Chronic Fissure Research Articles

Randomised Prospective Controlled Trial of Topical 2% Diltiazem Versus Lateral Internal Sphincterotomy for the Treatment of Chronic Fissure in Ano.

Fissure in ano is a very common disorder of the anorectal region. Internal sphincter hypertonia with decreased relaxation coupled with mucosal ischemia of posterior anal canal are the major pathologies in chronic anal fissure (CAF). Though lateral internal sphincterotomy (LIS) remains the gold standard of treatment for the disease, it is accompanied by the potential complication of incontinence to both flatus and faecal matter. The aim of our study was to explore the role of topical diltiazem as an effective and a safe alternative to sphincterotomy for chronic anal fissure. Ninety patients with CAF were randomly assigned to group A and group B, with 45 patients each. Group A patients received 2% diltiazem topical application, twice daily, and group B patients underwent LIS. All the patients were reviewed at first, fourth and sixth week after initiation of treatment. Visual analogue scores for pain and healing of fissure by visual inspection were recorded and compared. In group A, 71% had complete healing of fissure at 6weeks, with fair amount of pain relief (mean VAS-3.38), and in group B, 96% showed healing of fissure, with excellent pain relief (mean VAS-1.87). Headache and flushing were noted in two patients in group A while no patients in group B developed incontinence. We conclude that LIS is more effective than topical diltiazem in the treatment of CAF. Topical diltiazem may be employed as an initial conservative treatment option before considering the surgical alternative.

Open versus closed lateral internal anal sphincterotomy in the management of chronic anal fissures: A prospective randomized study

Chronic anal fissure is a benign disorder that is associated with considerable discomfort. Surgical treatment in the form of lateral sphincterotomy has long been regarded as the gold standard of treatment. This study compared the open and closed techniques of lateral sphincterotomy in terms of their postoperative outcomes. A prospective, randomized comparative study was conducted between October 2010 and August 2012. A total of 136 patients were randomly assigned to each of two groups. Patients were followed up postoperatively for more than 1 year to assess any complications. The outcomes were compared among the two groups using the Chi-square test and Student t test. The mean age at presentation was 40.13 years. The male to female ratio was 1.47:1. The typical presentation was painful defecation. Fissures were most often located in the posterior midline and associated with a sentinel pile. Delayed postoperative healing was found in 4.4% of the group of patients undergoing open lateral sphincterotomy. The mean pain score and duration of hospital stay were lower with the closed technique. Closed lateral internal sphincterotomy is the treatment of choice for chronic fissures as it is effective, safe, less expensive, and associated with a lower rate of complications than the open sphincterotomy technique.

The Efficacy and Morbidity of Different Surgical Treatment Techniques for Chronic Anal Fissure: An Academic Colorectal Experience

Up to 40 per cent of chronic fissures will fail to heal with medical treatment alone. Open (OLIS) and closed (CLIS) lateral internal sphincterotomies are considered by many to be the treatment of choice for chronic anal fissures (CAF). The aim of this study was to compare the efficacy and clinical outcomes of different surgical techniques for treatment of CAF. We performed a retrospective chart review of 387 patients with CAF who underwent surgical intervention performed by colorectal surgeons between 2006 and 2012 at Greenville Hospital System. Of 387 patients, 199 underwent OLIS, 124 CLIS, and 64 patients underwent fissurectomy alone (FE). We investigated the effect of the surgical technique on time of healing, rate of flatus incontinence, wound infection, recurrence, and the need for additional intervention. There was no statistically significant difference among patients undergoing OLIS, CLIS, and FE in demographic characteristic, time of healing, rate of wound infections, and fecal continence, or recurrence rate. Comparison of a combined lateral internal sphincterotomy (LIS) group with FE showed that there is similar time of healing (P = 0.58), no statistical difference in flatus incontinence rate (P = 0.61), urinary retention (P = 1.0), fissure recurrence (P = 0.11), and prolonged healing (P = 0.2). Patients in FE group more likely required additional treatment to complete wound healing (P = 0.02). LIS is a safe and effective technique for treatment of CAF. Although there was no difference in complications rate and healing time, patients in the FE group required additional surgical or medical treatment more frequently to achieve complete healing.

A Comparative Study of Lateral Sphincterotomy and 2% Diltiazem Gel Local Application in the Treatment of Chronic Fissure in ANO.

Anal fissures are commonly encountered in routine clinical practice. Anal fissure has traditionally been treated surgically. Developments in the pharmacological understanding of the internal anal sphincter have resulted in more conservative approaches towards treatment. In this study we compare symptomatic relief, healing and side effects of topical 2% Diltiazem gel and lateral internal sphincterotomy in the treatment of chronic fissure in ano. In this prospective trial, 60 surgical out patients and/or admitted patients with chronic fissure in ano were randomly divided into Group 1 (Diltiazem gel) and Group 2 (internal sphincterotomy) with 30 patients in each Group. Patients were followed up at weekly intervals for six consecutive weeks and biweekly for subsequent 3 months. Fissure was completely healed in 88.46% of patients in Group 1 and in 100% in Group 2. The mean duration required for healing of fissure was 5.04 weeks in Group 1 and 3.6 weeks in Group 2. 78.26% patients were free from pain in Group 1 whereas 85.18% patients were free from pain in Group 2. No patient had any side effects in either group. Topical Diltiazem should be considered as first line treatment in chronic fissure in ano. Internal sphincterotomy should be reserved for patients with relapse and therapeutic failure to prior pharmacological treatment.

Perianale Fistel und Analfissur

CRYPTOGLANDULAR ANAL FISTULA: Perianal abscesses are caused by cryptoglandular infections. Not every abscess will end in a fistula. The formation of a fistula is determined by the anatomy of the anal sphincter and perianal fistulas will not heal on their own. The therapy of a fistula is oriented between a more aggressive approach (operation) and a conservative treatment with fibrin glue or a plug. Definitive healing and the development of incontinence are the most important key points. ANAL FISSURES: Acute anal fissures should be treated conservatively by topical ointments, consisting of nitrates, calcium channel blockers and if all else fails by botulinum toxin. Treatment of chronic fissures will start conservatively but operative options are necessary in many cases. Operation of first choice is fissurectomy, including excision of fibrotic margins, curettage of the base and excision of the sentinel pile and anal polyps. Lateral internal sphincterotomy is associated with a certain degree of incontinence and needs critical long-term observation.

The degree of patient satisfaction with diltiazem gel in the treatment of anal fissures

BackgroundAnal fissure is a common and painful condition that often affects young adults of both sexes. Topical 2% diltiazem gel is described as an effective first-line treatment for chronic fissure...

Non surgical therapy for anal fissure

Because of the disability associated with surgery for anal fissure and the risk of incontinence, medical alternatives for surgery have been sought. Most recently, pharmacologic methods that relax the anal smooth muscle, to accomplish reversibly what occurs in surgery, have been used to obtain fissure healing. To assess the efficacy and morbidity of various medical therapies for anal fissure. Search terms include "anal fissure randomized". Timing from 1966 to August 2010. Further details of the search below. Studies in which participants were randomized to a non-surgical therapy for anal fissure. Comparison groups may include an operative procedure, an alternate medical therapy or placebo. Chronic fissure, acute fissure and fissure in children are included in the review. Atypical fissures associated with inflammatory bowel disease or cancer or anal infection are excluded. Data were abstracted from published reports and meeting abstracts, assessing method of randomization, blinding, "intention to treat" and drop-outs, therapies, supportive measures (applied to both groups), dosing and frequency and cross-overs. Dichotomous outcome measures included Non-healing of the fissure (a combination of persistence and recurrence), and Adverse events (including incontinence, headache, infection, anaphylaxis). Continuous outcome measures included measures of pain relief and anorectal manometry. In this update 23 studies including 1236 participants is added to the 54 studies and 3904 participants in the 2008 publication, however 2 studies were from the last version reclassified as un included, so the final number of participants is 5031.49 different comparisons of the ability of medical therapies to heal anal fissure have been reported in 75 RCTs. Seventeen agents were used (nitroglycerin ointment (GTN), isosorbide mono & dinitrate, Botulinum toxin (Botox), diltiazem, nifedipine (Calcium channel blockers or CCBs), hydrocortisone, lignocaine, bran, minoxidil, indoramin, clove oil, L-arginine, sitz baths, sildenafil, "healer cream" and placebo) as well as Sitz baths, anal dilators and surgical sphincterotomy. GTN was found to be marginally but significantly better than placebo in healing anal fissure (48.9% vs. 35.5%, p < 0.0009), but late recurrence of fissure was common, in the range of 50% of those initially cured. Botox and CCBs were equivalent to GTN in efficacy with fewer adverse events. No medical therapy came close to the efficacy of surgical sphincterotomy, though none of the medical therapies in these RCTs were associated with the risk of incontinence. Medical therapy for chronic anal fissure, currently consisting of topical glyceryl trinitrate, botulinum toxin injection or the topical calcium channel blockers nifedipine or diltiazem in acute and chronic fissure and fissure in children may be applied with a chance of cure that is marginally better than placebo. For chronic fissure in adults all medical therapies are far less effective than surgery. A few of the newer agents investigated show promise based only upon single studies (clove oil, sildenifil and a "healer cream") but lack comparison to more established medications.

“I Can Hear the Noise, But Not the Voice”—A Case of Bilateral Sylvian Fissure Infarct in a 52-Year-Old Man

“I Can Hear the Noise, But Not the Voice”—A Case of Bilateral Sylvian Fissure Infarct in a 52-Year-Old Man

CHRONIC ANAL FISSURE

Objective: To determine the role of chemical syphincterotomy as non surgical management of chronic anal fissure. Study Design: Descriptive. Setting: This study was conducted at Margalla teaching Hospital and United Medical center .Rawalpndi. Period: 1½ years. Patients &amp; Methods: This study included 70 patients of either sex. A personal bio data and detailed history of dietary and bowel habits were registered. Topical 0.2% GTN (Gylciryltrinitrate) was applied to anal verge 2 times per day for the period of two months and its effects were noted. Result: 58 patients (83%) got symptomatic relief and 12 patients (17%) did not get improvement. Conclusions: Chemical syphincterotomy heals majority of the fissure . Topical 0.2% GNT ointment is widely used as a first line treatment in U.K . It is generally accepted as an effective treatment for chronic fissure .

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.

The role of endoscopy in patients with anorectal disorders

The role of endoscopy in patients with anorectal disorders

Dermal Flap Coverage for Chronic Anal Fissure: Lower Incidence of Anal Incontinence Compared to Lateral Internal Sphincterotomy After Long-Term Follow-up

Internal sphincterotomy is considered the standard for treating anal fissure, but it is associated with a risk of impaired anal continence. This study aimed to conduct a long-term follow-up to compare postoperative anal continence using dermal flap coverage or lateral internal sphincterotomy for treatment of chronic anal fissure. Sixty patients with chronic anal fissure (male/female, 30:30; age range, 22-79 y) were treated by open lateral internal sphincterotomy (n = 30) or dermal flap coverage (n = 30) from 1997 to 2002. The postoperative course was evaluated using the clinical charts. A standardized questionnaire assessing complaints and anal continence was sent to the patients 70 to 94 months postoperatively and phone interviews were conducted. Operations were performed with general anesthesia as short-stay hospital procedures. The chronic fissure wounds healed in both groups regardless of surgical technique. Symptoms of mild anal incontinence (ie, soiling, flatus) were present 3 months after operation in 6 of 30 (20.0%) patients with lateral internal sphincterotomy and in no patient with dermal flap coverage (P < .05); 70 to 94 months postoperatively, mild anal incontinence was present in 10 of 21 (47.6%) patients with lateral internal sphincterotomy and in 1 of 17 (5.8%) patients with dermal flap coverage (P < .05). Long-term follow-up shows a very low incidence of mild anal incontinence after dermal flap coverage. We conclude from this study that the dermal flap procedure appears to be efficacious without an increased risk of incontinence and with results comparable to lateral internal sphincterotomy. The dermal flap procedure can be recommended for patients following failed conservative fissure treatment without the potential risk of anal incontinence.

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

BackgroundChronic anal fissure (CAF) is a painful condition that is unlikely to resolve with conventional conservative management. Previous studies have reported that topical treatment of CAF with glyceryl trinitrate (GTN) reduces pain and promotes healing, but optimal treatment duration is unknown.MethodsTo assess the effect of different treatment durations on CAF, we designed a prospective randomized trial comparing 40 versus 80 days with twice daily topical 0.4% GTN treatment (Rectogesic®, Prostrakan Group). Chronicity was defined by the presence of both morphological (fibrosis, skin tag, exposed sphincter, hypertrophied anal papilla) and time criteria (symptoms present for more than 2 months or pain of less duration but similar episodes in the past). A gravity score (1 = no visible sphincter; 2 = visible sphincter; 3 = visible sphincter and fibrosis) was used at baseline. Fissure healing, the primary endpoint of the study, maximum pain at defecation measured with VAS and maximum anal resting pressure were assessed at baseline and at 14, 28, 40 and 80 days. Data was gathered at the end of the assigned treatment.ResultsOf 188 patients with chronic fissure, 96 were randomized to the 40-day group and 92 to the 80-day group. Patients were well matched for sex, age, VAS and fissure score. There were 34 (19%) patients who did not complete treatment, 18 (10%) because of side effects. Of 154 patients who completed treatment, 90 (58%) had their fissures healed and 105 (68%) were pain free. There was no difference in healing or symptoms between the 40- and the 80-day group. There was no predictor of fissure healing. A low fissure gravity score correlated with increased resolution of pain (P < 0.05) and improvement of VAS score (P < 0.05) on both univariate and multivariate analysis. A lower baseline resting pressure was associated with better pain resolution on univariate analysis (P < 0.01). VAS at defecation and fissure healing significantly improved until 40 days (P < 0.001), while the difference between 40 and 80 days was not significant.ConclusionWe found no benefits in treating CAF with topical GTN for 80 days compared to 40 days. Fissure healing and VAS improvement continue until 6 weeks of treatment but are unlikely thereafter.

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

It was suggested that anal advancement flap be used to treat patients with chronic anal fissures that have failed medical management and have a low-pressure sphincter complex. We wished to assess anal advancement flap as a treatment for all chronic anal fissures. All patients with chronic anal fissures regardless of their previous management underwent V-Y advancement flap. Patient demographics, symptom duration, previous treatments, short-term postoperative outcome and long-term follow-up were recorded. Fifty-four consecutive patients, median age 39 years (22-66), underwent a V-Y advancement flap over a 7-year period; 34 were men. Duration of symptoms ranged from 2 to 36 months with a median of 8 months. Forty-two patients (78%) had failed a previous therapy: glyceryl trinitrate (GTN) (25), GTN and diltiazem (16) and lateral sphincterotomy (one). Wound dehiscence occurred in three patients of which only one required a surgical intervention. On follow-up at 6 months, all but one patient had a healed wound and was asymptomatic. We have shown excellent rates of healing of chronic anal fissures treated with a V-Y advancement flap regardless of sphincter pressures, previous treatment and symptom chronicity. These results show the technique can be applied to all chronic fissures with success and used as a primary therapy.

Subcutaneous internal lateral sphincterotomy (SILS) versus nitroglycerine ointment in anal fissure: A prospective study

Aim To compare the results of subcutaneous internal lateral sphincterotomy under local anesthesia and nitroglycerin ointment treatments in acute and chronic anal fissures. Methods This was a comparative, prospective study of 340 patients of acute and chronic anal fissure. The patients voluntarily opted either for the surgical procedure under local anesthesia, or the nitroglycerin treatment. All the patients were followed with regular checkups and complaints were documented. Results Except for 1.75% patients having bleeding/hematoma formation, and with a dropout of 2.60% patients, no failure, recurrence or long term complications like incontinence, were observed in patients who underwent subcutaneous internal lateral sphincterotomy after a mean follow up of 28 months. With surgical treatment pain, bleeding per rectum and constipation showed significant improvement as compared to nitroglycerin treatment. Fissure healing was 100% in surgical group as compared to 56.90% in medical group ( P = 0.000, odds ratio = 344.6). Nitroglycerin was equally effective in acute and chronic fissures ( P = 0.096). Conclusion Subcutaneous internal lateral sphincterotomy under local anesthesia is more curative, easy and safe, in the hands of a beginner as well as an experienced surgeon, with highest patient satisfaction, and should be considered as the first line of therapy in both chronic and resistant/recurrent acute anal fissures.

Innovations in chronic anal fissure treatment: A systematic review

A chronic anal fissure is a common perianal condition. This review aims to evaluate both existing and new therapies in the treatment of chronic fissures. Pharmacological therapies such as glyceryl trinitrate (GTN), Diltiazem ointment and Botulinum toxin provide a relatively non-invasive option, but with higher recurrence rates. Lateral sphincterotomy remains the gold standard for treatment. Anal dilatation has no role in treatment. New therapies include perineal support devices, Gonyautoxin injection, fissurectomy, fissurotomy, sphincterolysis, and flap procedures. Further research is required comparing these new therapies with existing established therapies. This paper recommends initial pharmacological therapy with GTN or Diltiazem ointment with Botulinum toxin as a possible second line pharmacological therapy. Perineal support may offer a new dimension in improving healing rates. Lateral sphincterotomy should be offered if pharmacological therapy fails. New therapies are not suitable as first line treatments, though they can be considered if conventional treatment fails.

Chronic Vulvar Fissure-A Rare Manifestation of Mycosis Fungoides

Vulvar fissures are a common cause of vulvar pain and discomfort. The differential diagnosis of the underlying process is broad, and some cases remain undiagnosed. Mycosis fungoides, the dominant component of cutaneous T-cell lymphoma, rarely present as fissures. We report a case of a chronic vulvar fissure due to mycosis fungoides. A 55-year-old woman was referred to the vaginitis clinic for evaluation of a chronic vulvar fissure, 6 cm in length, located at the left interlabial sulcus. A detailed history and examination for other skin lesions revealed an erythematous pruritic patch on left breast that had been present for years. Repeat biopsies from both sites showed a dense dermal lymphocytic infiltrate composed predominantly of CD3- and CD4-positive T cell with minimal epidermotropism. A T-gamma polymerase chain reaction analysis demonstrated a clonal T-cell rearrangement. Based on a diagnostic algorithm that combines clinical features, histopathology, and molecular biology, a diagnosis of mycosis fungoides was confirmed. Patients presenting with vulvar lesions should always be suspected of having an underlying dermatosis, and a detailed examination for other skin lesions should be performed. In the presented case, once both skin lesions were linked clinically, repeat biopsies of both sites led to a confirmed diagnosis of mycosis fungoides.

Chronische und akute Analulzera

Classic types of anal ulcers are acute and chronic anal fissure. Characteristic symptoms of chronic fissures are severe pain during defecation accompanied by the triad of ulceration, hypertrophic anal papilla and external skin tag. If the symptoms deviate other causes of ulceration must be considered. Primarily, malignancies should be excluded. The special setting in the anal fold, especially with concurrent immunosuppression, could lead to nonspecific manifestations of different proctological, dermatological and infectious diseases, which can only be clarified by further diagnostic workup and histopathology. Only the correct diagnosis will lead to causal and effective therapy. Successfully treated inflammatory dermatoses and precancerous lesions require regular follow-up because a recurrent or persistent course of the disease may result in malignant transformation.

Letter to the editor on article Subcutaneous lateral internal sphincterotomy (SLIS)—a safe technique for treatment of chronic anal fissure

Dear Editor: We read with interest the article on the efficacy of subcutaneous lateral internal sphincterotomy (SLIS) for chronic anal fissure. The important outcome was the low incidence of incontinence (6%) as against that quoted in literature. We believe the technique and supervision of an experienced consultant could be the contributing factor, which unfortunately cannot be well addressed in a singlesurgeon case series. We would like to highlight two aspects of the management of chronic anal fissure. The author has been honest about the 42-year-old woman with multiple vaginal deliveries and second degree tear, who continues to be incontinent. Any patient with such an obstetric history or previous perianal surgery including the old school anal stretch (beware! it is still practiced in some countries other than UK) should have undergone an endo-anal ultrasound for assessment of sphincter before proceeding to SLIS. The other point we would like to highlight is the increasing role of botulinum toxin as an option if GTN/ diltiazem is not effective, before subjecting the patient to SLIS, especially in young patients with chronic fissure. In short, we believe that the debate on management of chronic anal fissure has moved from one of the efficacy of different techniques to one of patient selection.

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

Subcutaneous lateral internal sphincterotomy (SLIS) is an effective treatment for fissure in ano but carries a definite risk of incontinence. The aim of this study was to assess the efficacy and complications of SLIS in patients with chronic fissure in ano. All patients presenting with a chronic anal fissure who underwent SLIS were entered into a prospective database. This is a review of these patients over 5 year's period (September 2002-2007). All operations were performed or directly supervised by a consultant colorectal surgeon. Short-term follow-up was at the first outpatient appointment (6 weeks postoperatively) and any impairment of continence was documented. During the study period of 5 years, 96 patients underwent SLIS at our institution. Median patient age was 45 years (range 19-81). The median duration of symptoms was 65 days. No fissure failed to heal after SLIS. Minor complications were noted in five patients; 85% (82/96) attended the follow-up and out of these, 6% (5/82) reported early incontinence. One patient was incontinent to flatus, one to liquid and three to solid stool. After 12 weeks of follow-up, two patients were completely symptom free, one was incontinent to flatus and two were incontinent to liquid stool. SLIS remains an effective treatment for chronic anal fissure. A small proportion of patients do suffer from faecal incontinence, which may be permanent in some cases. Careful patient selection and proper surgical training can reduce this risk.