical referral. Secondary anal fissures require further investigation. Multidisciplinary management is preferable and is essential in the case of malignancy.

Myoxinol (Hydrolyzed Hibiscus esculentus Extract) in the Cure of Chronic Anal Fissure: Early Clinical and Functional Outcomes

Objective. This study was designed to evaluate the early results of the topical application of Hydrolyzed Hibiscus esculentus Extract 3% ointment (Myoxinol 3%), a novel local product with Botox-like activity, in the conservative treatment of chronic anal fissure (CAF). Methods. Among all patients with CAF observed during the study period, 31 subjects met the inclusion criteria and underwent medical therapy with Myoxinol 3% ointment every 12 hours for 6 weeks. Two patients were lost to follow-up. Clinical and manometric follow-up was carried out eight weeks after treatment. Results. At follow-up the success rate was 72.4% (21/29); median VAS score and mean anal resting pressure were significantly lower if compared with respective baseline data. The only one adverse effect of the topical application of Myoxinol 3% ointment was perianal itch, which was reported by 3,4% (1/29) of the patients available for the analysis. However, in this case this symptom did not cause interruption of the treatment. Conclusions. The topical application of Myoxinol 3% ointment in the cure of CAF shows encouraging early results. Further researches with a larger series and a longer follow-up are needed to confirm these data.

The epidemiology and treatment of anal fissures in a population-based cohort

BACKGROUND

Anal fissure (AF) is regarded as a common problem, but there are no published epidemiologic data, nor information on current treatment. The purpose of this study was to examine the incidence, associated comorbidities, and treatment of AF in a population-based cohort.

METHODS

We conducted a retrospective analysis of all persons who were enrolled in one large regional managed care system and treated for AF during calendar years 2005-2011. All persons aged 6 years or older who had a clinic, hospitalization, or surgical procedure associated with AF were identified from utilization data. To identify comorbidities associated with AF, each case was matched by age and gender to 3 controls.

RESULTS

There were 1,243 AF cases, including 721 (58%) females and 522 (42%) males; 150 (12%) of the cases occurred in children aged 6-17 years. The overall annual incidence was 0.11% (1.1 cases per 1000 person-years), but ranged widely by age [0.05% in patients 6-17 years to 0.18% in patients 25-34 years]. The incidence also varied by sex, and was significantly higher among females 12-24 years, and among males 55-64 years (P < 0.001). Comorbidities associated with AF included chronic constipation (prevalence 14.2% vs 3.6%), hypothyroidism (14.7% vs 10.4%), obesity (13.0% vs 7.7%), and solid tumors without metastasis (5.2% vs 3.7%) (P < 0.001 for all comparisons). A total of 448 were dispensed a topical prescription medication, 31 had botulinum toxin injection, and only 13 had lateral internal sphincterotomy.

CONCLUSIONS

AF is a common clinical problem, and the incidence varies substantially by age and sex. Constipation, obesity, and hypothyroidism are associated comorbidities. Most patients are prescribed topical treatments, although it appears that many prescriptions are never filled. Surgical interventions for AF including botulinum toxin and lateral internal sphincterotomy are uncommon.

Maintenance therapy with partially hydrolyzed guar gum in the conservative treatment of chronic anal fissure: results of a prospective, randomized study

Purpose. This study was designed to evaluate the role of maintenance therapy with partially hydrolyzed guar gum (PHGG) after topical application of glyceryl trinitrate (GTN) in the conservative treatment of chronic anal fissure (CAF). Methods. From all the patients with CAF observed during the study period, 165 subjects with healed CAF after standard therapy with topical GTN 0.4% ointment were randomized to receive (group II) or not (group I) maintenance therapy with PHGG for 10 months. Clinical and manometric followup was carried out 6 and 12 months after treatment. Results. At six-month followup, median visual analogue scale score was significantly higher in group I if compared with group II. The success and recurrence rate at 12-month followup were, respectively, 38.3% (28/73) in group I versus 58.5% (41/70) in group II (P = 0.019; Fisher's exact test) and 30.2% (13/43) in group I versus 14.5% (7/48) in group II (P = 0.0047; Fisher's exact test). Conclusion. The maintenance therapy with PHGG in patients with healed CAF after chemical sphincterotomy by topical application of GTN 0.4% ointment seems associated with a significant reduction of recurrence rate and with a significant increase of success rate at 12-month followup.

Transcutaneous electrical posterior tibial nerve stimulation for chronic anal fissure: a preliminary study

PURPOSE

Recent studies showed that sacral nerve stimulation might be an effective treatment option for chronic anal fissure. We aimed to evaluate the efficacy of transcutaneous electrical nerve stimulation as a noninvasive alternative treatment for chronic anal fissure by stimulating the sacral nerve in the ankle via the posterior tibial nerve.

METHOD

In this prospective study, transcutaneous electrical nerve stimulation was applied for 10 days in addition to conventional medical treatment in ten patients. Wexner's constipation score, visual analog scale for pain, quality of life (Short Form-36), Hamilton anxiety and depression scores, symptom relief, compliance, fissure healing, and side effects were evaluated before and after treatment (days 0, 5, and 10).

RESULTS

Ten patients (eight females/two males) with a mean age of 50.7 ± 18.5 years were enrolled in the study. Pain and bleeding resolved in all patients 2 days after the treatment, and mucosal healing was observed in six patients 10 days after the treatment. Wexner's constipation and visual analog scale scores for pain decreased significantly (p = 0.001 and p = 0.002, respectively). Hamilton anxiety and depression scores decreased as well (p = 0.001 and p = 0.01, respectively). Among Short Form-36 subscales, only mental health score increased significantly (p = 0.003). One patient underwent surgery at follow-up due to recurrence of symptoms, and rubber band ligation was applied to another patient who had internal hemorrhoidal rectal bleeding at the end of 10 days.

CONCLUSIONS

Transcutaneous electrical nerve stimulation application to the posterior tibial nerve has the potential to be an alternative treatment option for chronic anal fissure patients who seek noninvasive treatment modality.

Common anorectal disorders for the intensive care physician

Although anorectal disorders such as abscess, fissure, and hemorrhoids are typically outpatient problems, they also occur in the critically ill patient population, where their presentation and management are more difficult. This article will provide a brief review of anorectal anatomy, explain the proper anorectal examination, and discuss the current understanding and treatment concepts with regard to the most common anorectal disorders that the intensive care unit clinician is likely to face.

Systematic review of the use of topical diltiazem compared with glyceryltrinitrate for the nonoperative management of chronic anal fissure

AIM

The study analyzed clinical trials investigating the effectiveness of diltiazem (DTZ) and glyceryltrinitrate (GTN) for the nonsurgical management of chronic anal fissure (CAF).

METHOD

Randomized trials on the effectiveness of DTZ and GTN were analyzed systematically using RevMan(®) where combined outcome was expressed as risk ratio (RR).

RESULTS

Seven randomized controlled trials that included 481 patients were analyzed. Two-hundred and thirty-eight patients were treated with DTZ and 243 patients were treated with GTN. There was significant heterogeneity [Tau(2) = 0.24, χ2 = 13.16, d.f. = 6 (P < 0.05); I(2) = 54%] among the included trials. In the random-effects model, DTZ was associated with a lower incidence of side effects (RR = 0.48; 95% CI = 0.27, 0.86; z = 2.46; P < 0.01), headache (RR = 0.39; 95% CI = 0.24, 0.66; z = 3.54; P < 0.004) and recurrence (RR = 0.68; 95% CI = 0.52, 0.89; z = 2.77; P < 0.006) of CAF. Both GTN and DTZ were equally effective (RR = 1.10; 95% CI = 0.90, 1.34; z = 0.92; P = 0.36) in the nonsurgical management of CAF.

CONCLUSION

This systematic review of seven trials validates and strengthens the finding of a previously published meta-analysis of two randomized trials. Both DTZ and GTN are equally effective in the management of CAF. However, DTZ is associated with a lower incidence of headache and recurrent fissure. Therefore DTZ should be the preferred first line of treatment for CAF.

Manometric Evaluation of Internal Anal Sphincter after Fissurectomy and Anoplasty for Chronic Anal Fissure: A Prospective Study

Chronic anal fissure (CAF) is a common painful clinical disease and its pathogenesis remains poorly understood. After failure of pharmacological therapy, that is the first-line treatment, surgical sphincterotomy remains the treatment of choice although it is followed by a high rate of anal incontinence resulting from the sphincter damage; therefore, the research of a sphincter-saving surgical option has become an important goal. The aim of this study was to evaluate the manometric modifications and the incidence of anal incontinence after fissurectomy and anoplasty with advancement skin flap in patients affected by CAF with hypertonia of the internal anal sphincter (IAS). Fifteen patients affected by CAF with hypertonia of IAS, unresponsive to medical therapy, were enrolled. All subjects underwent fissurectomy and anoplasty with advancement skin flap. Anorectal manometry was performed preoperatively and after 6 and 12 months from surgery. Maximum resting pressure (MRP), maximum squeeze pressure (MSP), ultraslow wave activity (USWA), fissure healing, anal continence, and postoperative complications were recorded. All patients healed within 30 days from surgery. No intra- or postoperative complications were recorded except for a case of partial donor site break. No significant modifications of MSP were detected. Six months after surgery, MRP was higher with respect to healthy subjects but significantly reduced in comparison to baseline levels. At 12 months, it was higher have versus 6-month values but significantly lower versus preoperative values. USWA was significantly represented in patients with CAF versus healthy subject. Both at 6 and 12 months, they decreased significantly with respect to preoperative values without significant differences versus healthy subjects. Both at 6 and 12 months, anal continence did not differ with respect to preoperative time. The fissurectomy with anoplasty resulted in a high healing rate without surgical sequelae or anal incontinence. Also, it was able to reduce IAS pressure in the same manner as surgical sphincterotomy or forceful dilatation.

A prospective, randomized, double-blind study comparing the efficacy of diltiazem, glyceryl trinitrate, and lidocaine for the treatment of anal fissure in children

PURPOSE

Anal fissure (AF) is a common perianal condition in children. Although adult patients with AF have been treated successfully using diltiazem, it has not been studied in children. The present randomized, prospective, double-blind study assessed the response, side effects, and recurrence of diltiazem.

METHODS

Ninety-three children with AF were randomly divided into three groups. Each group received topical ointment. Group GTN received 0.2% glyceryl trinitrate, group L received 10% lidocaine, and group D received 2% diltiazem ointment.

RESULTS

Eighty-two patients completed the 12-month study. At the end of the first 8-week course, the healing rate in group D was significantly higher than that of the other groups (p < 0.0001, χ (2) = 19.82). Nonresponders received a second course of the same treatment. Group D showed significantly higher healing rates than the other groups (p < 0.05, χ (2) = 7.227) at the end of the second 8-week course. The group D recurrence rate was significantly different than that of the other groups (p < 0. 002, χ (2) = 12.79).

CONCLUSION

Diltiazem application is effective and safe for the treatment of AF in children, and has a low recurrence rate. The smooth dose-concentration curve causes minimal side effects.