Sphincterotomy For Chronic Anal Fissure Research Articles

The role of endoscopy in patients with anorectal disorders

The role of endoscopy in patients with anorectal disorders

Botulinum Toxin A with Fissurectomy is a Viable Alternative to Lateral Internal Sphincterotomy for Chronic Anal Fissure

Lateral internal sphincterotomy (LIS) is the gold standard surgical treatment for anal fissure. However, it carries potential complications, including fecal incontinence. The goal of this retrospective study was to compare the outcome of botulinum toxin A injection coupled with fissurectomy ([BTX + FIS) versus LIS. There were 59 patients who underwent BTX + FIS or LIS over a 5-year period. LIS was performed in the standard fashion without fissurectomy. BTX + FIS entailed internal sphincter injection with 80 units of botulinum toxin A coupled with fissurectomy. Forty patients underwent LIS and 19 had BTX + FIS. The choice of operation was based on the patient's preference. Primary healing rate was 90 and 74 per cent in the LIS and BTX + FIS groups, respectively (P = 0.13). The complication rate was 10 per cent in the LIS vs 0 per cent in the BTX + FIS groups (P = 0.29). Complications of LIS included anal sepsis in one patient and flatal and/or fecal incontinence in three patients. During a mean follow up of 19 months; recurrence rate was 0 and 5 per cent in the LIS and BTX+FIS groups, respectively (P = 0.32). The results of this study demonstrate that BTX + FIS is a viable alternative to LIS for patients with chronic anal fissure and should be considered as an alternative first-line surgical therapy.

Complications and results of lateral internal sphincterotomy for chronic anal fissure

Background Treatment of chronic anal fissure has been directed at relaxing increased sphincter tone. Lateral internal sphincterotomy (LIS), since its introduction in 1951 by Eisenhammer, has been considered the gold standard approach with healing rate of approaching 95%. However, concerns have been raised about postoperative impairment of faecal incontinence after LIS. Actually, the incidence of faecal incontinence reported in literature varies widely from 1.3% to 30% or more. Several factors have been associated to affect LIS outcomes and morbidities, first of all accurate surgical technique, length of sphincterotomy, previous anorectal surgery, additional procedures and obstetric history.

LATERAL INTERNAL SPHINCTEROTOMY

Anal fissure is a common anorectal problem, presenting with pain during and after defecation. It is associated withincreased tone of the internal anal sphincter muscle. The relief of this hypertonia is the cornerstone of the treatment of the anal fissure. Thesurgical relief of this hypertonia is very successful in treating the fissure with minor morbidity of the procedure. Patients & M e t h o d s : A studywas conducted in 486 patients,(344-males and 142 females,25-40 range). Setting: Saad Surgi-med hospital Faisalabad. Period: 1999to 2007. Lateral internal anal Sphincterotomy for chronic anal fissure. The therapeutic outcome and complications of the procedure wererecorded. Results: Out of 486 patients, 344 were males and 142 females.frange 25-40) The site of fissure was in posterior midline 6 O' clockin 350 patients.(m=257,f=93);Anterior midline. 12 O'clock in 99 patients.(m=76,f=23);both anterior and posterior in 41 patients.(m=l 5,f=26)Eleven patients had associated peri-anal abscess and 19 patients had associated Fistula in ano. All the patients were discharged after 24hrs with regular follow up at 1,2,6,24 wks. 275 patients had significant relief of pain in 48 hrs, 107 became pain free in 1 wk.37 has had somepain for 2 wks. In 479 patients fissure healed in 3 months, 7 patients has had delayed healing out of which five patients required curettageof the wound under local anaesthesia which healed subsequently in next six wks. 12 patients had minor incontinence whichdisappeared in 4 wks. In one patient the incontinence persisted for six months then it got settled. Conclusion: Lateral subcutaneous internalSphincterotomy is a safe and effective treatment of chronic anal fissure.

Systematic review and meta-analysis of randomized controlled trials comparing botulinum toxin injection with lateral internal sphincterotomy for chronic anal fissure

The aim of this review is to systematically analyze the prospective randomized controlled trials on the efficacy of botulinum toxin injection (Botox) vs. lateral internal sphincterotomy (LIS) for the treatment of chronic anal fissure (CAF). A systematic review of the literature was undertaken. The prospective randomized controlled trials on the effectiveness of Botox vs. LIS for the management of CAF were selected according to specific criteria and analyzed to generate pooling data. Four studies encompassing 279 patients were qualified for the meta-analysis. There was a statistically significant higher healing in LIS group compared with Botox group (RR 1.31[1.57, 1.50] 95% CI, z = 4.11, p < 0.0001). Absolute benefit increase rate (ABI) is 23% for LIS group compared with Botox group. The recurrence rate was statistically significantly higher in Botox groups than in LIS groups (RR 5.83[2.96, 11.49] 95% CI, z = 5.09, p < 0.00001).LIS was associated with a high rate of minor anal incontinence as compared to Botox (RR 0.08[0.01, 0.59] 95% CI, z = 2.47, p = 0.01). Botulinum toxin injection was associated with a higher rate of recurrent disease. LIS was more effective in healing chronic anal fissure.

Evaluation of Healing and Complications After Lateral Internal Sphincterotomy for Chronic Anal Fissure: Marginal Suture of Incision vs. Open Left Incision: Prospective, Randomized, Controlled Study

Internal sphincterotomy remains the standard for treatment of anal fissure, but it is associated with risks of infection, bleeding, and incontinence. Recent studies have suggested that the complications after lateral internal sphincterotomy are related to surgical technique. This study was designed to assess the incidence of early and late complications after lateral internal sphincterotomy with marginal sutured incision. Fissure healing, pain, and complications were compared in patients undergoing a procedure involving three interrupted marginal sutures after open lateral internal sphincterotomy procedure. Ninety patients of chronic anal fissure were randomly assigned to two groups. Both groups received open lateral internal sphincterotomy via standardized method. The incisions of the patients in Group 1 (n=45) were sutured marginally with three interrupted sutures using 2-0 chromic catgut, whereas the incisions of the patients in Group 2 (n=45) were left open. The patients were assessed at 12 weeks postoperatively by an independent observer. The fissure-healing rate was not significantly different in both groups (95 and 93.1 percent, respectively). The pain score was slightly higher in Group 2, and it was statistically significant. Four cases of bleeding and two abscesses were observed in Group 2. These complications were not observed in Group 1. One case of incontinence was observed at the beginning in Group 1 and four in Group 2, but the incontinence was transient in both cases. Marginal sutures of incision after lateral internal sphincterotomy may be beneficial to reduce complications related to early wound healing.

Clinical, Manometric, and Ultrasonographic Results of Pneumatic Balloon Dilatation vs. Lateral Internal Sphincterotomy for Chronic Anal Fissure: A Prospective, Randomized, Controlled Trial

This prospective, randomized, controlled trial was designed to compare the clinical, functional, and morphologic results of pneumatic balloon dilatation with lateral internal sphincterotomy for the treatment of chronic anal fissure. All patients with symptomatic chronic anal fissure were randomly assigned to pneumatic balloon dilatation or lateral internal sphincterotomy and invited to complete a standardized questionnaire inquiring about their symptoms. Anal ultrasonography and anal manometry were performed before and six months after surgery. A proctologic examination was performed between the fifth and sixth postoperative weeks. Anal continence, scored by using a validated continence grading scale, was evaluated preoperatively at 1 and 6 weeks and at 12 and 24 months. Fifty-three patients, who satisfied selection criteria, were enrolled in the trial. Four patients (7.5 percent) were lost to follow-up. Twenty-four patients (11 males; mean age, 42 +/- 8.2 years) underwent pneumatic balloon dilatation and 25 patients (10 males; mean age, 44 +/- 7.3 years) underwent lateral internal sphincterotomy. Fissure-healing rates were 83.3 percent in the pneumatic balloon dilatation and 92 percent in the lateral internal sphincterotomy group. Recurrent anal fissure was observed in one patient (4 percent) after lateral internal sphincterotomy. At anal manometry, mean resting pressure decrements obtained after pneumatic balloon dilatation and lateral internal sphincterotomy were 30.5 and 34.3 percent, respectively. After pneumatic balloon dilatation, anal ultrasonography did not show any significant sphincter damage. At 24-month follow-up, the incidence of incontinence, irrespective of severity, was 0 percent in the pneumatic balloon dilatation group and 16 percent in the lateral internal sphincterotomy group (P < 0.0001). As lateral internal sphincterotomy, pneumatic balloon dilatation grants a high anal fissure-healing rate but with a statistically significant reduction in postoperative anal incontinence.

Anal dilatation versus left lateral sphincterotomy for chronic anal fissure: a prospective randomized study.

BACKGROUND: Several surgical methods are accepted for the treatment of chronic anal fissure. The most popular are anal dilatation (AD) and left lateral sphincterotomy (LLS). The objective of the current study was to prospectively evaluate the results of these two procedures in terms of recurrence rate, complications and patient satisfaction. METHODS: The study enrolled all patients who required operation for chronic anal fissure in the Division of General Surgery, Campus Golda, Rabin Medical Center, between the years 1997 and 2001. Exclusion criteria were acute anal fissure or inflammatory bowel disease. RESULTS: A total of 108 patients participated in the study, at an average age of 42.4 years (SD=12.5). The patients were randomly assigned to two groups; one for LLS (53 patients, 49.1%) and one for AD (55 patients, 50.9%). The study protocol included a questionnaire and a physical examination performed 1, 2, 3, 6 and 12 months after operation. The questionnaire contained questions about pain, bloody stool, incontinence for gas, fluid or hard feces, during the day or night, and soiling. The patients were also asked about their satisfaction on an analog scale from 1 to 10. The average follow-up was 11.2 months (SD=4.1). Minor incontinence occurred in 8 patients of AD group and in 2 patients of LLS group (p<0.005). Recurrence occurred in 6 cases of the AD group and in one case of the LLS group (p<0.003). Satisfaction score was insignificantly higher in the LLS group (9.1+/-0.8 in the LLS group and 7.4+/-2.0 in the AD group). CONCLUSIONS: These results suggest that LLS is the preferred method for the treatment for chronic anal fissure.

Results of Lateral Internal Sphincterotomy for Chronic Anal Fissure With Particular Reference to Quality of Life

The aim of this study was to investigate the effects of lateral internal sphincterotomy on quality of life in patients with chronic anal fissure using the Gastrointestinal Quality of Life Index and the Fecal Incontinence Quality of Life Scale. Adult patients with chronic anal fissure underwent lateral internal sphincterotomy with the open technique. Two hundred forty-four patients completed the Gastrointestinal Quality of Life Index questionnaire at admission and at 12 months postoperatively. The Fecal Incontinence Severity Index score was calculated preoperatively and at 2 and 12 months postoperatively. The Fecal Incontinence Quality of Life Scale was administered to any patient who had a Fecal Incontinence Severity Index score greater than 0 at 12 months postoperatively. The mean preoperative Gastrointestinal Quality of Life Index score was 118.34 +/- 6.33, which developed to 140.74 +/- 2.38 postoperatively (P< 0.001). At the two-month follow-up, 18 patients (7.38 percent) had a Fecal Incontinence Severity Index score greater than 0. By 12 months, the number of patients with Fecal Incontinence Severity Index score greater than 0 was reduced to seven (2.87 percent). These seven patients had a Gastrointestinal Quality of Life Index score similar to that of the group with postoperative Fecal Incontinence Severity Index score of 0, and only three patients (1.22 percent) had evident deterioration in the Fecal Incontinence Quality of Life Scale. The 12-month total Gastrointestinal Quality of Life Index score of the three patients who developed anal abscess/fistula after sphincterotomy (139.33 +/- 3.21) was similar to the Gastrointestinal Quality of Life Index score of those without complications. However, the Gastrointestinal Quality of Life Index score of the recurrent cases (111.53 +/- 3.53) was apparently low. The gastrointestinal quality of life improved significantly following lateral internal sphincterotomy, regardless of the surgical complications or postoperative disturbances of continence. Only 1.2 percent of the patients experienced deterioration in Fecal Incontinence Quality of Life Scale.

Technical failure of lateral sphincterotomy for the treatment of chronic anal fissure: A study using endoanal ultrasonography

Abstract Long-term follow-up of outcome after lateral internal sphincterotomy for chronic anal fissure suggests that the healing rate is in excess of 95 per cent. A group of patients who continue to have symptoms following surgery has been investigated by endoanal ultrasonography to determine its value in determining why sphincterotomy has failed.

Adequate internal sphincterotomy for chronic anal fissure: Subcutaneous or open technique?

The extent of sphincter division by the subcutaneous or the open technique is examined by comparing the change in anal canal pressure after either method of sphincterotomy in twenty-eight patients with chronic anal fissure randomly allocated. In all patients the fissures healed at one month with significant reduction (P less than 0.01) of anal canal pressures to 52 (17-75) cmH2O after subcutaneous and 47.5 (35-100) cmH2O after open sphincterotomy, a 51 (22-77) and 50 (11-68) per cent reduction of their respective pre-operative measurements. Adequate sphincterotomy can be achieved by both techniques.

Topical nitroglycerin versus lateral internal sphincterotomy for chronic anal fissure: prospective, randomized trial

Topical nitroglycerin (GTN) is one of the medical treatments of choice in chronic anal fissure. The present prospective, randomized, clinical trial was conducted to study the symptomatic relief, healing, and changes in the maximum anal resting pressure (MARP) in patients with chronic anal fissure comparing topical GTN and lateral sphincterotomy. Forty consecutive patients with chronic anal fissure were randomized for treatment with either topical GTN or internal sphincterotomy (20 patients in each group). Anal manometry was done before treatment in all patients, and 1 h after application of GTN or sphincterotomy. Patients were followed at 2-weekly intervals for 6 weeks for symptomatic relief and healing. Both GTN and sphincterotomy brought about a highly significant, but comparable drop in the MARP after treatment (P < 0.0001 in both groups). Sphincterotomy relieved pain much earlier compared to GTN (70% vs 40% at 2 weeks, P = 0.0032); but after 4 weeks of treatment, pain relief in both groups was comparable. Healing in the sphincterotomy group was also earlier than with GTN (55% vs 0% at 2 weeks, P < 0.0001; and 85% vs 30% at 4 weeks, P < 0.0001); but after 6 weeks, healing in both groups was comparable. Sphincterotomy had a significant incidence of minor, short-term complications; it also required surgical expertise, theatre time, and day-care beds. Nitroglycerin is safe, with mild and tolerable side-effects of headache and local burning sensation. Topical GTN should be the initial treatment in chronic anal fissure. Lateral sphincterotomy should be reserved for patients with severe disabling pain (because pain relief is much faster), and for patients not responding to at least 4 weeks of GTN therapy.

Nitric oxide deficiency in the internal anal sphincter of patients with chronic anal fissure

Anal fissure is a common condition affecting young to middle-aged adults. It causes severe pain on defecation and rectal bleeding. The aetiology remains uncertain. Spasm of the internal anal sphincter is a constant feature. Nitric oxide (NO) is the major inhibitory neurotransmitter of the internal anal sphincter (IAS). In other spasmodic conditions of the GI tract a lack of normal nitric oxide synthase (NOS) activity has been reported. The aim of this preliminary study was to compare the presence of NOS in the internal sphincters of patients with and without chronic anal fissure. Internal anal sphincter biopsies were taken under general anaesthesia from patients having lateral internal sphincterotomy for chronic anal fissure and from sphincter of patients having abdominoperineal resections as controls. Sections of IAS were stained to show the presence of NADPH diaphorase (and hence presence of NOS). Internal anal sphincter was taken from 6 patients with chronic anal fissure and 6 controls. IAS taken from patients with chronic anal fissure showed little NOS presence compared with controls. It may be that there is an abnormal failure of relaxation of internal sphincter in those patients who develop chronic anal fissure caused by an intrinsic lack of neural NOS in the internal anal sphincter.

Calibrated lateral internal sphincterotomy for chronic anal fissure

Lateral internal sphincterotomy is an effective procedure for the treatment of anal fissure, but may affected anal continence. We describe a procedure aimed at tailoring the division of the sphincter according to the degree of the hypertonia and to the sphincter length in order to offer an effective and safe treatment for chronic anal fissure. The internal sphincter was divided on the basis of anal manometry results. The average of maximum values of resting pressure determined by the stationary motility protocol was considered the reference parameter to measure hypertonia. Mild hypertone was considered to be 50-60 mmHg, moderate hypertone 60-80 mmHg, and severe hypertone >80 mmHg. In case of mild hypertone, 20% of the internal sphincter was divided; in case of moderate hypertone; 40% and 60% for severe hypertone. Calibrated lateral internal sphincterotomy is the division of the internal sphincter based on these parameters. Over 5 years, 388 patients underwent this procedure (197 men, 191 women) with a median age of 43 years (range, 18-80). Postoperative complications consisted of abscess in 4 patients (1.0%), hemorrhage in 2 patients (0.5%), and pain in 6 patients (1.5%). Follow-up data are available for 261 patients (67.3%). Two months after surgery, 9 patients (3.4%) complained of persistent or recurring pain with or without fissure and 1 (0.4%) complained of gas incontinence. At postoperative manometry, 12 patients (4.6%) revealed persistence of anal resting pressure over 40 mmHg, 9 patients (3.4%) were still symptomatic and 97.6% were cured at a median follow-up of 8 months. An anal resting pressure lower than 30 mmHg was found in 10 patients (3.8%), only one of whom was incontinent. Calibrated sphincterotomy may represent an effective and safe procedure for the treatment of chronic anal fissure.

Surgical versus chemical (botulinum toxin) sphincterotomy for chronic anal fissure: Long-term results of a prospective randomized clinical and manometric study

Background The aim of this prospective randomized trial was to compare the effectiveness and morbidity of surgical versus chemical sphincterotomy in the treatment of chronic anal fissure after a 3-year follow-up. Methods Eighty patients with chronic anal fissure were treated by whether open lateral internal sphincterotomy (group 1) or chemical sphincterotomy with 25 U botulinum toxin injected into the internal sphincter (group 2). Clinical and manometric results were analyzed. Results Overall healing was 92.5% in the open sphincterotomy group and 45% in the toxin botulinum group ( P <.001). There is a group of patients with clinical (duration of disease >12 months and presence of a sentinel pile before treatment) and manometric factors (persistently elevated mean resting pressure, % of time presence of slow waves, and number of patients or the time presence ultra slow waves after treatment) associated with a higher recurrence of anal fissure. The final percentage of incontinence was 5% in the open sphincterotomy group and 0% in the botulinum toxin group ( P > .05). Conclusion We recommend surgical sphincterotomy as the first therapeutic approach in patients with clinical and manometric factors of recurrence. We prefer the use of botulinum toxin in patients older than 50 years or with risk factors for incontinence, despite the higher rate of recurrence, since it avoids the greater risk of incontinence in the surgical group.

Controlled Lateral Sphincterotomy for Chronic Anal Fissure

This study assessed the usefulness of "controlled" lateral sphincterotomy for chronic anal fissures. Of 225 patients with chronic anal fissure, 110 underwent traditional sphincterotomy to the level of the dentate line, and 115 underwent controlled sphincterotomy in three steps according to the degree of anal stenosis. In Step 1, the internal sphincter was divided to the proximal level of the fissure. If the anal canal was still stenosed, the division was extended to the level of the dentate line in Step 2. Step 3 was a bilateral internal sphincterotomy. The anal stenosis was evaluated under anesthesia using a new conical calibrator scaled in 1-mm diameter increments. Forty adults without anorectal disease were examined as controls. In a telephone follow-up, 102 patients in the traditional sphincterotomy group and 106 patients in the controlled sphincterotomy group responded. The normal group measured 34.6 +/- 1.4 mm (mean +/- standard deviation). Confounding effects of age, gender, body weight, and height were not significant. Based on the anal caliber measured in the normal group, anal stenosis is present with values of 31 mm and below (mean--2SD of the control value). Of 115 patients in the controlled sphincterotomy group, 90 (78 percent) underwent sphincterotomy below the level of the dentate line, 18 (16 percent) underwent sphincterotomy to the level of the dentate line, and 7 (6 percent) underwent bilateral sphincterotomy. None had incontinence of feces or leakage of stool. Ten of 102 patients (10 percent) in the traditional sphincterotomy group and 2 of 106 patients (2 percent) in the controlled sphincterotomy group complained of minor incontinence, such as gas incontinence, minor staining, or urgency (P = 0.017). There was one recurrence in the traditional sphincterotomy group. Controlled lateral sphincterotomy could be a way of overcoming the risk of incontinence with lateral internal sphincterotomy for chronic anal fissure.

Fecal incontinence 1,2

Fecal incontinence 1,2

Fecal incontinence after minor anorectal surgery.

Fecal leakage after open lateral internal anal sphincterotomy for chronic anal fissure is common, but underreported. The aim of this study was to prospectively assess the physiologic and morphologic effects of sphincterotomy, comparing continent and incontinent patients after surgery. This group was further compared with an unselected group of patients presenting with incontinence after hemorrhoidectomy. Between January 1997 and June 1999, 23 patients were prospectively followed up through internal sphincterotomy with conventional and vector volume anorectal manometry, parametric assessment of the rectoanal inhibitory reflex, and endoanal magnetic resonance imaging. Fourteen continent patients were compared with 9 incontinent postoperative cases, 9 patients referred with incontinence after hemorrhoidectomy, and 33 healthy volunteers without anorectal disease. Significant differences were noted between continent and incontinent postsphincterotomy cases for all resting conventional and vector volume parameters and for some squeeze parameters. Although there was a significant reduction in postoperative high pressure zone length at rest, there were no differences between the postoperative groups. There was an increase in sphincter asymmetry of 6.7 percent (+/- 3.5 percent) in incontinent postsphincterotomy patients and a decrease of 2.8 percent (+/- 3.2 percent) in continent cases. Significant differences were noted for resting parameters between incontinent postsphincterotomy and posthemorrhoidectomy patients, with a higher resting sphincter asymmetry in the latter group. The area under the rectoanal inhibitory curve was smaller in postsphincterotomy incontinent patients when compared with continent cohorts over the distal and intermediate sphincter zones at rest with a reduced latency of inhibition. There was no difference in the magnetic resonance images of the sphincterotomy site between incontinent and continent postsphincterotomy cases and no posthemorrhoidectomy case had evidence of sphincteric damage. There are complex significant differences in the postoperative physiology of patients undergoing lateral internal sphincterotomy who become incontinent when compared with those who maintain continence. These physiologic changes are not reflected in detectable morphologic sphincteric differences. It is unknown whether these changes predict for long-term incontinence, and it is suggested that postoperative incontinence after minor anorectal surgery is not necessarily related either to a preexisting sphincter defect or inadvertent intraoperative sphincter injury.

Topical diltiazem ointment in the treatment of chronic anal fissure.

Chronic anal fissure has traditionally been treated surgically. Initial enthusiasm for chemical sphincterotomy has waned because of poor outcomes with glyceryl trinitrate ointment. In this study the use of topical 2 per cent diltiazem ointment has been investigated as an alternative method of chemical sphincterotomy. A prospective assessment of 71 consecutive patients with a chronic anal fissure treated with 2 per cent topical diltiazem ointment for a median duration of 9 (range 2--16) weeks was performed. Fifty-one patients (75 per cent) experienced healing of the fissure after 2--3 months of treatment with topical diltiazem. Seventeen patients who did not heal were treated for a further 8 weeks with topical diltiazem. Eight of these patients subsequently healed with diltiazem. Fifty-nine of 67 patients who completed follow-up therefore healed on diltiazem ointment. Four patients experienced perianal dermatitis and one patient experienced headaches. No other side-effects were recorded. After a median of 32 (range 14--67) weeks' follow-up following completion of treatment, 27 of 41 patients available remain symptom free. Six of seven patients with recurrent fissure were treated successfully by repeat chemical sphincterotomy. Topical 2 per cent diltiazem ointment used as an agent for chemical sphincterotomy for chronic anal fissure offers significant healing rates but does not have a significant side-effect profile, which may aid compliance to treatment. Early recurrences are common but usually amenable to further chemical sphincterotomy.

Faecal incontinence after internal sphincterotomy for anal fissure

Minor defects in continence following open lateral sphincterotomy are relatively common. This study prospectively assessed 28 patients undergoing lateral sphincterotomy for chronic anal fissure. There were substantial differences in both resting and squeeze anal pressures and vector volumes in the incontinent cohort when compared to the continent post-operative cases. Mean preoperative high pressure zone was 37.6 mm, significantly higher than the postoperative value of 17.0 mm (p < 0.001). There was a significant difference in percent asymmetry of the anal canal at rest between incontinent and continent post-sphincterotomy cases, with a 6.7% increase in the former group and a 3.1% fall in the latter group (p < 0.001). It is unknown whether these changes are predictive for long-term continence.