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TREATMENT OF ANAL FISSURES. ANAL FISSURE - DEFINITION. “ A crack or a tear in the vertical axis of the squamous lining of the anal canal between the anal verge and the dentate line “. Sentinel Skin Tag. Fissure. Anal Polyp. ACUTE FISSURE

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anal fissure definition
ANAL FISSURE - DEFINITION

“A crack or a tear in the vertical axis of the squamous lining of the anal canal between the anal verge and the dentate line “

Sentinel Skin Tag

Fissure

Anal Polyp

anal fissure classification
ACUTE FISSURE

Painful cleft in the anoderm exposing submucosa and possibly the internal sphincter

CHRONIC FISSURE

Anodermal cleft with scarred base and surrounding inflammation. Frequentlly seen with hypetrophied anal papilla and “sentinel pile”

ANAL FISSURE - CLASSIFICATION
anal fissure presentation
CHRONIC FISSURE

Deep indurated anal ulcer

Elevated, overhanging edges

Associated scarring

“Sentinel pile”+hypertrophied papilla

Visibile sphincter fibers

Rarely lateral

Less pain at defecationwith gradually decreasing intensity (lasts from minutes to several hours). No nocturnal

Pruritus

Blood on occasion

ACUTE FISSURE

Superficial without fibrosis

Flat edges

None (unless prior surgery)

None

Not always visible

May be lateral

Severe, sudden stinging sharp pain associated with defecation (lasts only a few minutes)

No pruritus

Blood usual, bright red, stains paper or drips into the toilet

ANAL FISSURE - PRESENTATION
anal fissure etiology
ANAL FISSURE - ETIOLOGY
  • Associated with passage of hard stool
  • Associated with sphincteric hypertone
  • ? Most common in posterior midline
  • ? Some heal spontaneously vs. become chronic
anal fissure pathogenesis
ANAL FISSURE - PATHOGENESIS
  • Abnormality of internal sphincter
    • High resting pressures
      • NO: Duthie & Bennet, 1964; Braun, Raguse & Dohrenbusch, 1986
      • YES: Northmann & Schuster, 1974; Hancock, 1977; Abcarian, 1982
      • DIGITAL EXAMINATION IS UNRELIABLE: Jones OM, Ramaligam T, Lindsey I, et al. Dis Colon Rectum 2005, 48:349-352
    • Abnormal reflex relaxation

in response to rectal distention

  • Ischemia
    • Posterior commissure is less perfused
      • Klosterhalfen B, Vogel P, Rixen H, et al. Dis Colon Rectum 1989; 32:43-52
      • Schouten WR, Briel JW, Aurweda JJA. Dis Colon Rectum 1994; 37:664-9
anal fissure differential diagnosis
Intersphincteric abscess

Pruritus ani

Crohn’s disease

Ulcerative Colitis

Tuberculous anal fissures

Syphilitic anal fissures

AIDS

Leukemia

Anal Malignancy

Previous surgery (hemorroidectomy, fistula-in-ano)

Childbirth

ANAL FISSURE - DIFFERENTIAL DIAGNOSIS
slide8

Men=Women

Posterior fissure most common

Anterior fissure most common inwomen (10%)

Both anterior and posterior (10%)

anal fissure treatment
ANAL FISSURE - TREATMENT

ACUTE FISSURE

MEDICAL TREATMENT

CHRONIC FISSURE

SURGICAL TREATMENT

conservative medical treatment
CONSERVATIVE MEDICAL TREATMENT
  • Correct precipitating cause (constipation, diarrhea)
  • Increased fluid
  • Sitz baths, bran, bulk laxatives
  • Topical Steroids
  • Local anesthetics
  • (solcoderm, sodium tetradecyulfate, anal dilators)

Effective in up to 50% of cases

(placebo in up to 35% of cases)

anal fissure conservative treatment
ANAL FISSURE - CONSERVATIVE TREATMENT

N = 103 patients

Jensen SL. BMJ 1986; 292:1167-1169

anal fissure new medical treatments
ANAL FISSURE - NEW MEDICAL TREATMENTS
  • NO Donors
    • Glycerin trinitrate-GTN; Isosorbide dinitrate-ISDN
  • Calcium Channel Blockers
    • Nifedipine, Diltiazem
  • Botulinum Toxin
  • Gonyautoxin

Reduce MRP - Increase microcirculation

medical treatment no donors glycerin trinitrate isosorbide dinitrate
MEDICAL TREATMENT - NO DONORS(Glycerin trinitrate - Isosorbide dinitrate)
  • Significant decrease in MRP
  • Effective at concentration from 0, 2% to 0, 5%
  • Immediate relief of pain that lasts for 2-6 hours
  • Healing 30% in 4-6 weeks, 86% in 3 months
  • Need for frequent application
  • Headache between 20 to 84% (commonly around 25%)
  • Discontinuation of therapy up to 20%
  • Recurrence rate up to 30%
medical treatment calcium channel blockers
MEDICAL TREATMENT CALCIUM CHANNEL BLOCKERS
  • Significant decrease in MRP
  • Healing from 65% to 95%
  • Side effects: headache (up to 25%), flushing, hypotension
  • Oral administration: lower healing rate, higher complications
  • Recurrence rate: up to 42 %
medical treatment botulin toxin
MEDICAL TREATMENT - BOTULIN TOXIN
  • Since 1993
  • Significant decrease in MRP (30%)
  • Two doses of 0,1 ml diluted toxin
  • Healing from 43% to 96%
  • Chemical denervation lasts 2 to 3 months
  • Transient incontinence: flatus 10-12%, stool 5%
  • Recurrence rate around 20%
  • Expensive
medical treatment gonyautoxin
MEDICAL TREATMENT - GONYAUTOXIN
  • Phytotoxin produced by microscopic planctonic algae
  • Stored in filter feeders like bivalves
  • Blocks the voltage-gated sodium channels in a reversible way
  • Two doses of 100 units (second one after 7 days)
  • Reduces both and MRP and MVCP
  • Immediate post injection sphincter relaxation and relief of pain
  • Healing rate: 98% in 28 days
  • Recurrence rate: ???
  • Further studies needed

Garrido R, Lagos N, Lattes K et al. Gonyautoxin: new treatmentfor healing acute and chronic anal fissures. Dis Colon Rectum 2005, 48:335-343

anal fissure surgical treatment history
ANAL FISSURE - SURGICAL TREATMENT HISTORY

1838 Recamier - Anal stretch

1835 Brodie

1892 Goodsall

1930 Gabriel

1934 Milligan & Morgan

1939 Miles - “pectenotomy” (division of “pecten band”)

  • Eisenhammer - open lateral internal sphincterotomy
  • Notaras - closed lateral subcutaneous internal sphincterotomy

sphincterotomy

fissurectomy

anal fissure surgical treatment
ANAL FISSURE - SURGICAL TREATMENT
  • Anal Dilatation
  • Fissurectomy and Posterior Sphincterotomy
  • Open Lateral Internal Sphincterotomy
  • Closed lateral Internal Sphincterotomy
  • Anoplasty (advancement flap, V-Y flap, rotational flap, etc.)
anal dilatation
ANAL DILATATION
  • Still popular in the UK (36% of surgeons)
  • Sphincter damage in > 50% of patients
  • Incontinence to flatus 12,5 - 28.6%
  • Major incontinence 2 - 7,1%
  • Soiling up to 39.3%
  • 4 fingers x 4 minutes
  • Parks retractor at 4.8 cm
  • Healing rates from 43/ to 94%
  • Recurrence rate:10 to 30%
fissurectomy posterior sphincterotomy
FISSURECTOMY-POSTERIOR SPHINCTEROTOMY
  • Cure rate : 93%
  • “Keyhole” deformity: 5%
  • Incontinence to flatus: 17-34%
  • Incontinence to feces: 3 -15%
  • Soiling up to 41%
  • Large external wound
  • Prolonged time for healing
  • Recurrence rate: 1,3 %

Gabriel WB , 1930

lateral internal sphincterotomy
LATERAL INTERNAL SPHINCTEROTOMY

OPEN - Eisenhammer S, 1951

CLOSED - Notaras MJ, 1969

lateral internal sphincterotomy22
LATERAL INTERNAL SPHINCTEROTOMY

No difference for persistence of symptoms, fissure recurrence or need for reoperation between open and close. Statistical significant difference for soiling of underwear (26,7% vs. 16,1%) and stool incontinence (11,8% vs. 3,1%). Almost significant for flatus incontinence (30,3% vs. 23,6%).

Garcia-Aguilar et al., 1996

No difference between the two methods.

Nelson RL, 1999

Boulous PB et al., 1984

Kortbeek JB et al., 1992

anal fissure treatment25
ANAL FISSURE - TREATMENT

“…Fully 45% of patients had some degree of fecal incontinence at some point after LIS. However, by one month after surgery, only 6% were incontinent to flatus. More importantly, 98% of patients were satisfied with the outcome of surgery, and < 1% of patients had their life affected by incontinence…”

Nyam DC, Pemberton JH, Dis Colon Rectum1999; 42:1306-10

lateral internal sphincterotomy26
LATERAL INTERNAL SPHINCTEROTOMY
  • Forceful anal dilatation is inferior to LIS owing to a higher recurrence rate with higher rates of incontinence

Olsen J et al., 1987

Weaver RM et al., 1987

  • LIS is superior to fissurectomy and posterior midline sphincterotomy owing to faster healing rates, less pain and less postoperative incontinence

Abcarian H, 1980

Saad AM et al., 1992

  • LIS is superior to anal dilatation and posterior midline sphincterotomy

Nelson R, 2004

anoplasty
ANOPLASTY

Advancement

Flap

V-Y Flap

Rotational Flap

anoplasty28
ANOPLASTY
  • Associated stenosis (mild, moderate, severe)
  • Usually postoperative (hemorrhoidectomy, fistulotomy)
  • In patients with normal or low MRP
  • In recurrences
  • V-Y flaps: 60-70% of donor sites break down and median healing time of 4 months (2 - 6)
  • Rotational flap: lower break down rate
  • No incontinence
  • A viable alternative to LIS

Leong AF, Seow-Choen F. Dis Colon Rectum 1995;38:69-71

Kenefick NJ, Gee AS, Durdey P. Colorectal Dis 2002; 4:463

Singh M et al. Int J Colorectal Dis 2005; 20:339-42

anal fissure personal survey 1993 2004
ANAL FISSURE PERSONAL SURVEY (1993-2004)

295 Pts Male:151 Female: 144

Mean FU: 96 mths (18-150)

Post.: 255 (87,5%) Ant.: 40 (13%) Both: 31(10%)

274 (93%) operated on under local anesthesia

Open LIS: 239 (81%)

Post. IS+Fissurectomy 5 (1,6%)

Advancement flap 27 (9%)

V-Y flap 23 (8%)

Rotation Anoplasty 1 (0, 4%)

Associated Excision 146 (50%)

Associated pathologies 211 (70%)

(hemorrhoids 62%; mucosal prolapse 19%; hemorrhoids+mucosal prolapse 11%; fistula-in-ano 1%)

anal fissure personal survey 1993 200430
ANAL FISSURE PERSONAL SURVEY (1993-2004)

LIS

Incont. Flatus: 21 (8,7%) Soiling: 11 (4,5%) Recurrence: 2 (0,6%)

Hematoma: 8 (3%); Perianal abscess: 1 (0,4%) ;

Thrombosed Hemorrhoids: 1 (0,4%) ; Hemorrage: 2 (0,8%)

Post. IS

1/5 not healed at 3 months (DTC); 1/5 Incont. Flatus+Soiling

Advancement Flap

6/27(22%) Ant.+Post. - 3/27 (11%) Breakdown - Healing T: 7,7 wks (2-40)

V-Y Flap

1 deceased - 15/22 (68%) Breakdown - Healing T: 6,5 wks (3-12)

anal fissure comparison of treatment
ANAL FISSURE-COMPARISON OF TREATMENT

Nelson R. Dis Colon Rectum 2004, 47 (4):422-431

anal fissure treatment32
ANAL FISSURE - TREATMENT

“…first line use of medical therapy cures most chronic anal fissures cheaply and conveniently…”

Lindsey I, Jones OM, Cunningham C, Mortensen NJ. Br. J. Surg 2004;91:279-9

“…medical therapy for chronic anal fissure may be applied with a chance of cure that is only marginally better than placebo… [and] far less effective than surgery…”

Nelson R. Dis Colon Rectum 2004;47:422-31

ascrs practice parameters
ASCRS PRACTICE PARAMETERS
  • Conservative therapy is safe, has few side effects, and should usually be the first step
  • Anal fissures may be appropriately treated with topical nitrates because they can relieve pain; however, nitrates are only marginally associated with a healing rate superior to the placebo
  • Anal fissures may be appropriately treated with topical calcium channel blockers, which seem to have a lower incidence of adverse effects than nitrates. There is insufficient data to conclude whether they are superior to placebo in healing fissures
  • Botulinum toxin injections may be used for anal fissures that fail to respond to conservative measures and have been associated with a healing rate superior to placebo. There is inadequate consensus on dosage, precise site of administration, number of injections or efficacy
ascrs practice parameters34
ASCRS PRACTICE PARAMETERS
  • Lateral internal sphincterotomy is the surgical treatment of choice for refractory anal fissures
  • Open and closed technique for LIS seem to yield similar results
  • Anal advancement flap is an alternative to LIS; further study is required
  • Surgery may be appropriately offered without a trial of pharmacologic treatment after failure of conservative therapy; patients should be informed about the potential complications of surgery
thank you for your attention
THANK YOU FOR YOUR ATTENTION!

“The one who knows much talks little. The one who talks much does not know”

Lao Tse