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Miklós Kassai MD EBSQ colo. Anal Fissure What? When? Why?. Anal Fissure. Acute fissure Paper cut Spontaneous healing likely Chronic fissure Undermined edges Sentinel pile Anal papilla Treatment needed Comes with increased anal tone. Medline search. Fissure in Ano Heading - PowerPoint PPT Presentation
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ANAL FISSURE WHAT? WHEN? WHY?
Miklós Kassai MD EBSQ colo
Anal Fissure Acute fissure
Paper cut Spontaneous healing likely
Chronic fissureUndermined edgesSentinel pileAnal papillaTreatment needed
Comes with increased anal tone
Fissure in Ano Heading1696 hits
Medline search
Anal resting pressure
Internal Anal Sphincter Physiology
The vicious circle of anal fissure
Microinjury
Pain
Increased anal tone
Ischaemia of the anoderm
Inadequate healing
Ulcer formation
Treatment Exclude other causes
IBD, HIV, Anal Ca Break the circle
Regulate bowel○ Fibre○ Fluid
Decrease pain○ Local anaesthetics
Decrease spasm○ Surgical interventions○ Chemical sphincterotomy
Surgical treatment
Surgical options
Anal dilatation Sphincterotomy Fissurectomy Advancement flaps
Anal dilatation 4 fingers 2-4 minutes Very effective, 90% healing rate Recurrence 2% - 57% Incontinence 50%
Multiple disruption of IAS Today it is obsolete
Jensen SL, Lund F, Nielsen OV, Tange G (1984) Lateral subcutaneous sphincterotomy versus anal dilatation in the treatmentof fissure in ano in outpatients: a prospective randomised study. Br Med J (Clin Res Ed) 289:528–530
Speakman CT, Burnett SJ, Kamm MA, Bartram CI (1991) Sphincter injury after anal dilatation demonstrated by analendosonography. Br J Surg 78:1429–1430
SphincterotomyPosterior Midline Posteriorly, in the fissure Effective, but Prolonged healing Keyhole deformity
Incontinence○ IAS defect○ Deformity
Nelson R (2005) Operative procedures for fissure in ano.Cochrane Database Syst Rev:CD002199
Sphincterotomy Lateral Internal Sphincterotomy Away from fissure Open – Close technique Partial division
To dentate line„Tailored” (Less incontinence)
Healing rates 95% Incontinence 0% - 50%
Gets better with timeDependent on follow up techniquesWomen are more at riskPreop US and manometry may be necessary
Fissurectomy Excision of the fissure
With or without closure Alone or in combination with
Botulinum toxinLocal Nitrates
Healing 90% - 100%But no RCTs!
Engel AF, Eijsbouts QA, Balk AG (2002) Fissurectomy and isosorbide dinitrate for chronic fissure in ano not respondingto conservative treatment. Br J Surg 89:79–83
Lindsey I, Cunningham C, Jones OM, Francis C, Mortensen NJ (2004) Fissurectomy-botulinum toxin: a novel sphinctersparing procedure for medically resistant chronic anal fissure.Dis Colon Rectum 47:1947–1952
Modified fissurotomy
Deroofing a narrow subcutaneous tractCaudal to the fissureProvides cleaning
Healing 92%
Pelta K, Davis K, Armstrong D (2007) Subcutaneous fissurotomy: a novel sphincter-saving procedure for chronic fissurein- ano. Dis Colon Rectum 50:738
Advancement flaps Skin graft Infection – failure Success in normal, low pressure cases Healing comparable to LIS Recommended in selected cases only
Nyam DC, Wilson RG, Stewart KJ, Farouk R, Bartolo DC (1995) Island advancement flaps in the management of anal fissures. Br J Surg 82:326–328
Internal Anal Sphincter Physiology
Non-surgical treatment Nitrates Ca channel blockers Neurotoxins L-Arginine K channel openers Alpha-1 adrenoceptor blockers Phosphodiesterase-5 inhibitors Angiotensine-converting enzyme inhibitors
Nitrates NO donors Relax smooth muscles Variable pharmacokinetics Effective both systemically and topical Prospective, randomised, double blind,
placebo controlled trial showed66% success in GTN arm8% in placebo arm
Initially 0.2%, now 0.4% ointment Works as dermal patch too
Lund JN, Scholefield JH (1997) A randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrateointment in treatment of anal fissure. Lancet 349:11–14
Nitrates Overall healing 66% - 91% Symptom free vs. healed Higher recurrence rate Side effect – Headache
Reported by placebo patients as well Many trials compared GTN with LIS
LIS slightly superiorBut incontinence
Ca channel blockers Nifedipine 0.2% - 95% Healing rate Diltiazem 0.2% - 75% Healing rate Oral treatment effective but
Side effects 60%○ Headaches○ Flushing○ Ankle oedema
Antropoli C, Perrotti P, Rubino M et al (1999) Nifedipine for local use in conservative treatment of anal fissures: preliminary results of a multicenter study. Dis Colon Rectum 42:1011–1015
Jonas M, Speake W, Scholefield JH (2002) Diltiazem heals glyceryl trinitrate-resistant chronic anal fissures: a prospective study. Dis Colon Rectum 45:1091–1095
Neurotoxins Inhibit neurotransmitters
Results in relaxation PRCT with saline Healing rate → → → → → Recurrence 55% at 3y Side effects
Incontinence Haematomas Infections Long term?
Botox Saline0
20
40
60
80 73
13
Maria G, Cassetta E, Gui D, Brisinda G, Bentivoglio AR, Albanese A (1998) A comparison of botulinum toxin andsaline for the treatment of chronic anal fissure. N Engl J Med 338:217–220
Non-surgical treatment Nitrates Ca channel blockers Neurotoxins L-Arginine K channel openers Alpha-1 adrenoceptor blockers Phosphodiesterase-5 inhibitors Angiotensine-converting enzyme inhibitors
What is the current guideline? ASCRS revised in 2004
Orsay C, Rakinic J, Perry WB et al (2004) Practice parameters for the management of anal fissures (revised). Dis Colon Rectum 47:2003–2007
PRODIGY revised in Nov 2005 CKS (2005) Anal Fissure (PRODIGY guidance). Clinical Knowledge Summaries
Service. ww.cks.library.nhs.uk/ anal_fissure
European clinicians in 2006 Lund JN, Nystrom PO, Coremans G et al (2006) An evidencebased
treatment algorithm for anal fissure. Tech Coloproctol 10:177–180