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Associate Professor Nick Rieger Adelaide University Department of Surgery http://www.colorectalsurgery.com.au
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Nitroglycerin, Botox or Sphincterotomy for Anal Fissure
Associate Professor Nick Rieger
Adelaide University
Department of Surgery
Aetiology ?
Trauma Sphincter spasm Ischaemia
Typical Anal Fissure
Treatment
Relieve Sphincter spasm
Alleviate ischaemia
Healing
How to relieve spasm?
• Mechanical - Sphincterotomy, Stretch
• Chemical - GTN, Diltiazem, Nifedipine
• Neurotoxic - Botox
Botox
• Botulinum Toxin A• Prevents release of acetylcholine by
presynaptic nerve terminals.• Lasts up to 3 months• Regrowth new axon terminals• Few side effects• Cost $400.00
GTN
• Glyceryl trinitrate
• NO2 donor (inhibitory neurotransmitter in the Internal Anal Sphincter)
• 3 applications per day for 6 weeks
• Headache (dose related)
• Efficacy 47 to 86%
Sphincterotomy
• Requires anaesthesia
• Day case admission
• Very effective (90-95%)
• Incontinence; may be minor (flatus, smearing) but can be permanent
• Up to 5% of patients (some studies quote more)
SphincterotomyDefine the IASOpen or Closed?Tailored?Debride the fissure?
Adelaide study 1
• GTN vs Sphincterotomy (RCT)Evans J, Luck A, Hewett P. DCR 2001
GTN (33 pt) vs LAS (27 pt)
Healed 8 Weeks 20/33 (61%) 26/27 (97%)
Recurrence 9 patients
Sphincterotomy 12 patients
Time to healing significantly faster for sphincterotomy
No incontinence reported
Adelaide study 2
• Open vs Closed Sphincterotomy (RCT)• Wiley M, Day P, Rieger N, Stephens J, Moore J. DCR 2004
• RCT 76 patients; 36 closed:40 open• 6 weeks 96% healed• Incontinence of any grade was seen in 6.8 percent
of patients at 52-week follow-up. Three patients (4.1 percent, 1 closed, 2 open) suffered major incontinence at 52 weeks.
Adelaide study 3• Botox vs Sphincterotomy (RCT)• 38 patients; 17 Botox® ; 21 sphincterotomy• Healing at 6 weeks 7/17 (41%); 18/21 (86%) P = 0.004*• Healing at 26 Weeks 7/17 (41%); 19/21 (91%) P < 0.001†• Of the 17 patients who were treated with Botox®, 9 required
reoperation (53%) within six months, as compared to 2 of 21 cases treated with sphincterotomy (9.5%).
• Eight of the nine Botox® “failures” were cured by sphincterotomy, while 1 continued to have symptoms. One patient who had healing of the fissure by Botox® treatment, had recurrence following a vaginal delivery, some 18 months following the procedure. This was treated by sphincterotomy.
• Botox group were found to have significantly higher two-week pain scores and re-operation rates,
• Continence scores were not significantly different in the two groups.
Literature
Meta-analysis: Nelson; DCR 2004 (Cochrane)• 31 trials• Medial therapy for chronic anal fissure, acute fissure
and fissure in children may be applied with a chance of cure that is only marginally better than placebo.
• For chronic anal fissure surgery more effective than medical therapy (OR=0.12, 95% CI, 0.07-0.22)
Management Considerations
• Crohn’s disease• Patient sex• Obstetric history• Patient age• Duration of symptoms• Prior treatment
Primary FissureWhat I do
• Explanation of treatment options
• Explanation of side effects
• Analgesia (local and systemic)
• Stool softeners
• GTN
• Failure or recurrence go to sphincterotomy
Recurrent Fissure after sphincterotomy
• GTN first line• Consider Botox• Anal ultrasound• Redo sphincterotomy
Other Alternatives?
• Fissure excision and primary closure
• Flap repair - V/Y flap
- Island flap
Incontinence Post Sphincterotomy
• Diet modification
• Physiotherapy
• Imodium
• Sphincter injection - PTP
- EVOH
Summary
• Sphincterotomy remains the best “curative” procedure for anal fissure (incontinence)
• GTN has a role in the initial management (failure and headache)
• Botox may be useful in selected patients (failure)
Conclusions
No perfect management for anal fissure
Informed consent paramount
Tailor the treatment to the individual
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