Anterior Fissures Research Articles

An observational study comparing and non-surgical treatment with surgical treatment for chronic anal fissures

Background: Chronic anal fissure is a common benign anorectal condition that causes significant morbidity. Symptoms consist primarily of pain and bleeding during defecation. Fissures are predominantly located in the posterior midline, but 25% of women and 8% of men have anterior fissures. Aims and Objectives: The aim of the study is to determine the outcome of various nonsurgical therapy for chronic anal fissure and comparison with the outcome of surgical treatment. Materials and Methods: This study was a non-randomized and observational study. All patients referred to the department of general surgery between December 2012 and November 2014 for a chronic anal fissure were included in the study, above the age of 12 years, and diagnosed to have anal fissure (Both Acute and Chronic) were included in the study. Results: Seventy-nine patients (91.9%) were having symptoms of pain; this pain was persistent for hours after defecation in 67 (78%) patients. Seventy-one (82.6%) patients complained of at least one episode of bleeding per Anum, other symptoms were perianal lump (10.5%), perianal itching (23.3%), and perianal discharge (30.2%). The examination findings of these patients revealed that 81 patients (94%) had developed sentinelpiles subsequently and anal fissure with visible fibers of underlying muscle were seen in 9 (10.5%) patients. Conclusion: Chronic anal fissures can be simply and effectively treated medically without the risk of incontinence associated with sphincterotomy. Topical nifedipine and botulinum toxin injections are an excellent combination, associated with a low recurrence rate and minimal side effects.

Be Kind to Your Behind: A Systematic Review of the Habitual Use of Bidets in Benign Perianal Disease.

Background Benign perianal disease carries significant morbidity and financial burden on the healthcare system. Given that sitz baths are recommended as a treatment modality, we considered whether using a continuous stream of water, in the form of a bidet, offers a convenient and effective alternative. Bidet use is the predominant form of perianal hygiene in Asia, but its role in perianal disease is unknown. Purpose To critically analyze and systematically review the current evidence regarding the effect of habitual bidet use on symptoms of benign perianal disease. Data Sources. A database search was conducted on MEDLINE and Epub Ahead of Print, Embase, ClinicalTrials.gov, the Cochrane Library, and ProQuest Dissertations. All studies on bidet use in pruritus ani, hemorrhoids, or anal fissures were included. Data Extraction. The studies were screened and critically analyzed by two independent reviewers in line with PRISMA guidelines. Results Two prospective trials and 1 cross-sectional study found that habitual use of bidets had no impact on the odds of developing hemorrhoids or hemorrhoidal symptoms. One RCT concluded that using bidets was non-inferior to sitz bath for post-hemorrhoidectomy pain. Two prospective trials and 1 cross-sectional study determined that habitual bidet use may increase the odds of developing pruritus ani. Two case series found that habitual bidet use may cause perianal burns or anterior anal fissures. A meta-analysis was not performed because only a limited number of studies were available, and they were of variable quality. Conclusion The current evidence does not identify using bidets as a treatment modality for perianal disease, and further research is warranted to study this increasingly utilized technology.

Fissurectomy with posterior midline internal sphincterotomy and anoplasty in the management of chronic posterior anal fissures

ObjectiveThe objective of this study was to evaluate the efficacy and safety of fissurectomy with posterior midline internal sphincterotomy and mucosal anoplasty in the management of chronic posterior anal fissures in terms of symptomatic relief and complications. Methods160 patients (male 74, female 86) aged 23–75 years (mean age, 38 years) were diagnosed having chronic anal fissures. Eighty patients from among them were randomly chosen for fissurectomy with posterior midline internal sphincterotomy and anoplasty (FPMISA), and the other 80 patients were chosen for lateral internal sphincterotomy (LIS). However, patients with acute anal fissures, fissures due to Crohn's disease, ulcerative colitis, tuberculosis, anterior fissures and hypotonic sphincter were excluded from this study. Symptomatic relief, postoperative healing and complications such as incontinence, keyhole deformity and recurrence were studied for a follow-up period of 18–24 months between September 2016 and December 2018. ResultsNone of the patients had bleeding per anum, except minor postoperative pain. In the FPMISA group, wound healed in 74 patients (92.5%) in 2–4weeks. However, 6 patients (7.5%) developed a keyhole deformity with a serosanguinous discharge duo to bacterial infection, which ultimately healed taking further 2 weeks. Transient incontinence to flatus (6.25%) and faeces (3.75%) were seen. None of the treated patients reported recurrence. On the other hand, in the LIS group of patients, wound healed in 90%, taking about 4–6 weeks. There was no significant difference in incontinence. ConclusionFissurectomy with posterior midline internal sphincterotomy and mucosal anoplasty is safe with minimal complications. It is still a dependable alternative treatment for chronic posterior anal fissures. The fear of keyhole deformity can be well addressed with the added anoplasty.

Comparison between lateral sphincterometry and Lord’s operation in treatment of anal fissure

Background: Two widely performed surgeries include Lord’s anal dilatation (LAD) and lateral internal sphincterotomy (LIS). LAD is one of the ancient and simple surgical techniques, but with high incidence of recurrence and incontinences. LIS is the preferred surgical technique these days, but again with high incidence of incontinence. Aim of this study was done to compare LAD with LIS in the treatment of anal fissure with regard to symptoms, post-operative complications and recurrence.Methods: In the present study the age of patient was to be between 18–50 years, having CAF, all the patients having CAF not responded to the medical management for more than 6 weeks. The patients were randomly assigned to either group. Pre and post-operative pain was accessed using Wong-baker faces pain rating scale. Constipation was accessed by modified Longo score. Incontinence was accessed by scoring system reported by Wexner.Results: When the Wong Bakers faces pain score was done there were 69% of patients with grade IV score and 31% had grade V pain score. The second most presenting complaint was of bleeding per rectum, it was found in 80% of the patients. For constipation the preoperative modified Longo score was 14. On examination sentinel tag was present in all the cases out of which 93% was posterior, 5% anterior and multiple in 2% cases.Conclusions: A total of 200 patients were studied during the study. In this study, females were commonly affected than males. Constipation was the major predisposing factor among all cases 85%. Most of the fissures were located in the posterior midline 89%. Anterior fissures were slightly more common in females. It is our view that the role of pharmacological agents is likely to assume greater prominence in the future and that more effective agents and modes of delivery will be developed.

Hiding Intersphincteric and Transphincteric Sepsis in a Novel Pathological Approach to Chronic Anal Fissure

The purpose of this study was to investigate whether endoanal ultrasonographic findings could better characterize chronic anal fissures, mostly in those patients with persistent and recurrent disease after medical treatment. Between January 2004 and April 2010, patients referred to our departments suspected for anal fissure were considered in a database. Physical examination and anoscopy confirmed the diagnosis of anal fissure in 543 patients. Chronicity was defined on the basis of morphological features of the fissure and mainly on its persistence or recurrence after medical therapy. Moreover, 172 out of 543 patients were selected with respect to the inclusion criteria and submitted to endoanal ultrasonography. Seventeen out of 172 were anterior fissures (9.8%) and 155 posterior (90.2%). In 112 (65.1%) out of 172 patients submitted to endoanal ultrasonography, an associated chronic abscess was demonstrated, with expression of 91 intersphincteric and 21 low transphincteric fistulas, respectively. According to clinical data as well as comorbidities and previous surgery, there were no significant differences between patients with associated abscess and those with only chronic anal fissure. The authors assume that chronic fissures may persist because of hiding sepsis in the anal canal and that chronic anal fissure might be the clinical and pathological expression of a coexisting intersphincteric or low transphincteric fistula, and the ultrasonographic findings strongly support this theory.

Cirurgias proctológicas em 3 anos de serviço de coloproctologia: série histórica

Em 2007, 72,5% do movimento cirúrgico do Serviço de Coloproctologia do HU/UFS foi de procedimentos proctológicos. A experiência desse Serviço, em 3 anos, foi compilada e analisada retrospectivamente. Foram 455 pacientes submetidos a hemorroidectomias(40%), fistulectomias (20%) e fissurectomias (13%), sendo os demais, cisto pilonidal, fístula retovaginal, etc. As doenças orificiais prevaleceram em mulheres (54%) e na faixa etária dos 30 a 50 anos. Hemorróidas e fissuras acometeram mais mulheres, enquanto as fístulas, homens. Hemorroidectomia a Milligan e Morgan foi realizada em 53,7% dos casos, com níveis de dor e sangramento comparáveis aos de Ferguson. Ela proporcionou maior número de fissuras residuais e incontinência fecal transitória. Estenose foi igual para as duas técnicas.A técnica de Ferguson tem o tempo de cicatrização inferior, mesmo com elevada taxa de deiscência. A fístula acometeu 4 vezes mais homens. Em 65% dos casos, a fistulectomia foi a técnica de escolha, com melhores resultados em termos de dor e sangramento, e piores índices de incontinência. Houve colocação de sedenho em 14% dos casos, mantidos em média por 20 semanas, e após sua retirada, 36% relataram sinais de incontinência minor. A fissura anal demonstrou uma preferência de cerca de 3 vezes maior pela comissura posterior. As fissuras anteriores ocorreram mais em homens.

Endoscopic lesions in low-to average-risk patients with minimal bright red bleeding from midline anal fissures. How much should we go in?

Anal fissure is a common condition in young patients, and the main symptoms include anal pain and bleeding. Our aim was to determine the need to perform lower gastrointestinal endoscopy on patients with midline anal fissure who present with minimal bright red rectal bleeding and who are at low risk for colorectal neoplasia. Patients with midline anal fissure who reported small amounts of red blood on toilet paper, toilet bowl or stool after defecation were evaluated. Patients with alarm signs (recently altered bowel habit, weight loss, anemia and family or personal history of colorectal neoplasms) were excluded. A total of 134 patients (80 female and 54 male, aged 35.8+/-11.4 years) were studied. Patients younger than 40 years underwent flexible sigmoidoscopy and colonoscopy was used for older ones. Fissures were posterior in 106 cases (79.1%) and anterior in 27 cases (20.1%); one patient (0.7%) had both anterior and posterior fissures. The lower gastrointestinal endoscopy was normal in 120 patients (89.6%), and 36 patients (26.9%) had associated internal hemorrhoids. Adenomatous polyps were found in 4 cases (3.0%), ulcerative colitis in 8 (6.0%) and Crohn's disease in one patient (0.7%). There was no case of adenocarcinoma. Clinical evaluation plus rectoscopy might be the appropriate evaluation in this selected group of patients, if our results are confirmed by further studies.

Anterior anal fissures are associated with occult sphincter injury and abnormal sphincter function

The pathogenesis of chronic anal fissure (CAF) remains incompletely understood but most are associated with a high resting anal pressure and reduced perfusion at the fissure site. To date, no major distinction has been made between anterior and posterior anal fissures and their aetiology and treatment. We compared anterior and posterior fissures in patients who have failed to respond to medical treatment with respect to their underlying aetiology, anal canal pressures and sphincter muscle integrity. Seventy consecutive patients (54 female:16 male) with a symptomatic CAF and 39 normal controls (19 female:20 male) without evidence of significant ano-rectal pathology were prospectively assessed by manometry and anal endosonography. Anterior anal fissures were identified in a younger age group [33 years (IQR 26-37) vs 41 years (IQR 36-52)] and predominantly in women. Anterior fissure patients were significantly more likely to have underlying external anal sphincter defects compared with posterior fissures [OR 10.9 (95% CI 3.4-35.4)]. Maximum resting pressure was not significantly elevated for anterior fissures compared with controls (P = 0.316) but was significantly elevated in posterior fissures (P = 0.005). The maximum squeeze pressure was significantly lower in the anterior fissure group [167 cmH2O (IQR 126-196) vs 205 cmH2O (IQR 174-262), P = 0.004]. A history of obstetric trauma was significantly associated with anterior fissure location [OR 13.9 (95% CI 3.4-55.7)]. Anterior anal fissures are associated with occult external anal sphincter injury and impaired external anal sphincter function compared with posterior fissures. These findings have implications for treatment, especially if a definitive procedure, such as lateral internal sphincterotomy, is considered.

Variation in Clinical, Manometric and Endosonographic Findings in Anterior Chronic Anal Fissure: A Prospective Study

Nearly all chronic anal fissures occur in the posterior midline of the anal canal. However, some of them are in the anterior midline and are rarely double or in the lateral anal walls. The aim of this study was to determine if the clinical, manometric and endosonographic characteristics in patients with chronic anal fissure varied according to topography of the fissure. The patients included in this prospective study were divided according to a fissure site in posterior midline location (Group A, n = 84) and anterior midline location (Group B, n = 30). No differences were found regarding clinical data except that anterior fissures were more common in females. Mean maximal anal resting pressure and internal anal sphincter thickness was higher in Group A. However, these differences were not statistically significant. We found correlation between mean maximal anal resting pressure and internal anal sphincter thickness in patients suffering from anterior chronic anal fissure.

Use of glyceryl trinitrate ointment in the treatment of anal fissure

Anal fissure is often treated surgically by sphincterotomy. There is growing concern over the effects of this procedure on continence. Nitric oxide donors such as glyceryl trinitrate are thought to cause a reversible 'chemical sphincterotomy', capable of healing the fissure. Twenty-one consecutive patients with chronic anal fissure (13 women, mean age 36 years) were treated for 4-6 weeks with 0.2 per cent glyceryl trinitrate ointment applied to the fissure twice daily. Maximum anal resting pressure (MARP) was measured before and after application of the ointment at the first visit. There were 16 posterior and five anterior fissures. Mean(s.d.) MARP fell from 118.7(45.0) to 70.3(34.1) cmH2O over 20 min after application of the ointment (P < 0.001). Healing was complete in 11 patients at 4 weeks and in 18 at 6 weeks. The fissure recurred in four patients after cessation of treatment; three were successfully treated by further glyceryl trinitrate. Mild headache occurred in four patients. Anal fissure can be successfully treated with 0.2 per cent glyceryl trinitrate ointment applied topically.

Re-examination of clinical manifestations and response to therapy of fissure-in-ano.

This study was designed to reassess clinical manifestations of fissure-in-ano, in particular, the frequency of constipation and rate of response to medical management. Records of 876 patients with fissure-in-ano seen between February 1975 and December 1993 were reviewed. Information gathered included age, gender, site, symptoms, bowel habits, associated anorectal problems, response, failure, and recurrence rates. There were 439 women (51.1 percent) and 437 men (49.9 percent); mean age was 39.9 (range, 13.5-95) years. The fissure was located in the posterior mid line in 644 patients (73.5 percent), the anterior mid line in 144 patients (16.4 percent), both in 23 patients (2.6 percent), and only tenderness documented in 65 patients (7.4 percent). The fissure was located in the anterior midline in 12.6 percent of women and 7.7 percent of men. Dominant presenting symptoms included pain in 90.8 percent and bleeding in 71.4 percent of patients. Infrequent hard bowel movements (> or = 3 days) occurred in only 13.8 percent of patients. Mean follow-up was 26 (range, 0.5-215) months. A total of 44.7 percent of patients responded to nonoperative therapy, 60 percent of them in the first two months; of these, 18.6 percent developed recurrent symptoms. Of the latter group, 60 percent responded to further medical therapy, and 20 percent underwent a lateral internal sphincterotomy. Of the patients who initially did not respond to medical treatment (50.5 percent), lateral internal sphincterotomy was recommended. Anterior fissures are much more common in both men and women than previously reported, and constipation and hard bowel movement are not universally present in patients with fissure-in-ano.

6-OHDA-induced ectopia of external granule cells in the subarachnoid space covering the cerebellum. Genesis and topography.

The present report describes the genesis, development and topographical distribution of ectopic cells of the external granular layer in the subarachnoid space covering the rat cerebellum. Following one intracisternal injection to newborn rats of 100 micrograms 6-hydroxydopamine (6-OHDA), the meningeal cells degenerate and are removed by phagocytosis within 24 h post injection (p.i.), leaving the cerebellar cortex without a pia-arachnoid cover. Defects appear in the basal lamina investing the cerebellar cortex 3 to 5 days p.i., and both external granule cells and 'sprouts' from Bergmann-glia endfeet grow into the subarachnoid space. The latter form large, flat glial lamellae and cover extensive areas of the denuded cerebellar surface, although they do not form a glial scar over the exposed neuropil of the cerebellar cortex. The numbers of ectopic external granule cells increase within the subarachnoid space both by proliferation and a continuous efflux of cells from the cerebellar cortex. They migrate, aggregate, and ultimately develop into granule, stellate and basket cells, the morphology of which is indistinguishable from their counterparts in situ; they make specific afferent and efferent connections, both among themselves and with the underlying cerebellar cortex and brainstem. The distribution of ectopic external granule cells and their derivatives is restricted to the anterior vermal fissures and the vermal-hemispheric junctions. The present results indicate that external granule cells and their derivatives are capable of both differentiating normally and surviving in the subarachnoid space if they become associated with glial cells and establish synaptic connections.

The similarity of the microbiological flora of dental plaque collected from discrete contralateral sites on rat molar teeth

Streptococci, actinomycetes, actinobacilli, veillonellae, neisseriae, and lactobacilli were isolated from the anterior fissures of the second mandibular molar teeth of Sprague-Dawley rats. In individual animals, there were no great differences between the percentage bacterial composition of plaque collected from discrete sites on different sides of the same mouth. This bilateral similarity was apparent with each of four diets, irrespective of the cariogenicity of the diet. These findings indicate why the pattern of carious attack in rats is bilaterally symmetrical.