Anal Fissure Research Articles

Comparison of Botulinum Toxin Injection and Botulinum Toxin Injection with Glyceryl Trinitrate for Treatment of Chronic Anal Fissure

Anal fissure (AF) is an illness of anal canal and is characterized by cracks appearing in stratified squamous epithelium of distal anal canal. The tear, being present in the squamous part of the epithelium, causes considerable pain, fresh bleeding while defecation. The current study is planned to compare the Botulinum toxin Injection and botulinum toxin Injection with Glyceryl trinitate for the treatment of chronic anal fissure in terms of healing. Materials and Methods: Patients will be sent home after one hour with stool softener .while patients in group B will be will receive treatment with 0.2 ml (20 units) Botulinum toxin injection plus 1 gram 0.2% topical glyceryl trinitate cream 8 hourly with dose of 1 gram on middle fingers tip and apply it 1 cm2 in anal canal circumferentially. In both groups, patients will be assessed at follow up after 2 , 4 and 8 weeks post treatment. At follow up, patients will be examined for healing (yes or no) and any other side effect will be documented. Results: In Botulinum toxin injection group, 26(78.8%) had wound healing after 2 months and 30(90.9%) in Botulinum toxin injection with glyceryl trinitrate group with a p-value = 0.170. Conclusion: Botulinum toxin injection with glycerylyl trinitrate is a better technique for treatment of chronic anal fissure healing in comparison with Botulinum toxin injection alone. Keywords: Chronic Anal Fissure, Treatment, Botulinum Injection, Botilinum Injection with Glyceyl Trintrate, Comparison

Proctology

This article provides a practice-oriented overview of the most common proctological diseases: Anal eczema, hemorrhoidal disease, anal thrombosis, marisca, anal abscess and fistula, and anal fissure. Definitions and etiopathogenesis, clinic and diagnostics, and current therapy are presented.

Does Previous Perianal Surgery for Benign Diseases Have an Impact on Timing of Hospital Admission in Patients with Colorectal Cancer?

Objective. Colorectal cancer (CRC) is one of the most common and fatal malignancies worldwide. Although the clinical presentation varies according to the location of the tumor, hematochezia, tenesmus, changes in the defecation habit, chronic constipation, abdominal pain, and distension are the most common findings of CRCs. We aimed to investigate whether patients with CRC who had a surgical history for benign anal disease have more negative tumoral features or not. Material and Methods. Two-hundred fifty two patients who underwent surgery for CRC between 2010 and 2016 at general surgery clinic in Ankara Numune Training and Research Hospital included in this study. Patients were classified into two groups; patients who had undergone surgery for benign perianal disease such as hemorrhoid, anal fissure, perianal abscess and fistulae (Group 1) and patients without past history for perianal surgery (Group 2). Results. A total of 252 CRC patients with a mean age of 64.2 years were included in the study. There were 95 (37.7%) females and 157 (62.3%) males. There were 25 (9.9%) patients who had surgical history for benign perianal disease. There were no statistically differences in tumor size, lymph node positivity, presence of distant metastasis, and tumor stage between the groups (p > 0.05). Conclusion. Although not statistically significant, CRC patients with a history of surgery for benign perianal disease had less lymphatic metastases and tumor size than those without prior perianal surgery. We think that this finding is important in that it indicates the importance of detailed and appropriate evaluation of patients with CRC.

Fissurectomy with mucosal advancement flap anoplasty: The end of a dogma?

The goal was to compare fissurectomy with mucosal advancement flap anoplasty to fissurectomy alone in the surgical treatment of anal fissure. This study included patients who underwent surgery in 2019 for solitary, idiopathic, non-infected, posterior anal fissure, after failure of medical treatment. The choice to perform advancement flap anoplasty was based on surgeon preference and did not depend on the fissure itself. The main endpoint was the time to relief of pain. Of 599 fissurectomies performed during the study period, 226 patients (37.6% women, mean age 41.7±12.0 years old) underwent fissurectomy alone (n=182) or associated with advancement flap anoplasty (n=44). The two groups differed as to their sex ratio (33.5 vs. 54.5% women, P=0.01), body mass index (25.3±4.0 vs. 23.6±3.9, P=0.013) and Bristol score (3.2 vs. 3.4, P=0.038). Time to relief of pain, time to disappearance of bleeding and time to healing were 1.1 (0.5-2.3), 1.0 (0.5-2.1) and 2.0 (1.1-3.6) months, respectively. The rate of healing was 93.8% and the complication rate was 6.2%. The differences between the two groups for these outcomes were not statistically significant. The risk factors associated with absence of healing were age≥40 years (Odds ratio (OR): 3.84; 95% CI, 1.12-17.68) and pre-surgical duration of fissure<35.6 weeks (OR: 6.54; 95% CI: 1.69-43.21). Mucosal advancement flap anoplasty does not provide any added value to fissurectomy alone.

Safety and efficacy of Levorag emulgel in the treatment of anal fissures using a validated scoring system.

Anal fissure is one of the most common anal disease characterized by intense anal pain, and deterioration of patients quality of life. Treatment is mainly based on the topical administration of calcium antagonist or nitric oxide ointments, and in cases refractory to medical treatment patients can undergo surgery. This study aims to assess the efficacy and safety of Levorag emulgel in the treatment of acute and chronic fissures using of a validated scoring system. A prospective observational study was carried out on patients with anal fissures between February and May 2022. The efficacy of the treatment was evaluated using the REALISE score, a new validated scoring system that rates VAS for pain, NSAID use, pain duration, bleeding, and quality of life (QoL), recorded after 10, 20 and 30 days from the beginning of treatment. Forty patients (median age 46 years, IQR 29-57, 70% women) with acute (22, 55%) or chronic (18, 45%) anal fissures entered the study. The median anal pain score according to the VAS scale decreased significantly from 7 (IQR 4.7-8) at baseline to 1 (IQR 0-3.2, p = 0.05) after 20 days. At the 30-day proctological examination, 22 patients (61%) were pain free (median VAS of 0, IQR 0-1.2, p < 0.05). Pain duration after defecation measured according to the REALISE score, showed a significant decrease after 10 days, from a median value of 2 (IQR 1-4) to 1 (IQR 1-1.2) (p < 0.005). The median value of the REALISE score decreased significantly, from 15 (IQR 11-19.25) at first proctological evaluation to 4 (IQR 4-6, p = 0.139) after 30 days of treatment. At day 30, complete fissure healing was achieved in 30 patients (80%). The healing rate was 82% and 78% in patients with acute and chronic anal fissures, respectively. The use of Levorag® Emulgel may represent a safe and effective non-invasive first line treatment in patients affected by acute or chronic anal fissure.

Fissurectomy versus lateral internal sphincterotomy in the treatment of chronic anal fissures: no advantages in terms of post-operative incontinence

PurposeThe standard treatment for chronic anal fissures that have failed non-operative management is lateral internal sphincterotomy. Surgery can cause de novo incontinence. Fissurectomy has been proposed as a sphincter/saving procedure, especially in the presence of a deep posterior pouch with or without a crypt infection. This study investigated whether fissurectomy offers a benefit in terms of de novo post-operative incontinence.MethodsPatients surgically managed with fissurectomy or lateral internal sphincterotomy for chronic anal fissures from 2013 to 2019 have been included. Healing rate, changes in continence and patient satisfaction were investigated at long-term follow-up.ResultsOne hundred twenty patients (55 females, 65 males) were analysed: 29 patients underwent fissurectomy and 91 lateral internal sphincterotomy. Mean follow-up was 55 months [confidence interval (CI) 5–116 months]. Both techniques showed some rate of de novo post-operative incontinence (> +3 Vaizey score points): 8.9% lateral internal sphincterotomy, 17.8% fissurectomy (p = 0.338). The mean Vaizey score in these patients was 10.37 [standard deviation (sd) 6.3] after lateral internal sphincterotomy (LIS) and 5.4 (sd 2.3) after fissurectomy Healing rate was 97.8% in the lateral internal sphincterotomy group and 75.8% in the fissurectomy group (p = 0.001). In the lateral internal sphincterotomy group, patients with de novo post-op incontinence showed a statistically significant lower satisfaction rate (9.2 ± 1.57 versus 6.13 ± 3; p = 0.023) while no differences were present in the fissurectomy group (8.87 ± 1.69 versus 7.4 ± 1.14; p = 0.077).ConclusionsLateral internal sphincterotomy is confirmed as the preferred technique in term of healing rate. Fissurectomy did not offer a lower rate of de novo post-operative incontinence, but resulted in lower Vaizey scores in patients in whom this occurred. Satisfaction was lower in patients suffering a de novo post-operative incontinence after lateral internal sphincterotomy.

Awareness of the General Population Toward Constipation and Its Complications in the Western Region, Saudi Arabia.

Background and aim Constipation can be defined as unsatisfying defecation characterized by difficult stool passage, infrequent stools, or both. Complications include hemorrhoids, anal fissures, and prolapse of pelvic organs. Unfortunately, there needs to be more data available regarding awareness on this subject. Thus, in this study, we aim to measure the level of understanding of constipation and its complications in the western region of Saudi Arabia. Methods In this cross-sectional study, a valid and reliablequestionnaire was used in data collection. In addition, SPSS (IBM Corp., Armonk, NY) was used for the analysis of collected data. Results The present study included a total of 778 participants from the general public, 75.6% of whom were female and 24.4% of whom were male. We found that 70% of participants had an overall good awareness of constipation, with significant variation in levels of awareness among different groups; levels of awareness increased with age (P-value< 0.001), higher education also positively affected the level of understanding (P-value= 0.04), and participants who reported personal experience had higher levels of awareness than participants who did not have personal experience (P-value​​​​​​​= 0.002). There was no significant association between the level of awareness and gender or city of residence. Conclusion Much of our population was well aware of constipation and its complications, with significant variation in awareness among different age groups, educational levels, and personal experiences.

COMPARATIVE STUDY ON THE EFFICACY OF TOPICAL METRONIDAZOLE, TOPICAL NITROGLYCERINE, AND TOPICAL DILTIAZEM IN THE MANAGEMENT OF CHRONIC ANAL FISSURE

Background and Aims: Chronic anal fissure (CAF) is usually managed with surgical modalities but it imposes huge cost with recurrence rates. Hence, topical therapies are preferred is such cases which has a good patient acceptability rate. The present study aims to compare the topical metronidazole (MTZ), diltiazem (DTZ), and glyceryl trinitrate (GTN) in terms of healing rate and pain reduction in CAF patients. Methods: This was a randomized and prospective study conducted on 90 patients with CAF. The patients were grouped as follows (n=30), Group 1; 1% MTZ gel, Group 2; 0.2% Nitroglycerin ointment, and Group 3 (n=30): 2% DTZ ointment. The patients were evaluated at 2, 4, and 6 weeks for pain using visual analogue score (VAS) and healing rate. The results were compared and p&lt;0.05 was considered as significant. Results: The VAS scores between the groups was found to be non-significant (p&gt;0.05), however the VAS scores where markedly reduced within the group at 6 weeks. The healing rate was higher in MTZ group (90%) as compared to GTN (83.3%) and DTZ group (83.3%) but it was not significant. Regarding side effect, burning sensation was observed in MTZ and GTN, DTZ groups were devoid of side effects. Conclusion: The MTZ was more effective with good healing rate but with few side effects. Regarding the pain reduction, all the groups displayed equivocal effects. Thus topical MTZ is a suitable agent for the faster healing of CAF and thus avoids the requirement of surgical options.

Abstract Number ‐ 228: Two Cases of Vertebrobasilar Dolichoectasia +/‐ Obstructive Hydrocephalus

Introduction Dolichoectasia; “dolichos'' and “ectasia” respectively meaning elongation and distention of blood vessels is a process by which arteries undergo deterioration of the tunica intima or tunica media, resulting in smooth muscle atrophy.1 It can be atherosclerotic, non‐atherosclerotic, and dissection‐related. Prolonged hypertension resulting in breakdown and remodeling of collagen‐elastin meshwork produces the atherosclerotic subtype, though hyperlipidemia also plays a role. The incidence is approximately 3%, higher in males.2 Vessels commonly affected by dolichoectasia are in the vertebrobasilar system but the internal carotid arteries are also at risk. Vertebrobasilar dolichoectasia (VBDE) is radiographically defined by basilar artery diameter &gt; 4.5 mm, though it is sometimes overlooked due to healthy variations in basilar tortuosity and diameter. Smoker’s criteria includes artery diameter, laterality, and bifurcation height.3 Neurovascular compression often occurs, but high‐risk complications of VBDE such as hemorrhagic or ischemic stroke, TIA, brainstem compression, hydrocephalus, or subarachnoid hemorrhage are also possible.4 We present two cases of ventriculomegaly in the setting of VBDE. Methods Case Report Results Case #1: A 40 year‐old man with history of hypertension, gout, anal fissures, and bicuspid aortic valve presented to the hospital for intermittent visual obscuration for 2 weeks. He described it as a “Polaroid picture: starting dark and slowly developing” featuring positional exacerbation with Valsalva, leaning forward, and laying flat. Examination revealed bilateral papilledema, right eye ptosis, and right 6th nerve palsy. CT head showed hydrocephalus. CTA and CTV were negative. MRI brain with contrast showed dilated lateral ventricles (left &gt; right) and anterior third ventricle lacking significant transependymal CSF flow. The distal basilar was tortuous extending towards the mid‐portion of the third ventricle (Figure 1). A precipitating factor was thought to be an epidural for anal fissure surgery 2 months prior. Initially treated with acetazolamide, the patient later underwent endoscopic third ventriculostomy (ETV). One‐year follow‐up showed significant improvement of papilledema with minimal residual visual field deficits. Case #2: A 71 year‐old man with history of atrial fibrillation presented to the Neurology clinic for memory loss. It started with misplacing belongings, complicated by an episode of getting lost while driving to a familiar location. Examination showed 1/5 word recall at 5 minutes and mild impairment of serial sevens and abstract thinking. MRI brain revealed dilatation of the lateral and third ventricles out of proportion to the sulci and fourth ventricle, dolichoectatic basilar artery up to 8 mm with superior displacement of nearby structures and effacement of the anterior third ventricle. Repeat MRI with CSF flow one month later showed unchanged ventricular dilatation favored secondary to volume loss without evidence of an obstructive process. Conclusions These cases characterize the rare phenomenon of VBDE and highlights the importance of acquiring MRI with CSF flow when it presents with hydrocephalus.

Secondary anal fissures: a pain in the a*.

An anal fissure is a painful tear of the sensitive anoderm, distally from the dentate line. It is a prevalent disorder and impairs quality of life dramatically. Typical or primary fissures are associated with constipation and mostly located at the posterior midline. About 1% of fissures are atypical in appearance and are generally secondary in nature. These secondary fissures should arouse attention and require further exploration for underlying conditions, such as Crohn’s disease, malignancy, trauma or venereal infections. The aim of this manuscript is to provide a comprehensive review on the clinical aspects, evaluation and treatment of secondary anal fissures.

Botulinum toxin as a promising surgical strategy for chronic anal fissure: do the dose and injection site matter? Comparison of doses and injection sites of botulinum toxin for chronic anal fissure: A systematic review and network meta-analysis of randomized controlled trials

Chronic anal fissure (CAF) often shows a considerable reluctance to heal for the hypertonia and spasm of the internal sphincter. CAF pain is very intense and sharp and always described as tearing, knife-cut or passing broken glass. Lateral internal sphincterotomy remains the preferred treatment modality of all surgical options with high healing rates ranging from 88 to 100%, followed by incontinence rates ranging from 8 to 30% which can have a significant impact on a person’s quality of life.1 Botulinum toxin (BT) has been widely used in the treatment of CAF due to its ability to promote healing and lower risk of incontinence. However, there is still no consensus on the BT dose and injection site which are associated with the curative effect. Vitoopinyoparb et al.2 performed a systematic review and network meta-analysis of randomized controlled trials and identified that low-dose (≤20 U) BT was optimal, and injection out of the fissure site improved short-term outcomes while injection each side of the fissure site tended to reduce recurrence in the long run. It is of great interest to provide a relatively standard protocol to guide anorectal surgeons in the management of BT. BT, as a temporary chemical sphincterotomy, can lead to the blockade of acetylcholine release and cause short-term paralysis of internal sphincter muscle to reduce the anal tone. Based on our clinical experience, the higher the BT dose (within 100 U in general), the higher the healing rate of CAF. According to the survey conducted by the American Society of Colon and Rectal Surgeons, dose above 50 U of BT appeared to correlate with higher success rate and healing rate.3 Maria et al.4 has confirmed that higher doses can improve the healing rate without increasing complications or side effects. However, a meta-analysis including 18 clinical trials concluded that the healing rate decreased with the increase of the BT dose (P=0.048), but the incontinence rate (P=0.048) and recurrence rate (P=0.002) increased slightly with the increase of the BT dose5. Another meta-analysis involving 1577 patients from 34 prospective studies showed that the healing rates ranged from 33 to 96% the BT with the reported BT doses ranging from 5 to 150 IU across the analyzed studies. However, there was no correlation between postoperative healing rate and BT dose (P=0.0708), and the rates of postoperative complications and fecal incontinence were not found to be in a dose-dependent manner.6 Conflicts over BT dose selection often cause confusion among anorectal surgeons. In this network meta-analysis, Vitoopinyoparb and colleagues found that low-dose (≤20 U) BT was optimal based on 27 randomized controlled trials, providing high-level evidence on this regard. Based on the existing knowledge, most studies recommend injecting BT into internal sphincter in three or four quadrants around the anal canal. We also believe that BT should be injected into the internal sphincter because the fundamental pathogenic is hypertonia and spasm of the internal sphincter in CAF. As Brisinda et al.4 said, the internal sphincter is readily visible and easier to inject than the external sphincter. To improve the healing rate, we usually inject the BT both outside the fissure and on each side of the fissure. A study which included 50 CAF patients showed that injections on both sides of the anterior midline were more effective than those on the posterior midline.7 In this study, the short-term healing rate of external injection was better than that of both sides of the fissure, while the long-term recurrence and incontinence of bilateral injection were less.1 In general, we believe these results of this study have high value for clinical application, and large multicenter randomized controlled studies should be advocated to further confirm the findings. Ethical approval Not applicable. Sources of funding This study is funded by the Shenkang Clinical Three-Year Action Plan (major research) (grant no. SHDC2020CR2007A), and the National Natural Science Foundation of China (81774112). Authors’ contribution H.X.: design and write the commentary. W.Y.: review the commentary. Z.M.: design, review, and revise the commentary. Conflicts of interest disclosure The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) None. Guarantors Zubing Mei, Hao Xu.

Role of Madhuyashtyadi Tail in the Management of Parikartika (Fissure-in-Ano) - A Case Study

Ayurveda is the most ancient science of life. It is not only a type of pathy which focus on treatment but also a guide to live a life in a right way without any disease[1]. Shalyatantra is one of the eight main branches of Ayurveda which deals with the types of shalya i.e. foreign bodies and ways to remove them by surgical or para surgical procedures[2]. According to Ayurveda Marmas are the vital points in the human body, trauma/injury on which can cause a disease/deformity or even death[3]. Guda is one of the marma[4] which we can correlate with anus. Injury to anus can cause severe pain and discomfort to the patient. Parikartika is a disease in which there is a tear at mucocutaneous junction of anal canal. In western medical sciences we can match up it with Fissure-in-ano[5]. For this disease there are so many treatment modalities available now a days right from conservative management to surgery. But the main issue is with the severe pain experienced by the patient. So we can alleviate this pain with the help of Vranabasti. It is a type of wound enema/irrigation with medicated oil. In the present study a sincere attempt has been made to evaluate the role of Madhuyashtyadi tail[6] Vranabasti in fissure in ano. This case study concludes that Madhuyashtyadi tail Vranabasti is very simple and effective procedure that can implied as an outpatient procedure for treating fissure in ano.

The efficacy of laser haemorrhoidoplasty (LHP) in the treatment of symptomatic haemorrhoidal disease: Anobservational cohort study.

Laser haemorrhoidoplasty (LHP) is an emerging nonexcisional surgical procedure in which the arteriovenous flow of the haemorrhoidal plexus is interrupted through laser coagulation. The aim of this cohort study was to assess efficacy of LHP in treating symptomatic haemorrhoidal disease through patient satisfaction, remission of symptoms (blood loss, pain, itching, soiling, mucosal prolapse) and recurrence of haemorrhoids. Patients who underwent treatment for symptomatic haemorrhoids (degrees 1-4) through an LHP procedure between 2015 and 2021 were included in the study. A 1470 nm-diode laser was used. A total of 200 patients (71% male, average age 51 years) were analysed. Primary outcomes were patient satisfaction and/or complete recovery of symptoms. Secondary outcomes were operating time, complications and recurrence rates. Patient satisfaction, postoperative blood loss, pain and complications were evaluated 6-7 weeks postoperatively. Room turnover time and operating time were documented. Recurrence of haemorrhoids following LHP treatment within 1 year was evaluated. Patient satisfaction regarding LHP treatment was reached in 155 (84,7%) patients. Postoperative blood loss was reported by 44 (24,0%) patients during time of evaluation. Twenty-four (13,1%) patients reported postoperative pain after 6-7 weeks. Postoperative complications occurred in seven patients (3 anal fissures, 2 perianal abscess, 1 perianal fistula, 1 postoperative anaemia). Room turnover time (patient in to patient out) was 21 min with an average operating time of 7min. Recurrence of haemorrhoids within 1 year occurred in 50 (27,3%) patients. Laser haemorrhoidoplasty appears to be a promising and effective nonexcisional surgical procedure in the treatment of symptomatic haemorrhoidal disease with high patient satisfaction, acceptable postoperative symptoms, minimal complications and short operating times.

Analysis of the range of rectal drugs used for the treatment of proctologic diseases in Ukraine

Proctological diseases (acute and chronic hemorrhoids, anal fissure, proctitis) have frequent relapses, are characterized by a severe course and are common among broad strata of the working-age population. The leading clinical sign of this group of diseases is lesions of the mucous membrane of the rectum of varying degrees of severity which is accompanied by signs of inflammation, pain syndrome, deterioration of local circulation, involvement of secondary infection. It determines the use of complex products that combine anti-inflammatory, analgesic effects and promote the reparative processes of the mucous membrane. On the Ukrainian pharmaceutical market the number of such products is limited, most of them are foreign-made.&#x0D; The purpose of the work is to study the assortment of medicines for rectal use on the pharmaceutical market of Ukraine, to determine the feasibility and prospects of developing new combined soft medicines of domestic production. Methods of marketing, statistical and graphic analysis were used in the work from official sources of information: (The State Register of Medicinal Products of Ukraine and the ATC classification system).&#x0D; While researching the assortment of medicines for rectal use it was established that there are 34 names of medicines for rectal use in various forms of release on the domestic market, of which suppositories ‒ 55.9%, ointments ‒ 35.3%, creams ‒ 8.8%; the share of foreign-made medicines is 61.7% and domestic ‒ 38.3%. Complex synthetic medicines occupy 49.9% of the assortment and complex medicines of natural origin ‒ only 2.95%.&#x0D; In the production of soft medicines for rectal use, hydrophobic (40%), emulsion (40%) and diphilic bases (20%) are more often used. Solid fat (78.9%) is more often used in the production of suppositories.&#x0D; Considering the limited range of medicines for rectal use based on medicinal plant raw materials, it is advisable to develop new combined soft medicinal products which will include biologically active substances of plant origin.

Comorbidity of Urogynecological and Gastrointestinal Disorders in Female Patients With Lichen Sclerosus.

Lichen sclerosus (LS) is a chronic inflammatory disease with a significant impact on quality of life. The aim of this cross-sectional case-control study was to characterize concomitant urogynecological and gastrointestinal disorders in female patients with LS. A medical records search between 2004 and 2012 yielded 455 women and girls (mean age 64 years) with LS. The study cohort was compared with a 10-fold age- and sex-matched control cohort. Gynecological cancers and their precursors; gynecological, urinary, and gastrointestinal disorders; and pain syndromes were evaluated. The well-known association between LS and increased risk of vulvar cancer and its precursors was also found in our study (relative risk [RR] = 100.0; p < .001 and high-grade squamous intraepithelial lesions RR = 110.0; p < .001, respectively), but we also found an increased risk for cervical cancer (RR = 6.0; p = .005) and endometrial cancer (RR = 2.9; p < .001). Gynecological pain syndromes such as dyspareunia (RR = 20.0; p < .001) and interstitial cystitis (RR = 5.0; p < .001) and urinary incontinence (RR = 4.8; p < .001) were also increased. Among gastrointestinal disorders, we found increased risk for celiac disease (RR = 6.8; p < .001), diverticular intestine diseases (RR = 1.9; p < .001), functional intestinal disorders (RR = 2.3; p = .003), and anal and rectal fissures (RR = 2.4; p = .046). We found that female patients with LS have an increased risk for gynecological cancers as well as for several urogynecological and gastrointestinal disorders. Increased awareness is required to identify and treat these concomitant disorders.

A clinical study on the efficacy of Isabgol as a Pathya along with Yogabhyas and Yastimadhu Siddha Taila Matra Basti in the management of Parikartika w.s.r. to Acute Fissure-in-Ano

Swasthavritta Palana is the primary prevention mentioned in classics. By the practice of which an individual always lives with healthiness, a physician should instigate for such practice as because good health is the most desirable objects of human beings. This can be achieved by means of preventing diseases, preserving, and promoting health. The Aahar-Vihar which is beneficial and nutritional to the body and also give the happiness to the mind is known as Pathya and opposite to that is known as Apathya. Acharaya Charaka mentions that the people living in Jangala Pradesha are dry and they have dry food that vitiates Vata and produces Vibanda or constipation. Acharaya Susruta describes as Pitta &amp; Vata Dosha predominance in Parikartika. Hence the proper and effective therapy is required for the treatment of anal fissure which is simple, safe and effective, without any complication, avoidance of incontinence of stool and recurrence at end of therapy. Still there is need of evaluation of certain drugs clinically on various scientific parameters which could be safe, effective, cheap &amp; radially available in the management of Parikartika.

CLINICAL EVOLUTION OF KADALI KSHARA SUTRA IN THE MANAGEMENT OF BHAGANDAR WITH SPECIAL REFERENCE TO FISTULA-IN-ANO

Background: Bhagandar or fistula is an anorectal disease affecting many of the world's population and decreasing the quality of life after haemorrhoids. This disorder's most common etiological are Cryptoglandular origin, Fissure in ano, haemorrhoidectomy, Infections, trauma and malignancy. Kadali kshara sutra is explained in Ayurvedic classics for the management of Bhagandar. So, betterment of human-being and to rule out the clinical efficacy of Kadali kshara sutra in Bhagandar or fistula-in-ano, this study was conducted. Aims and Objectives: To determine the clinical effectiveness of Kadali kshara sutra in Bhagandar management. Methodology: 10 patients of Bhagandar were selected randomly from the Shalya O.P.D of sex, race, and religion. All the ingredients were purchased from the local market and authenticated by the RSBK department, and Kadali kshara sutra was prepared in a teaching pharmacy under an aseptic method. Conclusion: Kadali kshara sutra showed 61.77% clinical efficacy in managing Bhagandar.

Evaluation of the Efficacy of Topical Hydrocortisone in the Treatment of Anal Fissure in Patients Undergoing Pharmacological Treatment

Background and Objective: Anal fissure can be associated with trauma caused by passing hard stools or prolonged diarrhea. The present study aimed to determine the effectiveness of topical hydrocortisone in the treatment of anal fissures in patients under medical treatment referred to Fatemi Hospital and Kausar Clinic of Ardabil Medical Sciences, Ardabil, Iran, in 2019. Materials and Methods: In this clinical trial study, 200 patients with anal fissures were randomly divided into two groups. The intervention group was treated with diltiazem gel, psyllium powder, lactulose syrup, and hydrocortisone topical ointment. Hydrocortisone ointment was not used in the control group. Results: The mean scores of initial pain were 8.06±0.7 and 7.79±1.02 in the intervention and control groups, respectively. The mean pain at the end of the first week was 2.5±1.06 in the intervention group and 3.34±0.89 in the control group. Pain reduction was significantly higher in the intervention group than in the control group in the first week of treatment. Two weeks later, the pain was 1.46±0.7 in the intervention group and 1.86±0.74 in the control group. There was a significant difference between the two groups in the first and second weeks of treatment. Conclusion: The therapeutic combination of a topical corticosteroid with a calcium channel blocker at the beginning of treatment for chronic fissures during the first week of treatment led to a faster response in the form of pain reduction

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.

Comparison of Outcome in Unilateral and Bilateral Sphinctorotomy in Patients of Haemorrhoidectomy

The anal canal is the site of the dilated veins known as haemorrhoids. They're essential for achieving and maintaining complete continence. In the anal canal, they can be either internal or external. Haemorrhoids can cause pain, pruritis, mucous discharge, mucosal prolapse, bleeding (which is often painless), and brilliant red haemorrhage. 2 There are four different types of haemorrhoids, ranging from first degree (just bleeding) to fourth degree (prolapse and stay reduced on reduction) (permanently prolapsed).3 Even though every case of haemorrhoids bleeds, there are different categories based on how far the haemorrhoids have prolapsed. Only when things get complicated do you see any signs. 4 Objective and Methodology: This research aims to compare the rates of pain experienced by patients after undergoing haemorrhoidectomy, lateral internal sphincterotomy, and bilateral internal sphincterotomy. A Randomized Controlled Trial (RCT) study design was used for this investigation. The investigation took place at the Surgery Department of Allied Hospital in Faisalabad (March to September 2021). In all, 140 patients aged 25-65 with severe haemorrhoids (grades III and IV) were chosen. Any neurological deficiency or chronic pain syndrome, renal disease, or bleeding disorders, as well as patients with recurring haemorrhoids or other anorectal pathology (fistula in ano, anal fissures, etc.), were not included in the study. Hemorrhoidectomy with bilateral internal sphincterotomy (Group BL) and hemorrhoidectomy with lateral internal sphincterotomy (Group UL) were performed on patients. After 24 postoperative hours, all patients were evaluated for postoperative pain. Results: Patients in Group BL had a mean age of 45.36 10.33 years, whereas those in Group UL had a mean age of 43.94 10.22 years. A whopping 76 (54.29%) of the patients fell within the 25-45-year-old age range. The ratio of male to female patients was 2.1:1, with 95 males (67.86%) and 45 females (32.14%) in a total of 140 patients. Pain was experienced by 4 (5.71%) of my patients following haemorrhoidectomy with bilateral internal sphincterotomy and by 25 (35.71%) of my patients following haemorrhoidectomy with lateral internal sphincterotomy (p 0.0001). Conclusion: Patients undergoing hemorrhoidectomy were less likely to experience postoperative pain if bilateral internal sphincterotomy was performed. Keywords: Haemorrhoids, internal sphincterotomy, post-operative pain.