Fissure Healing Research Articles

Therapeutic properties of botulinum toxin on chronic anal fissure treatment and the patient factors role.

Background:One of the most frequent distressing diseases which causes anal pain and bleeding after defecation is anal fissure. Despite a poorly understood pathogenesis, the internal anal sphincter spasm has been identified to play a central role in pathogenesis. Recently, botulinum toxin is being used increasingly for the treatment of chronic anal fissure to achieve chemical sphincterotomy and reduce internal sphincter tonicity. Based on the heterogeneity among the published studies, we aimed this study to evaluate its healing rate and for recognizing the factors of patients which may affect the outcome.Subjects and Methods:In a prospective case series medical research, 106 patients who suffer from chronic anal fissure were treated by botulinum toxin injections. All patients received 30 units of botulinum toxin and were physically examined every week for 2 months. They were evaluated for bleeding, pain, hematoma, thrombosis, infection, incontinence, and healing of the fissure. At the end of the follow-up period, the fissure healing rate and its relation to age, gender, prior topical therapy, duration of symptoms, and the position of the fissure were assessed.Results:At the end of the study (8 weeks), the healing rate was 84.9% (90 patients responded to injections). Healing rate was higher in females and in patients who experienced a shorter duration of symptoms before injection. The mean healing time was 4.68 weeks. In addition, patients with one fissure (anterior or posterior) demonstrated higher healing rate and shorter healing time compared to patients with two fissures (anterior and posterior).Conclusion:This study demonstrated that botulinum toxin injection is safe and effective for the treatment of chronic anal fissures, with a low complication rate. In addition, the healing rate was higher in females, patients with shorter duration of symptoms, and those with one fissure.

A RETROSPECTIVE EVALUATION ON THE SURGICAL MANAGEMENT OF CHRONIC ANAL FISSURE WITH DIFFERENT METHODS OF ANAESTHESIA

Introduction: Fissure-in-Ano or Chronic Anal Fissures (CAF) is a linear ulcer in the squamous epithelium of the anus, distal to the dentate line & one of the most common and painful anorectal conditions encountered in surgical practice. Surgeons working in a rural setups and First Referral Units are faced with several challenges and limitations. Patients undergoing surgery under spinal anaesthesia have to undergo a battery of blood tests and imaging as a result for poorer patients the cost of treatment becomes manifold. This retrospective study was aimed to compare the outcome of lateral anal sphincterotomy (LAS) for chronic anal fissure, done under Spinal Anaesthesia and Local Anaesthesia.
 Methods: This Retrospective study involved Prior Consent from the Hospital Authorities & was found to be within ethical standards. Data of 200 patients were selected which were proven cases of Chronic Anal Fissures admitted to the local surgical units in last 4 years. Subjects included both the genders, all age groups including pediatric and geriatric age group and all classes of socio economic strata.
 Results: Data of total 200 patients were obtained, out of 200 participated 127 were women and 73 were men. A total of 100 patients (50%) underwent LAS under local anaesthesia and 100 patients (50%) underwent LAS under spinal anaesthesia. The mean age of the patients was 41.37 years with Standard Deviation of 3.42 years. There was No Statistical Difference between the two groups in terms of Intraoperative and Postoperative Complication like Pain, Incontinence & Infection after follow up.
 Conclusion: Lateral anal sphincterotomy (LAS) provides very good healing of Chronic Anal Fissure. Few distinct advantages were noted in the study while doing LAS under LA. It provides adequate pain relief for the procedure apart from the advantage of easy palpability of the sphincter. It can be done as an Outpatient procedure without the need for an anesthetist, and carries a significant cost benefit to the patient especially in lower socio-economic settings. There is no significant difference in the complications or the healing of the fissure when compared with SA.
 Keyword: Fissure-in-Ano , Lateral anal sphincterotomy, Spinal Anaesthesia , Local Anaesthesia , Retrospective Study.

Comparative study of Glyceryl Trinitrate ointment versus lateral internal sphincterotomy in management of Chronic anal fissure.

Objectives: To compare efficacy of topical 0.2% glyceryl trinitrate ointment with lateral internal sphincterotomy in treatment of patients with chronic anal fissure. Study Design: Randomized Control Trial. Setting: Department of General Surgery, DHQ Teaching Hospital, Sahiwal. Period: From 20 September 2016 to 31 December 2017. Material & Methods: A total number of 60 patients included in this study and divided into two groups GTN and LIS group through computer generated randomization method. Three main outcome variables were assessed in this study; pain relief, healing of fissure and recurrence. SPSS version was used to analyze data. P value ≤ 0.05 was considered as significant. Results: A total number of 60 patients included in this study. Relief of pain GTN and LIS was (95%) and (86.7%) respectively. Fissure healing GTN and LIS was noted as (88.3%) and (83.3%) respectively. Recurrence was not found in any patient of the present study. Relief of pain was statistically significant. Conclusion: Topical application of GTN ointment for relief of pain is safe and effective method for relief of chronic anal fissure but pain relief is slow. On other hand lateral internal sphincterotomy is first line treatment and treatment of choice for chronic anal fissure when performed by an experienced surgeon.

Clinical evaluation of Kasisadi Ghrita local application in Parikartika (Fissure-in-ano)

Background: Parikartika is characterized by sharp cutting pain in anal regionIn Parikartika, Teevrashoola, bleeding is seen, similarly severe pain and slimy blood discharge are seen in Fissure-in-ano. Objective: To assess the efficiency of Kasisadi Ghruta local application in the management of fissure-in-ano. Methods: The patient having classical signs and symptoms of Parikartika (fissure in ano) having Age group 20 to 60 years were recruited for the study. Trial group was treated with Kasisadi Ghruta twice a day local application for 28 days. Results: Average relief observed was 62.5% in most of symptoms. Kasisadi Ghruta is having Shothahara, Vedanasthapana and Ropana properties due to which it helps in healing of fissure in ano. Conclusion: Kasisadi Ghruta local application is having better results in fissure-in-ano.

Outcome of bilateral versus unilateral lateral internal sphincterotomy for chronic anal fissures

Background: Gold standard treatment for chronic anal fissure is lateral internal sphincterotomy (LIS) which is usually performed at a single location. This randomized study compares bilateral to unilateral lateral internal sphincterotomy.Methods: Patients were randomized into two equal groups (64 each) to undergo either bilateral (Group A) or unilateral (Group B) open lateral internal sphincterotomy (LIS). Comparative study was done in terms of symptomatic relief of pain, incontinence, complete healing of fissure, and recurrence. Chi-square test was used as a test of significance.Results: Both groups had comparable demographic and clinical characteristics. Mean operative time for was longer for bilateral LIS (P-value <0.05). Mean pain score (VAS) in bilateral LIS group was lower in early post-operative period (P-value <0.05). At the end of 4th week 65.6% of patients in bilateral LIS group and 56.25% of patients in unilateral LIS group had completely healed fissures (P-value <0.05). Mean Wexner score for incontinence was comparable, while significant decrease in resting anal pressure was noted at 1 month in BLIS group. There was one recurrence in unilateral LIS group.Conclusions: Bilateral LIS resulted in better outcome in terms of early pain relief, early reduction of anal pressures, complete healing rate in 4 weeks with no recurrence. It does not increase the risk of incontinence and has better patients’ satisfaction as compared to unilateral LIS.

Percutaneous tibial nerve stimulation (PTNS): an alternative treatment option for chronic therapy resistant anal fissure

BackgroundThe aim of the present study was to evaluate percutaneous tibial nerve stimulation (PTNS) for treatment resistant chronic anal fissure.MethodsConsecutive patients with chronic anal fissure were treated with neuromodulation via the posterior tibial nerve between October 2013 and January 2014. Patients had PTNS for 30 min on 10 consecutive days. All patients had failed conventional medical treatment. The visual analogue scale (VAS) score, St. Marks score, Wexner’s constipation score, Brief Pain Inventory (BPI-SF), bleeding and mucosal healing were evaluated before treatment, at termination, after 3 months, and then yearly for 3 years.ResultsTen patients (4 males and 6 females; mean age 49.8 years) were identified but only 9 were evaluated as one patient’s fissure healed before PTNS was started. At 3-year follow-up, fissures had remained completely healed in 5 out of 9 patients. All patients stopped bleeding and were almost completely pain-free at 3 years (VAS p = 0.010) and pain relief improved from 50% at completion to 90% at 3 years. The patients’ Wexner constipation scores improved significantly (p = 0.007).ConclusionsIn this small series, PTNS enhanced healing of chronic anal fissure and reduced pain and bleeding with an associated improvement in bowel function.

How the Complementarity at Vicinal Steps Enables Growth of 2D Monocrystals.

Large 2D monocrystals are highly sought after yet hard to achieve; unlike graphene, most dichalcogenides and h-BN possess low symmetry, which allows for nucleation of mutually inverted pieces, merging into polycrystals replete with grain boundaries. On vicinal substrate surfaces such growing pieces were observed to orient alike, and very recently this effect apparently enabled the growth of large single crystal h-BN. Addressing the compelling questions of how such a growth process can operate and what the key mechanisms are is crucial in guiding the substrate selection for optimal synthesis of perhaps many materials. To this end, the basic crystallography and atomistic-modeling theory presented here reveal (i) how the undulations of the ever-wandering steps do not, surprisingly, disturb the orientations of the attached 2D-nuclei, whose direction remains robust owing to complementarity between the meandering step and h-BN counterpart if their kinks have similar size of negligible misfit, δ k < 0.1 Å. (ii) Stronger chemical affinity of metal to the N atoms at the zigzag edge of h-BN singles out its particular orientation, without evidence of any epitaxy, at the edge or to the surface. (iii) The monocrystal integrity requires unhindered growth spillover across the steps and the seamless healing of the residual fissures, caused by the very same steps necessary for co-orientation. Molecular dynamics simulations show this happening for the steps not taller than the BN bond, s < 1.44 Å. These criteria point to [-1 1 2] steps on the Cu (110) surface, in accord with experimental results (Wang et al. Towards the growth of single-crystal boron nitride monolayer on Cu. arXiv:1811.06688 Cond. Mat. Mtrl. Sci., 2018), while other possibilities can also be predicted.

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 &lt; 0.001). The herbal medicine had a significant effect in terms of wound healing at the end of the period (P &lt; 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.

A proper application of chemotherapeutic agent at the site of anal fissure: a major concern in healing anal fissure

Background: To show the efficacy of chemotherapeutic agent by special emphasis on its proper application at the site of anal fissure.Methods: All patients were seen in outpatient department and were initially started with 0.2% Glyceryl trinitrate ointment along with sitz bath and psyllium fiber as a primary treatment while 2% diltiazem cream reserved for refractory cases. The follow up visits were made weekly for perianal pain relief and ulcer healing rate.Results: Results in terms of healing of anal fissure and perianal pain relief in 2 or 4 weeks duration were recorded in SPSS version 17. 0.2% GTN ointment showed 75% results in 2 weeks. While complete response was achieved in 95% cases in 4weeks. 2% diltiazem responded in 98% cases in 2 weeks. Non-compliant (2%) abandoned the medical treatment early in the course and proceeded for surgery where 99.99% results were seen in 2weeks only.Conclusions: Conservative treatment is the gold standard for managing anal fissure. Effective counseling of proper application of ointment at the site of anal fissure is emphasized, which is usually failed by the patient due to intense, excruciating peri anal pain and spasmodic sphincter contraction which led them to proceed to surgery.

COMPARATIVE STUDY OF 2% DILTIAZEM OINTMENT VERSUS LATERAL INTERNAL SPHINCTEROTOMY IN THE TREATMENT OF CHRONIC ANAL FISSURE

Objective: Comparative study of 2% Diltiazem ointment versus lateral internal sphincterotomy in the treatment of chronic anal fissure. Study Design: The present study included a total of 50 patients presenting with chronic anal fissure. First 25 patients were subjected to 2% Diltiazem ointment(Group A) and the next 25 patients underwent open lateral internal sphincterotomy(Group B). Patients were followed twice a week initially and then at the end of 3rd and 6th week. At each visit they were examined for symptomatic relief of pain (VAS), healing of fissure, side effect or complications. The healed fissures were then subsequently followed up at 3 month for recurrence. Results: Complete relief of pain and fissure healing was observed in 72% and 96% patients in Group A and B respectively which is statistically significant for pain relief but not for fissure healing(p>0.001).There were no side effects such as pruritus ani in Group A or incontinence in Group B. Only 5.5% of patients in Group A and 8.33% in Group B had recurrence at the end of 3 month. However, there was no statistically significant difference in the frequency of recurrence between the two groups (P=0.561).Conclusion: Lateral Internal Sphincterotomy may be regarded as treatment of choice in the management of chronic anal fissure where as 2% Diltiazem can be used in elderly patients and those who refused surgery.

Experience of using an individual approach in the anal fissures treatment

To objectify the criteria for choosing the method of treatment of anal fissures, to determine the indications for surgery and sphincterotomy. The results of treatment of 206 patients with chronic and acute anal fissures between the ages of 17 to 75 years are analyzed. The posterior anal fissure was detected in 175 (84.9%) patients, the front - in 18 (8.7%), the combination of fissures was noted 13 (6.3%) times. The history of the disease - from 1 month to 12 years. The examination included analysis of clinical data, indicators of pre- and postoperative anorectal manometry, endorectal ultrasound. The period of postoperative monitoring is from 6 to 12 months, control examinations with a functional study of the anal sphincters were carried out 1 and 2 months after healing. Concomitant hemorrhoids were noted in 65 (31.5%) patients, of which 20 (9.7%) patients were simultaneously hemorrhoidectomized. In 11 (5.3%) patients, simultaneous operations were performed in the presence of paraproctitis, rectal fistula. In 77.8% of patients with acute fissures, the use of conservative therapy, which included myotropic antispasmodics and local application of glycerol trinitrate made it possible to achieve healing of fissures without surgery. Operated 185 (89.8%) patients. With an increase in the basal anal pressure at the level of the internal sphincter, an increase in the average pressure in the anal canal, a decrease in the amplitude and duration of the rectoanal reflex, the indications for dosed sphincterotomy were determined in 167 patients. At the same time, in 117 persons, the excision of fissures was supplemented with a lateral 'closed' sphincterotomy, in 50 cases the posterior 'open' dosed sphincterotomy was performed. In 18 (9.7% of the operated ones) patients in the absence of sphincter hypertonus, the fissures were excised without sphincterotomy. The best functional results were obtained after performing the lateral 'closed' subcutaneous sphincterotomy. It was noticed that in the absence of characteristic complaints and clinical manifestations of incontinence, in 14 patients there was a decrease in the average pressure in the anal canal at rest and with volitional contraction. At the same time, 6 patients out of 14 belonged to the older age groups, and in 9 women there was a rectocele, pelvic floor prolapse. Postoperative incontinence was not observed. Recovery with complete epithelialization of the anoderm defect and the absence of complaints was achieved in 191 (92.7%) patients, satisfactory results (healing of fissures in the presence of pain or proctitis) - in 8 (3.9%) and in 7 (3.4%) patients relapse of the disease was noted with the ineffectiveness of therapy. The ineffectiveness of complex conservative treatment for more than two weeks, with a history of more than 3 months, is an indication for surgical treatment. Preoperative functional and clinical and physiological examination of patients allows the formation of surgical tactics. A differentiated approach to the choice of treatment method, as well as individual determination of indications for surgery and sphincterotomy can improve long-term results. The technique of simultaneous operations with the combination of anal fissure and other proctological diseases needs to be improved.

Treatment of a chronic anal fissure with a botulin toxin A injection and fissurectomy.

pharmacological treatment of a chronic anal fissure (CAF) achieves healing in half of cases and lateral internal sphincterotomy (LIS) is the definite treatment. The objective of this study was to assess the combination of fissurectomy and botulin toxin A (BTA) injection. this was a retrospective study of 54 patients with anal sphincter hypertonia and CAF treated with an injection of BAT and fissurectomy, after an unsuccessful management with topical nitroglycerin (NGT) for eight weeks. Fissurectomy and an injection of BTA (33 or 50 units) in the internal anal sphincter was performed during the same session. The main outcome measure was the healing rate, with incontinence and the need of LIS as secondary outcomes. two patients were excluded from the study, one due to Crohn's disease and the other was lost to follow-up. Of the 52 patients included in the study, there were 36 females (70%) and 16 (30%) males, with a mean age of 49 years (range 22-75). Fissure healing was initially achieved in 49 patients (94.2%) and LIS was required in the remaining three patients (5.8%). After initial healing, 18 patients (34.7%) developed 23 recurrences at a mean time of 27 months (5-83 months). Of these patients, healing with conservative sphincter measures was obtained in eleven cases (NGT in eight and repeat fissurectomy and BAT in three); two patients are currently under treatment with NGT and five underwent LIS. BTA injection associated with fissurectomy is a safe and effective procedure in patients with CAF, avoiding the need of LIS in a high percentage of patients.

Potential Effects and Mechanisms of Action of Topical Wallflower (Erysimum cheiri (L.) Cranz) Administration in Anal Fissure

Anal fissure is an ischemic ulcer that occurs in anoderm and it has no obvious etiology and pathophysiology in current medicine. Anal fissure has a profound history in Persian and Persian medicine and wallflower (Erysimum cheiri (L.) Crantz) has been a common medication in this case. Traditional oil and/or dilute decoction of wallflower has been introduced as an effective topical medicine for anal fissure in Persian medicine.The aim of this study was to demystify the ancient wisdom in administration of low-dose wallflower for anal fissure, via the view point of modern pharmacological mechanisms. The basic idea and source of information was according to Persian and Arabic medicine manuscripts of the medieval Islamic era. Electronic literature was searched for related phytochemical and pharmacological studies available in Scopus, Google scholar, Pubmed and ScienceDirect databases from 1900 to 2018. The results showed that different parts of wallflower contain several types of cardiotonic steroids, isothiocyanates and flavonoids. Low-dose topical cardiotonic steroids, below their IC50, could have potential effects on the ischemic condition of anal fissure ulcer and collagen synthesis in the local fibroblasts, by stimulation of Na+/K+ ATPase pump. Furthermore, other active compounds in wallflower are isothiocyanates that could be responsible for tissue protective effects by induction of NRf2 expression and activating TRPA1 channels. Also wallflower flavonoids are responsible for anti-inflammatory, analgesic and wound healing properties. To the best of our knowledge, this is the first time that low-dose topical wallflower administration is hypothesized to have anal fissure healing potential in conventional medicine. This study has introduced a novel mechanistic approach for anal fissure treatment.

Topical Nitroglycerine Versus Lateral Sphincterectomy for Fissure in Ano: A Hospital Based Comparative Study

Background: Anal fissure is a common benign condition presenting as severe pain, constipations and bleeding per rectum. It is defined as longitudinal tear or defect in anal canal skin. Surgical treatment of this conditions requires hospital admission and complications, like bleeding, infection and to its severe extent continence disturbances. That warrants a new treatment modality as pharmacological sphincterotomy i. e topical GTN (glycerine trinitrate) whose effects are reversible, cost effective and simple.&#x0D; Objective: The objective is to compare the effectiveness of topical GTN over lateral sphincterotomy in terms of pain management and healing of fissure.&#x0D; Method: This was a comparative study carried out in the department of Surgery at Nepalgunj Medical College, Teaching Hospital. Two groups were created and 25 patients in each group were put randomly. First group (Group 1) used topical GTN whereas second group(Group 2) underwent lateral sphincterotomy for treatment of fissure. The two groups were reassessed at 4 and 8 weeks for pain and fissure healing.&#x0D; Result: Total number of patients was 50. Each group consisted of 25 patients. The male to female ratio in group 1 was 1:1.5 and in group 2 it was 1: 1.8. In group 1 patients after 4 weeks of application of GTN pain reduced from the mean of 80±15 at the time of presentation to 50±9.27. When these patients were seen after 8 weeks, the pain reduction on VAS was nil in 21 patients out of 25. In group 2 the mean score fell from 75±15 to 20±10 after 4 weeks and at 8weeks 23 out of 25 patients didn't have any pain. It was observed that the pain reduction and healing were faster in group 2 patients when evaluated after 4 weeks (p=0.0029). but at the end of 8 weeks both group patients were similar in terms of pain reduction and healing of fissure (p=.28).&#x0D; Conclusion: According to study local GTN application is as effective as lateral sphincterotomy with cost effectiveness, simple with tolerable side effect and no continence disturbances.

Role of Anorectal Manometry in Anal Fissure and Outcome of Tailored Lateral Sphincterotomy in Hypertensive Internal Anal Sphincter: A Modified Minimal Invasive Technique

AbstractBackground: CAF is a common benign anorectal problem that substantialy impairs the patient's life. Consequently, a rapid and effective solution is required.1Aim of Study: To do lateral internal sphincterotomy extending up to the upper end of the fissure (but not to the dentate line) in patients have CAF with hypertonic IAS to keep continence. In case of low RAP, V-Y plasty will be done.Patients and Methods: Our study was done on 34 patients with CAF divided into 2 groups, group 1 included 28 patients with hypertonic IAS underwent tailored LIS and group 2 included 6 patients with normotonic/ hypotonic IAS underwent V-Y plasty to keep continence from June 2017 till December 2017 in general surgery department ,Assiut university hospital.Results: In group 1 there is no incontinence or recurrence, complete healing of fissures occurred in 96.4%. Only one patient had unhealing fissures, postoperative complications include bruising occurred in 3.5% and minor sepsis of sphinc-terotomy wound in 3.5%, in group 2 there is minor sepsis of the flap in 16.6%.Conclusion: Our study was done on 34 patients with CAF. These patients were divided according to anomanometric study into 2 groups: - Group 1 included 28 patients with high RAP in whom tailored LIS was done by modified technique which is taiored equal to the length of the fissure which is minimally invasive with good healing rate and no recurrence or incontince postoperative and minor bruising and sepsis of the wound and significant reduction in postoperative RAP. - Group 2 included 6 patients with normotonic /hypotonic IAS in whom excison of fissures were done and the defect is closed by V-Y plasty with good healing rate and low postoperative sepsis.So tailored lateral internal sphincterotomy is the effective treatment of CAF with anal hypertonia, safe and not affect continence.

Treatment of anal fissure: a survey of surgical practice in Australia and New Zealand.

The aim was to determine whether or not the clinical management of anal fissure in Australia and New Zealand accords with published guidelines. A comprehensive survey based on common clinical scenarios was distributed to 206 colorectal surgeons in Australia and New Zealand. The response rate was 44% (91 surgeons). For 19 topic areas, only seven (37%) reached consensus (defined as > 70% majority opinion). Of these, six (86%) agreed with guideline recommendations. Twelve (63%) topic areas demonstrated community equipoise (defined as less than or equal to 70% majority opinion), of which five (42%) agreed with guideline recommendations and seven (58%) disagreed with guidelines. Of the seven topics that disagreed with guidelines, three were based on moderate quality evidence (first line management of acute anal fissure in a young patient, fissure healing and faecal incontinence rates following anocutaneous flap) and four were based on low quality evidence (length of sphincter division during a lateral sphincterotomy in women, management of chronic low-pressure anal fissures postpartum, fissure healing rate following anoplasty with botulinum toxin or sphincterotomy and faecal incontinence rates following repeat sphincterotomy for recurrence). Consensus and/or agreement with guidelines were more prevalent in management when medical therapy failed. While areas of consensus mostly agreed with guideline recommendations, there remain many areas of community equipoise which warrant further research.

The Role of Botox in Colorectal Disorders.

To overview the current medical literature on the efficacy of botulism toxin treatment (BTX-A) for lower gastrointestinal disorders (GIT). BTX-A was found to have a short-term efficacy for the treatment of dyssynergic defecation. Surgical treatment was found to be more effective than BTX-A for the healing of chronic anal fissures, and BTX-A can be considered when surgery is undesirable. Data regarding the effects of BTX-A injection for the treatment of chronic anal pain is limited. Beneficial effects were observed only in a minority of patients. BTX-A treatment was found to be effective for the treatment of obstructive symptoms after surgery for Hirsprung's disease as well as for the treatment of internal anal sphincter achalasia. BTX-A treatment has a short-term efficacy and is safe. Further research is still needed in order to establish the exact place of BTX-A treatment of lower GIT disorders.

Posterolateral versus lateral internal anal sphincterotomy in the treatment of chronic anal fissure: a randomized controlled trial.

Lateral internal anal sphincterotomy (LIS) is considered the treatment of choice for chronic anal fissure. This study aimed to compare the outcome of standard LIS and posterolateral internal sphincterotomy (PLIS) at 5 o'clock position as regards healing of anal fissure, improvement in symptoms, and complications. Patients with chronic anal fissure were randomly allocated to one of two groups; group I underwent PLIS and group II underwent LIS. Patients were compared regarding the duration of healing of anal fissure, improvement in anal pain as recorded by visual analogue scale (VAS), complications, particularly fecal incontinence (FI) and changes in the anal pressures. Eighty (49 females) patients were included to this trial. The mean age of patients was 35.5years. The duration of healing was significantly shorter in group I than in group II (4.1 ± 1.7 vs 5.8 ± 1.4weeks; p < 0.0001). Group I achieved significantly lower pain score at 1month postoperatively than group II (1.1 ± 0.9 vs 1.7 ± 0.98; p = 0.005). Two (2.5%) of group I patients and six (10%) of group II patients experienced minor FI postoperatively. The postoperative reduction in the mean resting anal pressure in group I was significantly higher than that in group II. Time to complete healing was significantly shorter and pain score was significantly lower after PLIS than after LIS which can be due to more reduction in the resting anal pressure after PLIS. Continence disturbances occurred after PLIS less frequently than after LIS; however, no significant differences between the two techniques were noted. www.clinicaltrials.gov NCT03426449.

Lateral Internal Sphincterotomy for Treatment of Chronic anal Fissure in Paediatrics

Aims: Lateral internal sphincterotomy is a well established surgical technique for treatment of chronic anal fissure in adult. We performed this study to evaluate the outcome of lateral internal sphincterotomy in Paediatrics. Patients and Methods: This is a prospective study performed over a period of 4 years from October 2008 to October 2012 on 37 patients with chronic anal fissure of a duration exceeding 3 months and history of failure to conservative treatment. All patients underwent left lateral internal sphincterotomy through an open technique. Outcome was evaluated by assessing the effectiveness of this procedure in relieving the symptoms, fissure healing, parents’ satisfaction and complication rate. Results: There were 26 boys and 11 girls, mean age was 11 months with a range of (6 months - 12 years), and symptoms were relieved within 2 weeks in 28 cases and within one month in 5 cases. 4 patients require postoperative oral laxative for 1-3 months to overcome the withholding behavior. Fissures were healed in 34 by 8 weeks postoperatively. Parent satisfied with the outcome in 32 patients. 4 patients developed postoperative bleeding and only one of them was serious and required cauterization, soiling occurred in 3 cases. No permanent incontinence was reported. Conclusion: Lateral internal sphincterotomy is an effective and safe surgical technique for treatment of chronic anal fissure not responding to medical treatment in paediatric. Complications are uncommon and the risk of incontinence is very minimal if proper surgical technique is performed.

Botulinum toxin injection vs topical nitrates for chronic anal fissure: an updated systematic review and meta-analysis of randomized controlled trials.

Chronic anal fissures (CAFs) are frequently encountered in coloproctology clinics. Chemical sphincterotomy with pharmacological agents is recommended as first-line therapy. Topical nitrates (TN) heal CAF effectively but recurrences are common. An alternative treatment modality is injection of botulinum toxin (BT) into the anal sphincter. We aimed to perform an updated systematic review and meta-analysis to compare the effectiveness of BT and TN in the management of CAF. PubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until March 2017. All randomized controlled trials (RCTs) that reported direct comparisons of BT and TN were included. Two independent reviewers performed methodological assessment and data extraction. Random effects models were used to calculate pooled effect size estimates. Six RCTs describing 393 patients (194 BT, 199 TN) were included. There was significant heterogeneity among the trials. On random effects analysis there were no significant differences in incomplete fissure healing (OR=0.47, 95% CI 0.13-1.68, P=0.24) or recurrence (OR=0.70, 95% CI 0.39-1.25, P=0.22) between BT and TN, respectively. BT was associated with a higher rate of transient anal incontinence (OR=2.53, 95% CI 0.98-6.57, P=0.06) but significantly fewer total side effects (OR=0.12, 95% CI 0.02-0.63, P=0.01) and headache (OR=0.10, 95% CI 0.02-0.60, P=0.01) compared with TN. BT is associated with fewer side effects than TN but there is no difference in fissure healing or recurrence. Patients need to be warned regarding the risk of transient anal incontinence associated with BT.