Treatment Of Chronic Anal Fissure Research Articles

Hydrolytic stability of diltiazem in the presence of chosen polymers - Poloxamer 407 and Ammonio Metacrylate Copolymer Type B (Eudragit RS): а preliminary study

Introduction : The hydrolytic stability of the calcium channel blocker representative diltiazem hydrochloride in the presence of different polymeric entourage was quantitatively assessed using HPLC. Aim: The experiment was performed in order to establish drug-excipients compatibility in Poloxamer 407 hydrogel formulations, where the drug was introduced either by a direct (conventional) approach or in the form of Eudragit RS microsponge -type particles with sustained drug release. Materials and Methods : Samples of conventional diltiazem 2% hydrogel and microsponge -enriched diltiazem 2% hydrogel were stored at 25±2 o C for 10 months, protected from light. Analysis of the chemical decomposition rate of diltiazem hydrochloride to its desacetyl degradant - O - desacetyl - diltiazem hydrochloride - was performed in the period between 4 th and 10 th month of storage. Results and Discussion: It was hypothesized that a polymeric “shield” of Eudragit RS in the composition of diltiazem -loaded porous microspheres and/or the enhanced viscosity achieved by the addition of high-molecular gelling agent Poloxamer 407 to an aqueous drug dispersion will benefit the drug’s stability. Instead, a negative effect on the hydrolysis rate was found to be dominant for both polymers, likely due to an “unfavorable” shift in the dielectric conductivity of the media and/or suspected catalytic effect of quaternary ammonium groups of Eudragit RS . Conclusion : These preliminary results led us to a deeper understanding of the polymeric impact on diltiazem hydrolytic behavior and a very useful foundation for a future preformulation stage in the development of diltiazem modified-release semisolid forms for the treatment of chronic anal fissure.

Manual anal dilatation for the treatment of chronic anal fissures: our experience

Background: In this study we aim to present our experience in managing chronic anal fissures by manual anal dilatation in order to clarify whether this method is still viable in a modern surgical setup.Methods: A total of 55 patients who underwent manual anal dilatation for chronic anal fissures from March 2016 till March 2017 were studied prospectively.Results: 43 of the 55 patients were male and 12 were female (male: female=3.58: 1), aged between 20 to 60 years. The fissure was posterior at 6 o'clock position in 44 patients (80%) and anterior at 12 o'clock position in 8 patients (14.5%). Mean duration of hospital stay was 1.5 days. At the end of 6 weeks post op, only 37 patients (67.3%) were symptom free with the remaining 18 patients (32.7%) having complications. Among the complications, the commonest was ulcer persistence in 12 patients (21.8%). 3 patients had incontinence for flatus (5.5%), 2 had recurrence of ulcer (3.6%) and 1 had incontinence for faeces (1.8%). Mortality was 0%.Conclusions: Anal fissure is a common benign ano-rectal condition. Once chronicity is established, it is difficult to treat and almost always warrants surgical management. Although manual anal dilatation is a simple and easy procedure, it is associated with significant rates of complication. For long term definitive treatment, manual anal dilatation should be abandoned completely in favour of other surgical techniques like lateral subcutaneous sphincterotomy.

Treatment of Chronic Anal Fissure

Chronic anal fissure is a non healing ulcer in the anoderm appearing as a painful tear below the dentate line. There are debates about the efficacy of different treatment options for chronic anal fissure. This review aims to evaluate existing and newer treatment modalities. Aspects of chronic anal fissure aetiology and pathogenesis are also reviewed. Glyceryl trinitrate (GTN) ointment, Diltiazem ointment can be used as first line and Botulinum toxin (BTX) injection as second line pharmacological treatment. The effects of these chemicals are not permanent with higher fissure recurrence rates. Lateral internal sphincterotomy is the operative treatment of choice for fissures with high anal tone. Flap anoplasty should be done for fissures with normal anal tone especially in female patients. Both surgical procedures can be used as primary treatment option. The newer treatment options like gonyautoxin, controlled balloon anal dilatation, closed anal spand fissurotomy need more research. Perineal support device can be used as an adjunct to other treatment modalities.
 Journal of Surgical Sciences (2015) Vol. 19 (2) : 67-71

Results of tailored lateral sphincterotomy for chronic fissure in-ano

Background: Fissure-in-ano is one of the common and most painful anorectal conditions encountered in surgical practice. Inspite of several conservative treatment options, surgical treatment in the form of lateral anal sphincterotomy remains the gold standard of treatment for chronic anal fissure, however it is associated with the significant rate of incontinence. This study reviews using a tailored lateral sphincterotomy by selecting the height of internal sphincter to be divided with aim of preserving more sphincter and hence reducing the incontinence rates.Methods: The study was carried out in 50 patients who were diagnosed clinically as chronic anal fissure attending Surgery department of ESIC medical college and hospital, Kalburagi over a period of 6 months from January 2019 to August 2019. Tailored left lateral internal sphincterotomy was performed in all patients. The date was recorded and analysed. Early post-operative follow-up was maintained every week for four weeks or till the fissure healed. Complications mainly incontinence rate was assessed.Results: Common age group was third and fourth decade of life. Pain (100%) was the commonest symptom. Majority of the patients (96%) had posterior fissure. Postoperatively about 97% patients had complete pain relief. Only one patient (2%) in the study reported incontinence to flatus during the first follow-up visit and had minor incontinence and other minimal complications were found.Conclusions: Tailored lateral anal internal sphincterotomy is safe and effective surgical procedure for the management for chronic anal fissure with lower rate of incontinence rate compared to gold standard lateral internal sphincterotomy.

Treatment for Anal Fissure: Where do we stand in 2020?

Anal fissure is arguably the most painful common anorectal disorder. The severity of pain is disproportionate to the size of the lesion (often 8–10 mm located in the posterior midline of the anal canal). Numerous surgical procedures have been advocated but Lateral Internal Sphincterotomy (LIS) has become the standard of care and the procedure of choice. Due to concerns regarding fecal incontinence (FI) following LIS various chemicals have been applied to the anal canal in hope of finding an alternative “chemical” or “pharmacological sphincterotomy”. Large numbers of studies in the literature suffer from being non-randomized case series with short follow-ups and with variable outcome measures. In 2020, LIS is the most reliable treatment for chronic anal fissure associated with almost immediate pain relief, lasting results, a very low recurrence rate, and a very small rate of postoperative FI.

MANAGEMENT OF THE EARLY POSTOPERATIVE PERIOD AFTER SURGICAL TREATMENT OF CHRONIC ANAL FISSURES

Taking into account a high rate of unsatisfactory results of surgical treatment of chronic anal fissures (CAF), low quality of life and the need for postoperative (p/o) rehabilitation of such patients, the objective of the work was to improve the results of surgical treatment of CAF due to optimization of the early p/o period. We examined 68 patients with the CAF. In the main group during the p/o period since the 2nd day, the intratissue electrophoresis was performed from 3 to 5 times with «Dioxysol®-Darnitsa» solution with a current density of 0.05 mA/cm2, during 60 minutes, in the control group - standard methods of p/o treatment were used. The intensity of pain was significantly reduced from the third day after the operation in patients who had galvanization sessions since the 2nd day, as well as during the entire period of the early period, the pain level was always significantly lower than in the control group. If on the first day after the operation all patients needed anesthesia, and the majority of them received narcotic analgesics, on the third day only 4 (11.43%) of the patients in the main group received anesthesia contrary to all patients (100%) of the control group. On the fourth day, the main group did not require anesthesia, while in the control group 28 patients (84.85%) still had anesthesia. Assessing the p/o period and remote results of treatment, according to all criteria, the effectiveness of treatment tactics in the main group is higher. In particular, the relapse of fissures occurred in 2.32 times more often in the control group. In addition, it became possible to reduce the time of complete wound healing by 2.66 days. The use of intra-tissue electrophoresis in patients at the early p/o period after surgical treatment of CAF increases the effectiveness of treatment by 31%, improves the quality of life of patients by 1,2-1,3 times, promotes rapid recovery after surgery, reduces the frequency of early and late p/o complications.

Effect of topical nifedipine in treatment of chronic anal fissure

Effect of topical nifedipine in treatment of chronic anal fissure

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.

Comparative study of manual anal dilatation and lateral internal anal sphincterotomy in the treatment of acute anal fissure

Background: An anal fissure is an extremely common condition which is also one of the most painful condition. It can be very troubling because, if acute, the severity of patient discomfort and extent of disability far exceed that which would be expected from a seemingly trivial lesion. This study compares two most commonly done procedures for anal fissure, manual anal dilatation (MAD) and lateral internal anal sphincterotomy (LAS).Methods: This is a prospective cohort study comparing MAD and LAS in the treatment of chronic anal fissure at Sri Venkateswara Medical College, Tirupati, from December 2017 to December 2018. A total of 60 patients who met inclusion criteria were randomized to undergo either MAD or LAS and analyzed for post-operative pain, post-operative complications, hospital stay, recurrence rates and compliance.Results: Total 60 patients were randomized to MAD and LAS. The patients who have undergone LAS have better pain relief and slightly increased risk of infection. Those who have undergone MAD have less risk of infection and recurrence rates and complications are not significantly less than LAS.Conclusions:MAD and LAS are both equally effective and safe for treatment of acute anal fissure with less chances of recurrence. However postoperative pain was slightly more in MAD group.

Postero-lateral Internal Sphincterotomy vs Botulinum Toxin Injection in the Treatment of Chronic Anal Fissure: A Randomized Controlled Trial

Postero-lateral Internal Sphincterotomy vs Botulinum Toxin Injection in the Treatment of Chronic Anal Fissure: A Randomized Controlled Trial

Topical diltiazem versus topical glyceryl trinitrate in the treatment of chronic anal fissure: a prospective comparative study

Background: Acute anal fissure (AAF) heals spontaneously with conservative line of treatment. Chronic anal fissure (CAF) needs either traditional surgical lateral sphicterotomy or chemical sphincterotomy with topical agents. The present study aims at the effectiveness of topical diltiazem (DTZ) cream over topical glyceryl trinitrate (GTN) ointment in the treatment of chronic anal fissure.Methods: A total of 100 patients with CAF were included in this comparative prospective study conducted in Rajarajeswari Medical College and Hospital Bengaluru from July 2017 to December 2018. Eligible patients were randomly assigned to one of the two treatment groups of 50 patients each and were advised to apply 2% DTZ cream or 0.2% GTN ointment by fingertip to the anal verge twice daily for 8 weeks. The results were analysed and compared on two weekly intervals to know the effectiveness of treatment. P value of <0.05 is considered to be significant.Results: Complete healing of the fissure occurred in 80% of the patients in DTZ group against 76% in the GTN group by the end of 6 weeks (p>0.05, statistically not significant). Mild headache was experienced by 14% of the patients in the DTZ group, while 46% of the cases in the GTN group reported about the same (p<0.05 statistically significant).Conclusions: Topical 2% DTZ appeared to be well tolerated and effective preferred first-line method of chemical sphincterotomy with less side effects for chronic anal fissure.

Outcomes of the Use of CO2 (Carbon Dioxide) Laser in the Treatment of Chronic Anal Fissure

Outcomes of the Use of CO2 (Carbon Dioxide) Laser in the Treatment of Chronic Anal Fissure

Closed Lateral Internal Anal Sphincterotomy Under Local Anesthesia for Treatment Of Chronic Anal Fissure: Our 10 Years Experience

Background: Chronic anal fissure is one of the most frequent proctological disorders worldwide. Closed Lateral Internal Sphincterotomy (LIS) is one of the therapeutic options accepted as the treatment of choice for Chronic Anal Fissure (CAF) as it reduces the hypertonia of the internal anal sphincter, decreases anal pain, and allows the fissure to heal. LIS can be done under general anesthesia or local anesthesia. Aim of this study was to see the post operative outcome of closed LIS done under local anaesthesia. Materials and methods : This retrospective study was conducted in Department of Surgery of Chattogram Medical College hospital and some private hospitals of Chattogram city from January 2008 to December 2017. Total 550 patients of CAF who underwent closed LIS under local anesthesia were included. Atypical fissures associated with other disease were excluded. Results: The mean duration of hospital stay was 3.38 ± 1.2 hours. Sentinel skin tag was excised in 296 patients. The fissure was posterior in 73.63% patients and anterior in 7.81% patients. Recurrence was noted in 1.3% patients within four months. 63.27% patients experienced normal continence except occasional lack of fecal control postoperatively and only one patient developed gross incontinence of solid and liquid stool. Conclusion : This study concluded that closed LIS under local anaesthesia is the procedure of choice for management of CAF as it is cost effective and time saving.
 JCMCTA 2018 ; 29 (2) : 53-56

Comparison of Open Versus Closed Lateral Internal Sphincterotomy in the Management of Chronic Anal Fissure

An anal fissure is a longitudinal split in the anoderm of the distal anal canal, extending from the anal verge proximally towards, but not beyond, the dentate line. Various surgical methods of treatment of chronic anal fissure (CAF) are available, including anal dilatation, fissure excision, fissure excision with sphincterotomy, open lateral anal internal sphincterotomy and closed lateral anal internal sphincterotomy. This prospective study compared the results and complications of the open and closed techniques of lateral internal anal sphincterotomy in patients with CAF. A total of 60 patients with CAF were enrolled in this study, of which 30 underwent open lateral sphincterotomy and 30 underwent closed lateral sphincterotomy. Post-operative complications (pain, bleeding, constipation, perianal abscess, incontinence) were compared between the two groups. Postoperative pain, bleeding, and constipation were significantly less in the group undergoing closed surgery (p > 0.05). Perianal abscess and incontinence did not occur in any study subject. Closed lateral anal sphincterotomy is the treatment of choice for CAF. It can be performed effectively and safely, with a low rate of complications and a reduced cost burden.

Evaluation of the results of patients who had undergone lateral internal sphincterotomy due to chronic anal fissure: analysis of 281 cases

Introduction and purpose: Pharmacological and surgical treatment options are available for the treatment of chronic anal fissure (CAF). Pharmacological treatments include treatment modalities such as glyceryl trinitrate, calcium channel blockers and alpha-adrenoreceptor antagonists. Surgical treatment options include anal dilatation and sphincterotomy, and among many sphincterotomy procedures open lateral internal sphincterotomy (open LIS) is now considered the gold standard. The aim of this study was to investigate the demographic data, complaints, early and late complications of patients who have undergone LIS due to chronic anal fissure and to contribute to the literature. Material and method: Data of 281 patients who have undergone open LIS operation between 2013-2018 due to chronic anal fissure that did not respond to conservative treatment were analyzed retrospectively. Age, gender, complaint (pain, bleeding, constipation, itching), follow-up period and postoperative complication (infection, bleeding, pain, fistula, gas or stool incontinence) data of the patients were evaluated retrospectively. Patients with gas or fecal incontinence were evaluated with Wexner incontinence score. Results: Out of 281 patients, 197 were female (70.1%), 84 were male (29.9%). Female / male ratio was 2.34. The mean age was 40.31 ± 13.59 (min 18-max 84) years. The mean follow-up period was 24.53 (min 6 - max 67) months. In 248 (88.3%) patients, pain was noted during defecation, while bleeding was noted in 208 (74%) patients, constipation was noted in 133 (47.3) patients and perianal itching was noted in 91 (32.4%) patients. In 7 (2.5%) patients, infection occurred at the site of operation. Perianal fistula was seen in one patient (0.4%), recurrence was seen in 12 (4.3%), transient gas incontinence was seen in 4 (1.8%) and fecal incontinence was seen (0.35%) in 1 patient. Seven patients who had developed infection responded to oral antibiotic treatment and none of them developed abscesses. Result: As a result, open LIS operation is an efficient and effective surgical treatment method for the treatment of CAF.

Combined mucosal advancement and lateral internal sphincterotomy in treatment of chronic anal fissure: could be an effective alternative procedure?

Background: Chronic Anal Fissure (CAF) is a common anal problem. Lateral Internal Sphincterotomy (LIS) is the recommended treatment when conservative treatment fails, however it has its drawbacks. On the other hand, Anal Advancement Flap (AAF) may help in some cases. In this study, we tried to combine both techniques to evaluate the outcome of this dual procedure.Methods: This prospective study was conducted on one hundred patients with chronic anal fissure who were divided randomly into two groups group (A) LIS, group (B) the combined technique. Both groups were compared regarding, pain and constipation prior to treatment and at 1, 2, 4, 6 weeks post-operative using Visual Analogue Scale (VAS) and Wexner constipation score at 6weeks in addition to timing of complete fissure healing.Results: Both groups were comparable preoperatively regarding demographic data, pain score, constipation score but post-operative group B has achieved an earlier significant decrease in pain score, (1.7±0.65 vs 4.4±1.1) at 1st week (P<0.001) and (1.5±0.55 vs 3.3±1.04) at 2nd week also (P<0.001). In addition to a superior healing rate (96% vs 76%) at 4th week (P=0.009) with non-significantly longer operative time or complication rate.Conclusions: The combined technique of mucosal advancement and LIS can achieve a superior outcome compared to the traditional LIS in the treatment of CAF regarding faster healing rates with marked decrease in early post- operative pain and by far earlier return to normal life habits.

A Randomised Study Comparing Topical Glyceryl Trinitrare, Anal Dilatation and Lateral Sphincterotomy for the Treatment of Chronic Anal Fissure

A Randomised Study Comparing Topical Glyceryl Trinitrare, Anal Dilatation and Lateral Sphincterotomy for the Treatment of Chronic Anal Fissure

Anoplasty with skin tag flap for the treatment of chronic anal fissure.

to evaluate the long-term results of the correction of chronic anal fissures (CAF) in patients without anal hypertonia using the technique of anoplasty with skin tag flap. we conducted a prospective study of CAF patients refractory to conservative treatment without anal hypertonia, subjected to anoplasty with the use of anal plicoma to cover the bloody area. We confirmed the absence of anal hypertonia through rectal exam and electromanometry. We applied a visual pain questionnaire and the Cleveland Clinic fecal incontinence score before and after surgery. we followed 15 patients with chronic anal fissure for a mean period of 29 months (12-56). The mean age was 41 years (29-69) and the duration of symptoms ranged from six months to five years. Healing occurred between three and six weeks for 13 patients (86.7%). The other two patients underwent debridement and new anoplasty successfully. No plicoma necrosis or anal stenosis occurred in any patient. The anal incontinence score did not change after the procedure, and all patients reported reduced pain. After 12 months of follow-up, none of the patients presented recurrence or anal incontinence, and 93.3% (14/15) of the patients were very satisfied. fissurectomy and anoplasty with the use of sentinel plie is a safe technique that results in improvement in pain without change of fecal continence and with high satisfaction rates.

Comparative Study of Chemical Sphincterotomy and Lateral Internal Sphincterotomy for Chronic Anal Fissure

Introduction Fissure-in-ano is a very common problem which causes considerable morbidity and affects the patient's quality of life to a great extent. This warrants prompt treatment of the condition with appropriate methods. In this study, we assess and compare the efficacy and adverse effects of topical application of 2% Diltiazem gel with that of Lateral internal sphincterotomy. Method 100 patients with chronic fissure in ano were divided into Diltiazem gel and Lateral internal sphincterotomy groups and followed up at regular intervals for symptomatic relief and healing. Results Fissure was completely healed in 42 (89.36%) out of 47 patients by 8 weeks in the Diltiazem group, 3 patients experienced mild headache, 2 local irritation, 13 patients were pain-free at the end of 4 weeks, 26 patients were 8 weeks and 3 patients by 14 weeks. 5 patients were not relieved of pain at the end of 14 weeks. Completely healed in 48 (100%) out of 48 patients by 4 weeks in the Lateral Internal Sphincterotomy group.21 patients experienced post-operative pain and incontinence for flatus in 1 patient. 32 patients were pain-free by 4 weeks and all the patients were free of pain by 8 weeks. Conclusion The current study shows results in favour of lateral internal sphincterotomy with a healing rate of 100% with a faster pain-relief and minimal complications if performed by the experienced surgeon. However topical 2% diltiazem gel is an effective agent can be safely prescribed for patients having contraindications for surgery. With a healing rate close to 90%, topical 2% Diltiazem therapy can be advised as the first line of treatment for the treatment of chronic anal fissure.

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.