Management Of Chronic Anal Fissure Research Articles

Comparative Study of Glyceryl Trinitrate Ointment Versus Surgical Management of Chronic Anal Fissure

Chronic Anal Fissure (CAF) is common perineal condition and well-known painful entity. Standard surgical treatment even though available, may require long hospital stay and sometimes have worrying complications like anal incontinence. So non-surgical treatment, Glyceryl Trinitrate has been shown to be an effective for chronic anal fissure. It decreases anal tone and ultimately heals the anal fissure. The present study is the attempt to know the efficacy of 0.2% Glyceryl Trinitrate ointment in the treatment of chronic anal fissure and to compare the effectiveness of 0.2% Glyceryl Trinitrate ointment (GTN) versus fissurectomy with lateral internal sphincterotomy (LIS) and fissurectomy with posterior internal sphincterotomy (PIS) in the management of chronic anal fissure. This is a prospective comparative study of management of chronic anal fissure done in our hospital during the period of one and half year from October 2005 to March 2007. Thirty patients treated with 0.2% Glyceryl Trinitrate ointment and 30 patients treated with fissurectomy and lateral internal sphincterotomy and 30 patients treated with posterior internal sphincterotomy, for chronic anal fissure were selected for study. A single brand of 0.2% Glyceryl Trinitrate ointment (Nitrogesic) used for trial arm. Dose of administration was 1.5cm to 2cm in the anal canal with device provided by manufacturers of the proprietary preparation and applied twice a daily for 12weeks. Patients were followed up for 12weeks and thereafter evaluated for relief of symptoms in all three groups. Observations were recorded at 2weeks; 6weeks and 12weeks of follow up period, regarding symptoms like pain and bleeding during defecation, healing of CAF and also for side effects like headache in GTN group and flatus, fecal incontinence in surgical groups. Data collected in proforma and analyzed. Study revealed CAF was more in male 59 patients (66%) than the female 31 patients (34%), the ratio being 1: 0.52. The maximum number of patients was encountered in the age group of 20 to 40years with mean duration of age 34.14years. In all three groups symptoms like pain, bleeding, constipation and sphincter spasm were present. Sentinel pile was present in 56% of the patients. Common site of fissure was found to be posterior in 94% of patients. Observations with respect to relief of pain, no bleeding and healing were recorded at 2, 6 and 12weeks of duration. Lateral sphincterotomy remains effective but should be reserved for the patients who fail to respond to initial chemical sphincterotomy or GTN therapy. GTN is good alternative mode of therapy for patients who refuse surgery and prefer medical line of treatment.

Lateral Internal Sphincterotomy for Chronic Idiopathic Anal Fissure: An Alternative Approach

BackgroundAn alternative approach to lateral internal sphincterotomy in the management of chronic anal fissure is presented and its potential advantages are described. MethodsUsing the conventional diathermy, the internal sphincter along with its overlying anoderm is cut to the caudal border of the dentate line. ResultsThis prospective study included 350 patients. Twenty-six patients (7.4%) reported spotting of blood with defecation and 266 patients (76%) reported minimal perianal discharge. The cessation of the discharge and spotting of blood correlated with the complete healing of the sphincterotomy wound. Urine retention requiring temporary catheterization was encountered in 19 patients (5.4%). Neither abscesses nor fistulae were encountered. Cure was achieved in all patients. Neither recurrences nor permanent fecal incontinence were encountered throughout the study period. ConclusionThe alternative approach is efficient and safe and may be added to the surgeon's armamentarium when attempting lateral internal sphincterotomy for chronic anal fissure.

Is high dose botulinum toxin in combination with fissurectomy safe and effective in the management of chronic anal fissure?

Is high dose botulinum toxin in combination with fissurectomy safe and effective in the management of chronic anal fissure?

Identifying the best therapy for chronic anal fissure

Chronic anal fissure (CAF) is a painful tear or crack which occurs in the anoderm. The optimal algorithm of therapy for CAF is still debated. Lateral internal sphincterotomy (LIS) is a surgical treatment, considered as the 'gold standard' therapy for CAF. It relieves CAF symptoms with a high rate of healing. Chemical sphincterotomy (CS) with nitrates, calcium blockers or botulinum toxin (BTX) is safe, with the rapid relief of pain, mild side-effects and no risk of surgery or anesthesia, but is a statistically less effective therapy for CAF than LIS. This article considers if aggressive treatment should only be offered to patients who fail pharmacological sphincterotomy. Aspects of anal fissure etiology, epidemiology and pathophysiology are considered with their meaning for further management of CAF. A molecular model of chemical interdependence significant for the chemistry of CAF healing is examined. Its application may influence the development of optimal therapy for CAF. BTX is currently considered the most effective type of CS and discussion in this article scrutinizes this method specifically. Although the effectiveness of BTX vs. LIS has been discussed, the essential focus of the article concerns identifying the best therapy application for anal fissure. Elements are presented which may help us to predict CAF healing. They provide rationale for the expansion of the CAF therapy algorithm. Ethical and economic factors are also considered in brief. As long as the patient is willing to accept the potential risk of fecal incontinence, we have grounds for the 'gold standard' (LIS) as the first-line treatment for CAF. The author concludes that, when the diagnosis of the anal fissure is established, CS should be considered for both ethical and economic reasons. He is convinced that a greater understanding and recognition of benign anal disorders by the GP and a proactive involvement at the point of initial diagnosis would facilitate the consideration of CS at an earlier, more practical stage with improved outcomes for the patient.

Fissurectomy with posterior midline sphincterotomy for management of chronic anal fissure.

To determine the efficacy and safety of fissurectomy with posterior midline sphincterotomy in the management of chronic anal fissure in terms of symptomatic relief, complications and recurrence. Observational case-series. Department of Surgery, Liaquat University Hospital, Jamshoro/Hyderabad, for a period of 3 years from January 2005 to December 2007. A total of 136 patients with chronic anal fissure were recruited for this study. All subjects underwent elective fissurectomy and posterior sphincterotomy. Surgery was performed either under spinal or general anaesthesia. Symptomatic relief and early postoperative complications were recorded. The patients were followed for 18 months. Follow-up included assessment for complications such as pain, incontinence, keyhole deformity, and recurrence. All patients presented with pain during and after defaecation. Forty (29.4%) patients presented with bleeding per rectum. One hundred and sixteen (85%) patients complained of perianal swelling while 8 (5.9%) patients complained of perianal itching. Retention of urine was the most common postoperative complication, seen in 10 (7.4%) cases. It occurred within the first 24 hours after operation and all cases required catheterization. Six (4.4%) patients complained of moderate to severe postoperative pain in the first 24 hours, requiring narcotic analgesics. Transient incontinence of flatus and faeces occurred in 5 (3.7%) and 3 (2.2%) cases respectively. One patient presented with a recurrent anal fissure after 8 months but responded to conservative treatment. Given the low rate of complications and almost negligible rate of recurrence, fissurectomy with posterior midline sphincterotomy is still a treatment of choice for the management of chronic anal fissure.

High Dose Botulinum Toxin is Safe and Effective in the Management of Chronic Anal Fissure

High Dose Botulinum Toxin is Safe and Effective in the Management of Chronic Anal Fissure

Lokales Nitroglyzerin vs. Sphinkterotomie bei chronischer Analfissur

BACKGROUND: To compare the effectiveness of local glyceryl trinitrate (GTN) versus internal sphincterotomy in the management of chronic anal fissure. METHODS: Eighty patients with chronic anal fissure were enrolled in the study. They were divided into two groups; group (1) included 40 patients treated with topical GTN 0.2% on liposomal base applied to the anoderm twice daily and group (2) included 40 patients treated with internal sphincterotomy. We compared the effectiveness of both techniques in the management of chronic anal fissure. RESULTS: In group 1, healing of fissures occurred in 85% of patients after 8 weeks therapy. Headache as a side effect developed in 65% of patients. In group 2, healing occurred in 97.5% of patients after 8 weeks. Incontinence to flatus occurred in 3 patients (7.5%), mild soiling in 2 patients (5%), and one patient developed wound infection. All complications were temporary except for one patient with persistent incontinence to flatus. At the end of 8 weeks both groups were equal in pain scoring. CONCLUSIONS: Topical GTN should be the initial treatment in chronic anal fissure while internal sphincterotomy may be reserved for patients who did not respond to GTN therapy and those with severe pain (as healing is faster with sphincterotomy).

Diltiazem (2%) versus glyceryl trinitrate cream (0.2%) in the management of chronic anal fissure.

To assess and compare the effectiveness of topical 0.2% glycerl trinitrate (GTN) and topical 2% diltiazem (DTZ), in the management of chronic anal fissure. Comparative, descriptive study. Department of Surgery, Liaquat University of Medical and Health Sciences, Jamshoro/Hyderabad from September 2004 to August 2005. Patients with chronic anal fissure were treated with topical 0.2% GTN (50 patients) and 2% DTZ (47 patients) application for 8 weeks, three times a day at peri anal area. Symtoms, recurrence, wound healing and side effects were compared. Data was analyzed using SPSS version 10 employing X2 test. A p-value below 0.05 were considered statistically significant. There were 53 females and 44 males with a mean age of 30 years. Patients who received topical diltiazem (DTZ) showed statistically significant difference than those who were prescribed topical glycerl trinitrate terms of wound healing and side effects mainly the headaches (p=0.02 and 0.003 respectively). Improvement in symptoms (p=0.345) and recurrence rates (p=0.612) turned to be statistically insignificant although recurrence rate was lower with DTZ. Chemical sphincterotomy is an effective first line management for chronic anal fissure. Both GTN and DTZ are equally effective in managing the chronic anal fissure. DTZ has fewer side effects, a better healing response and low recurrence rates.

Surgical or reversible neurochemical sphincterotomy?

The management of chronic anal fissure has received renewed interest and has been re-evaluated over the past 20 years. The use of botulinum toxin seems to be a promising and safe approach, particularly in patients at high risk for incontinence. A recent meta-analysis investigated the efficacy of botulinum toxin injection compared with lateral internal sphincterotomy for the management of this condition.

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.

A Comparison Between the Results of Fissurectomy and Lateral Internal Sphincterotomy in the Surgical Management of Chronic Anal Fissure

BackgroundWe compare lateral internal sphincterotomy as an effective treatment of chronic fissure in ano to fissurectomy, which is as an alternative surgical treatment. MethodsSixty two consecutive patients were divided into two groups through sequential sampling. Thirty patients underwent fissurectomy and 32 underwent lateral internal sphincterotomy. After a median follow-up of 22 months, we compared the results of the two procedures. In addition to frequent visits on a predetermined basis, a telephone inquiry into fissure recurrence and continence status was made. ResultsAll patients in both groups were pain-free and without bleeding within 1 week. In both groups, urinary retention was noted in one patient. Incontinence to flatus was noted in the fissurectomy (F) group in two (6.2%) patients, but no incontinence was noted in the lateral internal sphincterotomy (LIS) group. There was one patient (3.1%) with fissure recurrence in the F group but none in the LIS group. No patient in either group was afflicted with anal stenosis or perianal infections. All wounds healed within 8 weeks. Twenty nine patients (96.6%) in the LIS group and 28 (87.5%) in the F group reported satisfactory results with their procedure. ConclusionIn the surgical treatment of chronic anal fissure not responding to conservative management, LIS may be the better treatment and, perhaps, the preferable surgical technique with fewer total complications (P < 0.005).

Glyceryl trinitrate: The management of chronic anal fissure in patients who are unfit for surgery

Keywords: Anal fissure; Glyceryl trinitrate; Sphincterotomy; SurgeryOnline: 29-1-2009DOI: 10.3329/bmrcb.v34i3.1648Bangladesh Med Res Counc Bull 2008; 34: 111-111

CHRONIC ANAL FISSURE

. Topical application of glyceryl trinitrate (GTN) ointment heals anal fissures, providing an alternative to the traditional first linetreatment of surgical sphincterotomy. Setting: Tathlith General Hospital Saudi Arabia. Period: January 2001 – April 2003. Objective: Todetermine the effectiveness and safety of topical 0.5% glyceryl trinitrate (GTN) in the management of chronic anal fissure. Patients &amp; methods:Individual Patients were randomized to receive 0.5%GTN paste or placebo three times per day for six weeks in addition to oral senna and/orlactulose. Patients took laxatives alone for further 6 weeks. Patients were followed every week for six weeks and then fortnightly for anothersix weeks to assess pain scores and were given advice. Results: Fifty patients were recruited in this study and 44 patients completed the trial(23 in the GTN group and 21 in the placebo group), patients who could not complete the study were excluded. At 6 weeks, 74% of patients hadno pain in the GTN group as compared to the 29% in the placebo group. In 26% of cases treatment was unsuccessful. At three month followup there was no early recurrence. The prevalence of headaches was 65% in GTN group ( reported by 15 patients) and 24% in placebo group(reported by 5 patients). Mean pain scores were lower in the GTN group as compared to the placebo group. Conclusions: The use of 0.5%GTN induces healing of chronic anal fissures and may by used as a first line of treatment in patients with chronic anal fissure. Successfultreatment may come at the expense of a high incidence of headaches.

Botulinum toxin vs glyceryltrinitrate for the medical management of chronic anal fissure: a meta‐analysis

The objective of this review was to analyse systematically the prospective randomized controlled trials on the effectiveness of botulinum toxin (BTX) and glyceryltrinitrate (GTN) for the pharmacological management of chronic anal fissure (CAF). A systematic review of the literature was undertaken. Prospective randomized controlled trials on the effectiveness of BTX and GTN for the management of CAF were selected according to specific criteria and analysed to generate summative data. Six studies encompassing 355 patients with CAF were retrieved from electronic databases. Only three randomized controlled trials on 180 patients qualified for the meta-analysis according to inclusion criteria. There were 90 patients in BTX and 90 in the GTN group. BTX and GTN were equally effective in healing/improving the CAF. There was no statistically significant difference between the two pharmacotherapies [RR 1.29 (0.98-1.70) 95% CI, z = -1.83, P = 1.93, Fig. 1]. However, there was statistically significant heterogeneity among the trials (Q = 4.03, df = 1, P = 0.042). On fixed effect model, GTN was associated with higher incidence of total side effects [fixed effect model RR 0.14 (0.05-0.40) 95% CI, z = -3.71, P = 0.0002] and headache [RR 0.07 (0.02-0.20) 95% CI, z = -5.05, P = 0.0007] among patients of CAF. Botulinum toxin is as effective as GTN for the management of CAF but it is associated with a lower complication rate. BTX can be recommended as a first-line therapy for chemical sphincterotomy in patients of CAF. However, a major and multi-centre randomized controlled trial is required to support this treatment approach in order to establish stronger evidence.

Comparison of surgical vs chemical sphincterotomy using botulinum toxin for the treatment of chronic anal fissure: a meta‐analysis

To analyse systematically prospective randomized controlled trials dealing with the effectiveness of surgical sphincterotomy (SS) vs chemical sphincterotomy (CS) using botulinum toxin for the management of chronic anal fissure (CAF). A systematic review of the literature was undertaken. Prospective randomized controlled trials on the effectiveness of SS vs CS using botulinum toxin were selected and analysed to generate the summative outcome. Four prospective randomized controlled trials dealing with SS vs CS using botulinum injection, which included 279 CAF patients, were analysed. Based on the random effects model, there was a higher complication rate [Risk ratio (RR) 14.54 (-9.84, -38.9) 95% CI, df = 2, P < 0.0163] and a higher risk of transient faecal incontinence [RR 6.39 (-2.37, -15.1) 95% CI, df = 3, P < 0.0001] in the SS group than in the CS group. However, there was significant heterogeneity among the trials (Q = 8 408 891, P < 0.0001), indicating a wide confidence interval range; thus, the inferiority of SS could not be shown. SS had a significantly higher healing rate [RR 1.63, (1.34-1.91) 95% CI, df = 3, P < 0.0110] and a significantly lower recurrence rate [RR 0.35 (0.33-0.38) 95% CI, df = 3, P < 0.0221] than CS. Both CS and SS are comparable in the management of CAF. There are no differences in the complication rates and incontinence rates between the two procedures. SS has a higher healing rate and a lower recurrence rate than CS. As long as the patient is willing to accept a negligible risk of transient faecal incontinence, SS should be the first-line treatment for CAF.

The efficacy of diltiazem and glyceryltrinitrate for the medical management of chronic anal fissure: a meta-analysis

The objective of this review is to systematically analyze the prospective randomized controlled trials on the effectiveness of diltiazem (DTZ) and glyceryltrinitrate (GTN) for the pharmacological management of chronic anal fissure (CAF). A systematic review of the literature was undertaken. Prospective randomized controlled trials on the effectiveness of DTZ for the management of CAF were selected according to specific criteria and analyzed to generate summative data. Five studies encompassing 263 patients with CAF were retrieved from the electronic databases. Only two randomized controlled trials on 103 patients qualified for the meta-analysis. There were 53 patients in the DTZ group and 50 patients in the GTN group. Both DTZ and GTN were equally effective for the treatment of CAF (random-effect model risk ratio [RR] 0.29 [90.06-1.33] 95% confidence interval [CI], z=0.62, p=0.536). However, there was significant heterogeneity between the trials. GTN was associated with higher side effects rate (fixed-effect model RR 0.45 [0.28-0.73] 95% CI, z= -3.22, p=0.001) and higher headache rate (fixed-effect model RR 0.33 [0.17-0.64] 95% CI, z= -3.27, p=0.001) as compared to DTZ. There was no statistically significant recurrence rate of CAF between two pharmacotherapies (fixed-effect model RR 0.66 [0.18-2.41] 95% CI, z= -0.62, p=0.535). Both DTZ and GTN are equally effective and can be used for the management of CAF. However, GTN is associated with a higher rate of side effects (headache/anal irritation), and it should be replaced by DTZ. The recurrence rate of CAF after the use of both pharmacotherapies is equal.

Botulinum toxin A and chronic anal fissures – a literature review

BACKGROUND: The Botulinum toxin A is used in the management of chronic anal fissures. This review is aimed at consolidating the available evidence in the various aspects of the use of BT-A in the treatment of anal fissures. METHODS: A Medline search of studies related to effects of Botulinum toxin on anal fissures was performed. All relevant trials, studies, experiences and cross references were included. RESULTS: Botulinum toxin A has a demonstrable temporary paralytic effect on the anal sphincters. A varied rate of success has been observed with its use in management of anal fissures. The long term results are superior to those of exogenous nitric oxide donors and inferior to Lateral internal sphincterotomy. The need for re-injection and high recurrence rate makes it less effective than surgical options but its simplicity and lack of permanent complications make it a desirable option. CONCLUSIONS: Botulinum toxin should be considered in uncomplicated idiopathic chronic anal fissures refractory to topical nitric oxide donors and in patients unfit for anaesthesia. In view of its low complication rates and temporary effect on sphincters, it should be offered as an option prior to considering surgical intervention on the anal sphincters.

Toxine botulique et fissure anale chronique

Lateral internal sphincterotomy is widely used in the treatment of chronic anal fissure. However, it is associated with a high rate of irreversible incontinence. For this reason the botulinum toxin has become a medical means of reversible sphincterotomy. Indeed, this neurotoxin induces relaxation of the smooth internal anal sphincter lasting one to three months after one injection. We reviewed the published studies about the use of this technique in the management of chronic anal fissure. Healing occurred in more than 70% of fissures without irreversible incontinence. Although further studies are needed to determine the best modalities of administration, especially due to the remaining significant recurrence rate, this toxin may be a valuable treatment for chronic anal fissure in the future.

Cost-Saving Effect of Treatment Algorithm for Chronic Anal Fissure: A Prospective Analysis

Evidence-based medicine suggests that in the management of chronic anal fissure (CAF), lateral internal sphincterotomy (LIS) is far more effective than medical treatment in lowering the anal sphincter tone and curing the fissure. In the current study, we developed a treatment algorithm from topical nitroglycerin (NTG) to botulinum toxin type A (Botox [BTX]) to LIS and analyzed its cost benefit by calculating the effective and potential costs based on the treatment success and the rate of avoided surgeries. Patients presenting between November 2003 and December 2004 with CAF and symptoms for greater than 3 months were prospectively treated according to a treatment algorithm which started with (1) topical NTG, in case of failure (2) injection of BTX, thus limiting (3) surgery to those who failed both nonsurgical options or at any point chose the surgical approach. Based on the primary end points of fissure healing or surgery, we calculated the true cost (algorithm) and the potential incremental cost (BTX plus surgery or surgery in all patients, respectively). Sixty-seven patients with CAF (25 men and 42 women; median duration of symptoms, 16 weeks) were treated according to the algorithm. NTG alone was successful in fissure healing in 31 of 67 patients (46.2%). Two developed a recurrent fissure and then received BTX as part of the protocol. Of the 36 patients who failed NTG trial, 3 requested surgery; the others were treated with BTX, which was successful in 84.8%. Five patients (15.2%) failed BTX and subsequently required surgery. The overall surgery rate in the whole study group was 11.9%, whereas CAF healed in 88.1% of our patients with medical treatment alone. Cost for NTG is $10; for 100 units BTX, $528; and for outpatient surgery, $1119. The total cost for these 67 patients therefore was $33,252 ($290 for NTG, $20,580 for NTG plus BTX, $3,357 for NTG plus LIS, and $9,025 for NTG plus BTX plus LIS). If all patients had received BTX with a 15% failure rate, the total cost would have been $56,688 (70.3% cost increase). If all patients had undergone surgery as initial/only treatment, the total cost would have been $74,973 (125% cost increase). Our treatment algorithm for CAF with stepwise escalation can avoid surgery in 88% of the patients. It is highly cost-efficient and resulted in savings of 41% (compared with BTX plus LIS) and up to 70% (compared with surgery in all patients), respectively.

Pneumatic Balloon Dilatation for Chronic Anal Fissure: A Prospective, Clinical, Endosonographic, and Manometric Study

Pneumatic balloon dilation has been shown to be effective in the management of chronic anal fissure, but its effect on the anal sphincter has not been fully investigated. The aim of this study was to evaluate prospectively the clinical, anatomic, and functional pattern in a group of patients treated by pneumatic balloon dilation. A series of 33 consecutive patients suffering from chronic anal fissure underwent pneumatic balloon dilation. Anal manometry and ultrasonography were performed prior to and 6 to 12 months after the treatment. Manometry was accomplished by means of an endoanal 40-mm balloon inflated with a pressure of 1.4 atmospheres that was left in situ for six minutes under local anesthesia. All patients were interviewed daily for three days after surgery and then clinically evaluated between the third and fifth postoperative weeks. Most patients were interviewed after 25.7 +/- 8.4 months (mean +/- standard deviation). Anal incontinence was evaluated by means of a validated score of 1 to 6. The chronic anal fissure healed between the third and fifth weeks in 31 patients (94 percent), who became asymptomatic 2.5 +/- 1.4 days after pneumatic balloon dilation. None of them reported anal pain two years after the treatment (n = 20). The first post-pneumatic balloon dilation defecation was painless in 27 cases (82 percent). Two multiparous females (6 percent of the patients) complained of minor transient anal incontinence (score, 3). Chronic anal fissure recurred in one case (3 percent) after treatment. At manometry, the preoperative anal resting pressure decreased from 91 +/- 11.2 to 70.5 +/- 5.6 and to 78 +/- 5.7 mmHg, 6 and 12 months after pneumatic balloon dilation, respectively (P < 0.0001). Anal ultrasonography did not show any significant sphincter defect. Pneumatic balloon dilation seems to be an effective, safe, easy procedure that decreases anal resting pressure without endosonographically detectable significant sphincter damage.