Treatment Of Chronic Anal Fissure Research Articles

Anal fissure and lateral internal sphincterotomy

Anal fissure has a very large number of treatment options. The choice is difficult. To assist in this choice, presented herein is a summary of a systematic review and meta-analysis of all published treatments for anal fissure that have been studied in randomized controlled trials up through 2016. The review is divided into those studies that compared two or more surgical procedures and those that had at least one arm that was nonsurgical. Studies were further categorized by the specific interventions and comparisons. The outcome assessed was the inverse of sustained cure of the fissure, i.e., treatment failure. In addition, the harms of treatment assessed were headache and anal incontinence. Risk of bias was assessed for each study and the strength of the evidence of each comparison was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE). A total of 148 eligible trials were found and assessed, 31 in the surgical group (2606 patients) and 117 in the nonsurgical group (9456 patients). There were 14 different operations described in the surgical group and 29 different nonsurgical treatments in the nonsurgical group along with partial lateral internal sphincterotomy (LIS). There were 61 different comparisons. Of these, 47 were reported in two or fewer studies, usually with quite small populations. The largest single comparison was glyceryl trinitrate (GTN) versus control with 19 studies. GTN was more effective than control in terms of sustained cure (odds ratio = 0.68; 95% confidence interval = 0.63–0.77) but the quality of evidence was very poor due to severe heterogeneity and risk of bias due to inadequate clinical follow-up. The only comparison to have a high GRADE quality of evidence was a subgroup analysis of LIS versus any medical therapy, with outcome of treatment failure (0.12; 0.07–0.21) and mild incontinence (4.41; 1.97–9.87) assessed after at least 6 months from surgery. There were 12 studies in this analysis, the medical therapy being GTN in 6, Botox in 5, and calcium channel blocker (CCB) in 1. Most of the other analyses were downgraded in GRADE due to imprecision, i.e., too few or too small studies, and significant heterogeneity in almost all other comparisons with more than six studies. LIS is superior to nonsurgical therapies in achieving sustained cure of fissure with an increased risk of mild incontinence, usually meaning flatus. CCBs were more effective than GTN and had less risk of headache, but with only a low quality of evidence. Anal incontinence, once thought to be a frequent risk with LIS, was found in various subgroups in this review to have a risk between 3.4 and 4.4%. Among the surgical studies, manual anal stretch (Lord procedure) performed worse than LIS in the treatment of chronic anal fissure in adults. For those patients requiring surgery for anal fissure, open LIS and closed LIS appear to be equally efficacious, with a moderate GRADE quality of evidence. Most other GRADE evaluations of procedures were low to very low, due mostly to imprecision.

Safety and efficacy of the treatment of chronic anal fissure by lateral internal sphincterotomy: A retrospective cohort study

BackgroundAn anal fissure is one of the most common anorectal diseases resulting from a longitudinal tear in anoderm under the dentate line. It causes severe pain during defecation, and the resulting emotional stress leads to a reduction in the overall quality of life of a person. There are several medical and surgical treatment procedures that are employed to treat anal fissures. In the present retrospective study, we aimed to evaluate the safety and efficacy of lateral internal sphincterotomy (LIS) surgical procedure for the treatment of chronic anal fissure. Additionally, we also analyzed the complications arising after the surgery and the factors affecting the complications. MethodsThe present study is a retrospective study that included 691 patients treated for chronic anal fissure in a private sector setting, by a single Saudi female surgeon, starting from April 2004 to April 2020. ResultsOut of the 691 patients included in the study, all the patients were female, with an average age of 45.77 years (ranging from 17 to 82 years). Major complaints of the patients were as follows: pain, bleeding, constipation, pruritus, perianal discharge. Recurrence was reported in 2 patients (0.3%) while, 3 patients (0.4%) developed gas incontinence.The complaints of all patients with gas incontinence regressed over a period of time. ConclusionThis study reports that lateral internal sphincterotomy (LIS) is a safe surgical treatment for chronic anal fissure, leading to a reduction in recurrence, incontinence rate and substantially improves symptoms, especially pain.

Management options for chronic anal fissure: a systematic review of randomised controlled trials.

Anal fissure is the most common cause of severe anorectal pain in adults, contributing significantly to coloproctology workloads. There are a wide variety of management options available, including topical nitrites, calcium channel blockers, botulinum toxin injection and sphincterotomy. The aim of this study was to review current options for the treatment of chronic anal fissure. A comprehensive search identifying randomized controlled trials comparing treatment options for anal fissure published between January 2000 and February 2020 was performed. The primary outcome assessed was healing at 8 weeks post commencing treatment. Secondary outcomes included recurrence, intolerance of treatment and complications. A total of 2822 studies were identified. After removal of duplicates and non-relevant studies, we identified nine randomized controlled trials which met pre-defined criteria. There was a total of 775 patients. At 8 weeks, healing rates were 95.13% in those treated with sphincterotomy, 66.7% in the botulinum toxin group, 63.8% in the nitrate group, 52.3% for topical diltiazem and 50% for topical minoxidil. Recurrence was highest amongst those treated with botulinum toxin injection (41.7%) and lowest for sphincterotomy (6.9%). Although the absolute number is low, there was a risk of permanent incontinence with sphincterotomy. This review of the randomized control data demonstrates that healing was significantly higher amongst those treated with sphincterotomy versus more conservative modalities. Topical nitrites had similar outcomes to botulinum toxin injection but were poorly tolerated in comparison to other treatments. The benefit of sphincterotomy was at a cost of increased complications, notably permanent incontinence.

A Comparative Study of Conservative Management Vs Lord’s Anal Dilatation Vs Lateral Sphincterotomy in the Treatment for Chronic Anal Fissure

A Comparative Study of Conservative Management Vs Lord’s Anal Dilatation Vs Lateral Sphincterotomy in the Treatment for Chronic Anal Fissure

Evaluation of clinical effectiveness of topical 0.2% glyceryl trinitrate, topical 2% diltiazem and their combination in the treatment of chronic anal fissure

Background: The longitudinal tear or defect in the epithelial lining of the anal canal distal to the dentate line is called anal fissure. It is of two types: acute and chronic. The break in the cycle of pain, spasm and ischemia is essential for successful treatment of anal fissure. Among multiple non-surgical treatment approaches, the appropriate approach with good patient compliance might be the use of topical agents as chemical sphincterotomy. However, the effectiveness of these agents has not been evaluated widely.
 Objectives: To evaluate clinical effectiveness of topical 0.2% glyceryl trinitrate, topical 2% diltiazem and their combination in the treatment of chronic anal fissure.
 Methodology: The study was prospective comparative type including total 158 patients. Initially, they were given first line therapy followed by chemical sphincterotomy agents. The study drugs were given to 84 patients (three groups - 0.2% glyceryl trinitrate, 2% diltiazem and their combination) who were not healed after initial therapy. Patients were assessed for pain using visual analogue scale and other symptoms prior to and after two and six weeks of therapy.
 Results: Complete healing rate was higher with combination (92.86%) than individual agents. The reduction of visual analog scale score within each group and between the groups in the period between before and after treatment was found to be statistically significant. Headache and hypotension were the common side effects seen during study.
 Conclusion: Anal fissures can be successfully managed by chemical sphincterotomy. The topical nitrates and calcium channel blockers in combination are found to be effective choice rather than individual agents.

Symptomatic Efficacy of Aloe Vera 2% Cream in the Treatment of Chronic Anal Fissure

Symptomatic Efficacy of Aloe Vera 2% Cream in the Treatment of Chronic Anal Fissure

A Combined Topical Treatment versus Surgical Treatment in Chronic Anal Fissure

In the treatment of chronic anal fissure, both surgical and topical treatment methods are used. The purpose of this study was to research a combined topical treatment that we prepared and to compare the effectiveness of lateral internal sphincterotomy in chronic anal fissure with this topical treatment. A total of 183 patients with chronic anal fissure were divided into two groups. One hundred and four patients had topical medical treatment (group 1) and seventy-nine patients underwent lateral internal sphincterotomy (group 2). In the first group, a topical combination of ointments consisting of bacitracin-neomycin sulfate, dexpanthenol, and diltiazem was applied to the anal area. Four weeks after treatment, pain and bleeding during defecation, gas/fecal incontinence, treatment-related adverse events and recovery rates were evaluated in both groups. Also, patients were examined for recurrence between the 8th and 10th weeks. There was no significant difference in recovery rates between the groups. In group 1, recovery rate was 82.7%, while in Group 2 it was 92.4% (p = 0.054). In both groups, gas/fecal incontinence ratio was significantly different, supporting the medical treatment (p = 0.02). The severity of pain and bleeding during defecation were compared between the groups. Only the severe pain was significantly higher in the medical treatment group (p = 0.018). The recurrence rate was 5.8% in the medical treatment group, but no recurrence was detected in the surgical group. Due to possible complications of surgical treatment and similar recovery rates, medical treatment of patients with chronic anal fissure can be tried before surgical treatment.

BOTULINUM TOXIN TYPE A AND LATERAL SUBCUTANEOUS SPHINCTEROTOMY FOR CHRONIC ANAL FISSURE WITH THE SPHINCTER SPASM. WHAT TO CHOOSE? (systematic literature review and meta-analysis)

INTRODUCTION: for the treatment of chronic anal fissure, various surgical techniques are used, the main difference between which is the method of eliminating the anal sphincter spasm. One of the most serious postoperative complications is the development of anal incontinence. To date, there are a number of methods for drug-induced relaxation of the internal sphincter, which can significantly reduce the risk of developing anal incontinence after surgery.AIM: to evaluate the safety and effectiveness of botulinum toxin type A (BTA) and lateral subcutaneous sphincterotomy (LSS) in the treatment of chronic anal fissure with sphincter spasm.METHODS: a systematic review and meta-analysis of 7 selected randomized clinical trials comparing the results of treatment of chronic anal fissure using BTA and LSS was performed. The results of treatment of 489 patients were analyzed with an assessment of the following indicators: the incidence of epithelization of fissures, postoperative complications, development of anal incontinence and the disease recurrence. RESULTS: In the BTA group, the incidence of fissure epithelization is 0.88 times lower than in the LSS group (OR=0.12; CI=0.06;0.22; p<0.00001). There were no statistical differences in the rate of postoperative complications in both groups (OR=1.07; CI=0.50;2.30; p=0.85). The risk of developing postoperative anal incontinence is 0.86 times lower in the BTA group than in the LSS group (OR=0.14; CI=0.03;0.64; p=0.01). The risk of relapse after lateral subcutaneous sphincterotomy is 6.06 times lower than when using botulinum toxin type A (OR=6.06; CI=3.52;10.42; p<0.00001).CONCLUSION The use of botulinum toxin type A in the treatment of chronic anal fissure reduces the risk of developing postoperative anal incontinence, but this method is significantly inferior to lateral subcutaneous sphincterotomy in terms of the rate of chronic anal fissure epithelization.

Lateral internal sphincterotomy (LIS)—still top gun in chronic anal fissure treatment?

Anal fissure is one of the most common proctological complaints. If the fissure persists for more than 6–8 weeks, it is termed a chronic fissure and will most likely need surgical intervention. Surgical partial transection of the internal sphincter muscle, lateral internal sphincterotomy (LIS), is still seen as the gold standard procedure for chronic anal fissure in many parts of the world, especially in the Anglo-American community. In contrast, the German-speaking surgical community favors fissurectomy ± application of Botox, as some studies report high postoperative incontinence rates after LIS. This paper aims to give an overview of the literature on LIS and its outcomes and answer the question, “Is LIS still the gold standard surgical approach for chronic anal fissure?” A literature search for “sphincterotomy,” “internal sphincter,” and “anal fissure” was performed in PubMed. For the purpose of this overview article, randomized controlled trials (RCTs), meta-analyses, up-to-date guidelines, and retrospective cohort studies were taken into account. LIS produces excellent rates of fissure healing (~95%), quick symptom relief, and high patient satisfaction. Incontinence after LIS is mostly described as mild and transient. In the authors’ view, open LIS is therefore rightfully still the gold standard procedure for treatment of chronic anal fissure in the majority of patients. A conservative approach with limited division of internal sphincter muscle is preferred. For patients with preexisting sphincter weakness and an increased risk of incontinence, further preoperative diagnostic assessment (anal manometry, endoanal ultrasound) is recommended. In this high-risk group, alternative surgical options might be preferred.

Integrated Treatment Protocol with Dorsal Sphincterotomy and Local Application of Seethodaka Thaila in the Management of Parikarthika (Chronic Fissure in Ano)-A Pilot Study

The causes of anal fissure are not fully understood, but junk food, change or irregularity in diet and diet timings and also sedentary life style are some predisposing factors of ano rectal disorders. Anal fissure is second most common disease seen in Ano-rectal clinics. Modern surgical techniques like manual anal dilatation is advocated for fissure in ano, but it weaken the internal sphincter associated with risk of incontinence. Hence the proper and effective therapy is required for the treatment of chronic anal fissure which is simple, safe and effective, without any complication, avoidance of incontinence of stool and recurrence. Seethodaka thaila is Sri Lankan medicated oil widely used for treatment of aseptic wounds, burns and post-surgical wounds in Ayurveda. Material and Methods: Ten patients of chronic fissure in ano were treated with seethodaka thaila local application for postoperative wound, after fissurectomy and dorsal sphincterotomy, daily for 4 weeks. Results: Post-operative fissure wound healed within 4 weeks of time duration. The patients got complete relief of sign and symptoms after four weeks and no recurrence till one year. Conclusion: On the basis of this Pilot study, it is concluded that dressing with seethodaka thaila followed by fissurectomy and dorsal sphincterotomy is effective in wound healing.

Management of chronic anal fissures: a narrative review

Anal fissures are often encountered in surgical practice in both sexes. It is a distressing disease impacting quality of life and causes profound morbidity among those affected. If left untreated, it may lead onto perianal abscess or even malignancy in long standing cases. Surgery is the gold standard management for chronic anal fissures. Recently the widespread use of pharmacologic agents for chronic fissures has increased. The management of chronic anal fissures has migrated to an era of multifaceted approach. This narrative review looks into various studies spanning over a period of 16 years. Various articles were shortlisted and analyzed for efficacy of various treatment methods, their impact in hospital stay, quality of life improvement, recurrence rate and complications among various treatment methods. We concluded from this review, that open lateral internal sphincterotomy is still the gold standard method of treatment for chronic anal fissure. Among pharmacological agents, 2% diltiazem has the best effectiveness with good compliance rate. Modern surgical techniques like VY plasty can be reserved for special situations. We do not recommend the practice of manual anal dilatation.

Early Outcome of Open versus Closed Lateral Internal Anal Sphincterotomy in the Treatment of Chronic Anal Fissure

Background: Chronic anal fissure is a benign disorder that is associated with considerable discomfort. Surgical treatment in the form of lateral internal sphincterotomy has long been regarded as the gold standard of treatment. Two methods of sphincterotomy are currently practiced: open or closed technique.
 Objective: The objective of this study was to compare the early outcome of closed versus open lateral internal anal sphincterotomy for the treatment of chronic anal fissure, based on the assessment of post-operative pain and complications.
 Methods: A comparative study was conducted at the department of surgery in Dhaka Medical College & Hospital, over a period of 6 months from April 2015 to September 2015. A total of 80 patients were purposefully included in this study and were equally divided into two groups; Group A included 40 patients undergone closed lateral internal anal sphincterotomy and Group B included 40 patients undergone open lateral internal anal sphincterotomy. Patients were followed up postoperatively for 6 weeks to assess any complications. The outcomes were compared between the groups using the Chi-square (x2) test and Student's "t" test.
 Results: Delayed postoperative healing was found in 7.5% patients of the open lateral internal anal sphincterotomy group. The mean pain score and duration of hospital stay were lower in closed lateral internal anal sphincterotomy group.
 Conclusion: Closed lateral internal sphincterotomy is preferred to open technique in the treatment of chronic anal fissure, as it is effective, safe, less expensive, and is associated with low complication rate.
 Journal of Surgical Sciences (2018) Vol. 22 (1): 52-57

THE TREATMENT OF CHRONIC ANAL FISSURES WITH FISSURE EXCISION AND BOTULINUM TOXIN TYPE A INJECTION (ISRCTN97413456)

AIM: to assess the efficacy of botulinum toxin type A for chronic anal fissure.PATIENTS AND METHODS: the study included 80 patients randomized by random number generation in 2 groups. Forty patients underwent fissure excision in combination with injections of botulinum toxin type A into the internal sphincter (main group) and 40 – in combination with pneumatic balloon dilatation of the anal sphincter (control group).RESULTS: there were no statistically significant differences in the intensity of postoperative pain after defecation and during the day between the groups, p=0.45 and p=0.39, respectively. The groups were comparable in the complications such as perianal skin hematomas (p=0.84), external hemorrhoid thrombosis (p=0.1), urinary retention (p=0.46), long-term non-healing wounds (p=0.76). Transitory weakening of the anal sphincter was significantly more often in the control group. On day 30, the transitory anal incontinence in the main group was detected in 6 (21%), in the control group – in 18 (75%) patients, p=0.0002. On day 60, the weakness of the anal sphincter remained in the main group in 3 (10.7%), in the control group – in 10 (41%) patients, p=0.02.CONCLUSION: botulinum toxin type A and pneumatic balloon dilatation have equal effectiveness in the treatment of chronic anal fissure. The use of botulinum toxin type A can reduce the incidence of transitory weakening of the anal sphincter function in patients with chronic anal fissure.

Invited Commentary on: “Topical 5% Minoxidil versus topical 0.2% glyceryl trinitrate in treatment of chronic anal fissure”

Invited Commentary on: “Topical 5% Minoxidil versus topical 0.2% glyceryl trinitrate in treatment of chronic anal fissure”

Invited commentary on “Topical 5% minoxidil versus topical 0.2% glyceryl trinitrate in treatment of chronic anal fissure: A randomized clinical trial”

Invited commentary on “Topical 5% minoxidil versus topical 0.2% glyceryl trinitrate in treatment of chronic anal fissure: A randomized clinical trial”

Comparative efficacy of medical treatment versus surgical sphincterotomy in the treatment of chronic anal fissure.

Anal fissure which is defined as a longitudinal tear in anoderm below the dentate line is one of the most common benign diseases of anorectal area. Severe pain during the defecation and emotional stress that it causes may reduce people's quality of life. In this randomized clinical trial, we aimed to compare the efficiency of the topical ointment with medical treatment and surgical lateral internal sphincterotomy. This is a randomized clinical trial of 550 patients who were treated for chronic anal fissure. Patients were randomly divided into 4 groups according to the treatment type they received. In a vast majority of the patients, the primary complaint was pain (92.3%) and bleeding during defecation (62%). Both pain relief and healing of the fissure, which are the components of response to treatment, had not been observed in 56 (37.3%) patients of topical nitroglycerin ointment group until the second month. Among the recalcitrant patients in both topical nitroglycerin (56) and topical diltiazem ointment (47) groups, 27 (48.2%), and 36 (76.5%) patients underwent surgery, respectively. The best response to treatment was also obtained in lateral internal sphincterotomy group. LIS is still the gold standard for the treatment of chronic anal fissure when the physicians would like to avoid recurrence and obtain the best pain relief.

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.

Comparative Study to Assess the Effectiveness of Topical Nifedipine and Diltiazem in the Treatment of Chronic Anal Fissure.

Background:Chronic anal fissure is a common condition which is classically treated by surgery which may lead to incontinence. Recently medical treatment in form of calcium channel blockers (CCB) has gained interest.Aims:The aim of this study is to compare the effectiveness of local Nifedipine and Diltiazem with lignocaine as control. We also aimed to observe the clinical pattern of chronic anal fissure.Material and Method:Patients of chronic anal fissure were divided into three groups. First group received topical Nifedipine, second received topical Diltiazem, and the control group received only local lignocaine for 1 month. Their clinical data was recorded. The intensity of pain and bleeding was assessed from a visual analogue score (VAS). On the 4th week patients were examined for healing.Statistical Analysis:Statistical analysis was done by Medcalc statistical software v14. Student's t-test and Chi-square test was used accordingly.Results:Mean age was 35.89 with a male female ratio of 1.7:1. Most common clinical feature was pain (100%), followed by constipation, bleeding, and pruritus. Most common location was posterior. VAS scores for pain of the Nifedipine group and Diltiazem group was significantly better than control group (P < 0.0001). VAS scores for bleeding in the Nifedipine group (P = 0.0091) and Diltiazem group (P = 0.0045) was significantly better than control group. The healing rate for NFD group was 93.33% (P < 0.0001), that of DTZ group was 86.67% (P = 0.0002), which was statistically better than control group (36.67%). There was no significant difference between the two CCBs.Conclusion:Adding topical Nifedipine or Diltiazem in the treatment of anal fissure is far superior to treatment with only topical Lignocaine.

Topical diltiazem versus topical glyceryl trinitrate in the treatment of chronic anal fissure: A randomized clinical trial study

Topical diltiazem versus topical glyceryl trinitrate in the treatment of chronic anal fissure: A randomized clinical trial study

The Efficacy of Botulinum Toxin Injection Site in Chronic Anal Fissure Healing.

Chronic anal fissure is a common disease of the anoderm. Botulinum toxin injection has recently been recommended. However, the injection sites are still debatable. This study aimed to assess the site-dependent efficacy of Botulinum toxin injection for chronic anal fissure healing. Randomized clinical trial was performed, 80 patients were enrolled in two semi groups according to the site of botulinum toxin injection. Lateral sites of internal sphincter muscle were used in group 1, anterior and posterior regions were used in group 2 in lithotomy position. In this prospective study, the effect of injection site preference on the early complications (pain, infection, hematoma, incontinence) and late results (clinical fissure healing) of chronic anal fissure treatment were assessed. There was no statistical significant difference between the number of patients who achieved complete healing at the end of the 12th week. Postoperative pain scores were significantly lower in group 2 at the end of 1st week and they stayed lower at the end of the 2nd week. Thrombosed haemorrhoids were encountered significantly lower in group 2. Even though there was no statistical difference in the long term healing rate between groups 1 and 2, choosing 6 and 12 o'clock alignments of internal sphincter muscle for botox injection is more advantageous than 3 and 9 o'clock alignments in terms of better postoperative pain and lower complication rate in the early period.