slide1 l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Colorectal Surgical Society of Australia and New Zealand and Section of Colon and Rectal Surgery, Royal Australasian PowerPoint Presentation
Download Presentation
Colorectal Surgical Society of Australia and New Zealand and Section of Colon and Rectal Surgery, Royal Australasian

Loading in 2 Seconds...

play fullscreen
1 / 28

Colorectal Surgical Society of Australia and New Zealand and Section of Colon and Rectal Surgery, Royal Australasian - PowerPoint PPT Presentation


  • 497 Views
  • Uploaded on

Colorectal Surgical Society of Australia and New Zealand and Section of Colon and Rectal Surgery, Royal Australasian College of Surgeons. Spring Continuing Medical Education Meeting. October 2nd-5th 2007, McCracken Country Club Victor Harbor, South Australia.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Colorectal Surgical Society of Australia and New Zealand and Section of Colon and Rectal Surgery, Royal Australasian' - Samuel


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1

Colorectal Surgical Society

of Australia and New Zealand and Section of Colon and Rectal Surgery,

Royal Australasian College of Surgeons

Spring Continuing Medical Education Meeting

October 2nd-5th 2007,

McCracken Country ClubVictor Harbor, South Australia

International Visiting Speaker: Ronan O'Connell (Dublin)

introduction
Introduction
  • Chronic anal fissure
    • significant cause of morbidity
    • seen in up to 10% of patients presenting to colorectal clinics 1
    • 90% are located in the midline posteriorly 2

1 Pescatori MIA. Annual report of the Italian Coloproctolopgy units. Tech Colproctol. 1995; 3:29-30

2 Maria G, et al. A comparison of botulinum toxin and saline for the treatment of chronic anal fissure. N Engl J Med. 1998; 338: 217-20

pathogenesis
PATHOGENESIS
  • Tears to the anal canal that fail to heal.
  • Elevated resting anal pressures.
  • Local ischaemia of the posterior anoderm
  • Fewer arterioles in the posterior midline
  • Increased anal canal pressure exceeds the intraluminal pressure of arterioles
pathogenesis6
PATHOGENESIS
  • Fissure patients < blood flow in the posterior and anterior midline compared with controls
  • Following sphincterotomy < anal pressure with corresponding increase in blood flow to the fissure site.
lateral internal sphincterotomy
LATERAL INTERNAL SPHINCTEROTOMY
  • Improves blood flow to the posterior anoderm.
  • Fewer wound complications than posterior sphincterotomy.
  • Open or closed technique have healing rates of 90-100%
slide8

Ram et al

Annals of Surgery

August 2005 208-211

lateral internal sphincterotomy9
LATERAL INTERNAL SPHINCTEROTOMY
  • Incontinence rates: Variable
  • Lewis et al 17% 1988
  • Khubchandani & Reed 22% 1989
  • Hsu 0% (1750 pts) 1984
  • Ram et al 2% 2005
  • Mentes et al 1.2% 2006
glyceryl trinitrate gtn
GLYCERYL TRINITRATE (GTN)
  • Gel
  • Nitric Oxide donor
  • Smooth muscle relaxation of the IAS
  • Decrease in anal canal pressure 25-30%
  • Fissure healing rate of 50-70%
  • Recurrent fissure rates 50%
  • Adverse reaction rate 75%
glyceryl trinitrate gtn11
GLYCERYL TRINITRATE (GTN)
  • 65 patients : 31 (S) : 34 (GTN)
  • 8 weeks : 60% : 97% healing rate.
  • Poor tolerance and poor compliance
  • Faster healing with sphincterotomy
  • GTN 45% recurrence in 6 month followup
  • Conclusion: GTN is labour intensive for patient and physician has significant side effects and has been shown to be inferior to sphincterotomy in rate and efficacy of healing.
  • Evans J. Luck A. Hewett P. DCR 44: 93-97 Jan 2001
calcium channel blockers
CALCIUM CHANNEL BLOCKERS
  • Nifedipine or Diltiazem
  • Calcium channel blockers work by blocking L-type voltage gated calcium channels (VGCC). This prevents calcium levels from increasing as much in the cells when stimulated, leading to less contraction.
  • Relax IAS (RAP 36%)
  • Oral or gel (gel has better healing rates)
  • Healing rates of 60% @ 8 weeks
  • Less side effects (25%)
  • Compounding chemist
slide13

BOB THE ANAL FISSURE

www.zug.com/scrawl/analbob/

Uncontrolled anal dilatation has unacceptable levels of faecal incontinence and is less effective than sphincterotomy.1

Controlled dilatation has success

Rates of >90% with 2-9% incontinence rate2,3

1.Dis Colon & Rectum 13:67-76,2002

2.Dis Colon & Rectum 35:322-327,1992

3.BJS 86 : 651-655, 1999

botox
BOTOX
  • Botulinum toxin A
    • studies have suggested encouraging results 3-5
    • healing rates vary from 60-90% 3-5

3 Gui DC et al. Botulinum toxin for chronic anal fissure. Lancet. 1994; 344:1127/8.

4 Minguez M et al. Therapeutic effects of different doses of botulinum toxin in chronic anal fissure. Dis Colon Rectum. 1999; 42:1016-21.

5 Jost WH et al. One hundred cases of anal fissure treated with botulinum toxin: early and long-term results. Dis Colon Rectum. 1997; 40:1029-32.

mode of action 1
Mode of Action1
  • Blockade of sympathetic (noradrenaline mediated) neural output.
  • Postganglionic action involving a reduction in noradrenaline release at the neuromuscular junction.
  • No effect on nitregeric transmission.
  • 1. BJS 2004 Feb 91 (2): 224-8
slide17

A randomised prospective controlled trial of lateral internal sphincterotomy versus injections of botulinum toxin for the treatment of idiopathic fissure in ano.

H Iswariah, JH Stephens, NA Rieger, D Rodda, PJ Hewett

The Queen Elizabeth Hospital, South Australia

2:10pm Tuesday, 4 May 2004

slide18
Aims
  • To compare the short and long term outcomes of treatment of idiopathic fissure in ano via lateral internal sphincterotomy compared to injection with botulinum toxin.
procedure
Procedure
  • Lithotomy position
  • General anaesthesia

Sphincterotomy

    • open or closed
    • left lateral position

Botulinum injection

    • Botulinum toxin Type A (Botox® Allergan Australia Pty Ltd)
    • 20 units
    • either side of the fissure
    • into internal anal sphincter
randomisation

44 patients

38 patients

5 withdrew consent

1 lost to follow-up

17 Botox®

21 sphincterotomy

Randomisation
healing rates
Healing Rates

Chi-squared test

* p<0.05

† p<0.01

incontinence scores
Incontinence Scores

Values are mean (range). Student’s T-test & Paired T-test

pain scores
Pain Scores

Values are mean (range). Student’s T-test

* p<0.05

† p<0.01

‡ p<0.001

re operation
Re-Operation

Chi-squared test

† p<0.01

algorithm 1
Algorithm1
  • Topical treatment……. if fails
  • Botulinum toxin A (combine with topical agents)………..if fails
  • Lateral internal anal sphincterotomy
  • Avoid surgery in 88% of patients
  • Cost saving $10 : 528 : 1119 (125% reduction)
  • Continuing symptoms in 54% of patients ?social cost
  • QOL poor with ongoing or recurrent symptoms.
  • ( DCR 47:7 1045-1051)
conclusion
CONCLUSION
  • Lateral anal sphincterotomy remains the most efficient and effective treatment.
  • Delay in symptom relief worsens QOL and has an undisclosed cost
  • GTN topical heals 60% with significant side effects and at least 40% recurrence rate
  • Calcium channel blockers are as good with less side effects.
  • Botox is not effective but combination with a topical agent may improve its efficacy.
conclusion27
CONCLUSION
  • Realistic explanation of risks of sphincterotomy compared to efficacy of non surgical measures needs to occur for an adequate consent process
  • Timely intervention with failure of non medical treatments.
slide28

Colorectal Surgical Society

of Australia and New Zealand and Section of Colon and Rectal Surgery,

Royal Australasian College of Surgeons

Spring Continuing Medical Education Meeting

October 2nd-5th 2007,

McCracken Country ClubVictor Harbor, South Australia

International Visiting Speaker: Ronan O'Connell (Dublin)