Current status of various treatment modalities in the management of Fissure-in-ano

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1. Current status of various treatment modalities in the management of Fissure-in-ano

2. Review Article Current status of various treatment modalities in the management of Fissure-in-ano Niranjan Agarwal General, Laproscopic & Colorectal Surgeon, Salasar Nursing Home, Bombay Hospital, India 1. Introduction Fissure-in-ano is a longitudinal tear or split in the skin covering the distal anal canal, below the level of the dentate line, overlying the lower half of the internal sphincter. It is characterized by pain at defecation, burning, itching, and streaks of fresh red blood over a hard stool.1 It can be acute fissure (<6 weeks duration) or chronic with secondary changes such as sentinel tag and hypertrophic papilla (>6 weeks duration).2 Management is based upon the presenting features and the chronicity of the disease. Fissures with specific causes such as IBD, TB, CA, etc. are dealt as per their etiology. Various options ranging from conservative approach to surgical management are described in the literature with their indication, complica- tion, and results explained. 2. Conservative measures They aim at relieving pain by relaxing the anal sphincter and include stool softeners, sitz bath, and local anesthetic. 80% of the acute fissures respond well to these measures itself. High dietary fiber intake as maintenance therapy has shown to decrease recurrence rates.3 Recurrence ranges from 30% to 70% if the high fiber diet is abandoned after fissure is healed. This rate is reduced to 15–20% if the patient remains continuously on high fiber diet. Hence, lifelong dietary modification is recommended. Warm water sitz baths promote healing by soothing the area and aid in relaxing the sphincter.4 Application of local anesthetic agents like Lignocaine Cream before the act of defecation and after it helps in relieving pain.5 Antibiotics, antiamoebic and anthel- mintics are prescribed in the case of infections. Conservative a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x a r t i c l e i n f o Article history: Received 13 July 2015 Accepted 28 July 2015 Available online xxx Keywords: Chemical sphincterotomy Lord's procedure Fissurectomy Defecation Anal Sphincterolysis a b s t r a c t Fissure-in-ano is a tear in the skin around the distal anal canal below the level of the dentate line, overlying the lower half of the internal sphincter. It is characterized by pain at defecation, burning, itching, and streaks of fresh red blood over a hard stool. It is mainly managed by relaxing the anal sphincter in addition to the use of stool softeners, local anesthetic, and intake of high dietary fibers. Chemical sphincterotomy agents act as pain relievers by relaxing the internal sphincter and are available mainly in ointment forms including nitrates and calcium channel blockers. Besides these, surgical treatment is intended in the patients who fail to respond by other methods. The surgical methods include Internal sphincterotomy, Fissurectomy, Lord's procedure, and other such methods, which are discussed briefly in this article. # 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights reserved. E-mail address: nda@salasarhospital.com. APME-310; No. of Pages 4 Please cite this article in press as: Agarwal N. Current status of various treatment modalities in the management of Fissure-in-ano, Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.07.014 Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/apme http://dx.doi.org/10.1016/j.apme.2015.07.014 0976-0016/# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights reserved.

3. therapy is safe, has few side effects, and should usually be the first step of therapy. 3. Chemical sphincterotomy agents They relieve pain by relaxing the internal sphincter and aid in the improvement of the local blood supply. They are available mainly in local ointment forms and include nitrates and calcium channel blockers. The healing rate described varies from 70 to 90% for different agents with acceptable side effect, the greatest advantage being preservation of the sphincter. They are, therefore, the modality of choice in patients where above conservative management fails before subjecting them to surgery. They can be used along with conservative management if the fissure is seen as progressing toward chronicity. a) Topical nitroglycerine (local application) is a nitrate donor and a vasodilator which relieves the spasm by release of Nitric Oxide from Glycerol Trinitrate metabolism at cellular level and improves local blood supply.6 It is available in both 0.2% and 0.4% concentrations and applied 2–3 times per day with a gloved finger for 8 weeks. With healing rates of 70–80%, it also decreases the recurrence rate by 50% compared to placebo.7 Increase in dose or method of application has not shown to improve the healing rate.8 Headache is the main side effect, which limits its use. Other effects are rebound hypertension, syncope, crescendo angina, and allergic dermatitis. b) Topical calcium channel blocker (diltiazem 2%) applied twice a day for 8 weeks has shown healing rate of 88% with lesser side effects as compared to GTN,9 which include headache, drowsiness, mood swings, and peria- nal itching. Oral diltiazem 60 mg has been found to be inferior to topical diltiazem (38%) with more side effects.10 c) Topical nifidepine (0.3%), also a calcium channel blocker, has shown healing in 94.5% cases. Oral nifidepine (20 mg twice a day for 6 weeks) shows lesser healing rate and higher side effects.11 d) Topical Bethenecol 0.1% application locally has shown to heal fissures in up to 60% without side effects.12 e) Botulinium toxin, an Acetyl Choline inhibitor, paralyzes the muscles thereby relieving the spasm. 10–100 units are injected on either side of fissure and/or in the bed of fissure in the internal sphincter.13 The exact dose, the number of repetitions, and the precise site are still debatable. Success rate of 60–80% has been reported after 2 months.14 It rises to 100% after 2nd injection.15 It can be done on an outpatient basis. Side effects such as heart block, skin allergy, increased residual urine, muscle weakness, postural hypotension with fluctuations in heart rate and blood pressure, and transient incontinence in 10% patients are described. f) Topical Sildenafil, a Phospodiasterase-5 (PDE5) inhibitor is available as 0.75 ml of 10% cream (75 mg) applied to anal canal from 1 ml pre-loaded syringe. Side effects are transient itching and burning in perianal area. 4. Surgical management It is indicated in patients who fail to respond or recurs after initial healing, those with severe unbearable pain, and the ones with complications or secondary changes. It ensures immediate relief and eliminates need for any further treat- ment. The main principles of fissure surgery are relieving of Internal Anal Sphincter spasm, reducing Maximum Anal Resting Pressure, correction of ischemia, and ulcer healing. Closed lateral sphincterotomy is presently the gold standard amongst various procedures described in the literature. 4.1. Internal sphincterotomy Division of the hypertrophied internal anal sphincter to release the spasm is done laterally in the right or the left quadrant depending on the comfort and handedness of the surgeon. Both closed and open methods are described without any significant difference in outcome,16 as far as the healing rate and incontinence are concerned. The open variety takes slightly longer time for surgery. Better done under general anesthesia for better assessment of sphincters, the individuals who undergo this surgery under local anesthesia show faster recovery but with higher incidence of recurrence.17,18 The posterior midline position to divide the sphincter at the base of the fissure is better avoided to eliminate the chance of a keyhole deformity with its consequences in 30% of the patients. The lower 1/3 of the internal sphincter is cut below the level of the dentate line, at a position between 3 and 5 o'clock. Evidence is split between classical long sphincter- otomy (up to dentate line) against tailored conservative sphincterotomy (up to the upper limit of the fissure).19 The sentinel tag and the polyp, if significantly large, may be excised, as the chance of spontaneous regression of the same in such cases is feeble. Lateral Internal sphincterotomy results in pain relief in 99% of the patients with a recurrence rate of 3%. The resultant incontinence is 6% for flatus and 1% for feces.20–22 The other complications of lateral anal sphincter- otomy are infections (1–2%), fistule (1%), echymosis, and hematoma. LIS is superior to posterior midline sphincter- otomy with faster healing, less pain, and less risk of incontinence.23 4.2. Fissurectomy Fissurectomy to excise the sentinel tag and hypertrophy papillae along with the chronically indurate edges of the non- healing wound alone leads to a large uncomfortable external wound, which takes nearly 4–6 weeks to heal. It should be always combined with a lateral sphincterotomy avoiding it at the tempting base for reasons described above.23 4.3. Anal dilatation or stretch (Lord's procedure) The simplest of anal fissure surgery requiring no special gadgets and still popular among many general surgeons is actually condemned now for the high rate of incontinence 12–27% of patients24 and other complications such as bleeding, perianal bruising, strangulation of prolapsed hemorrhoids, a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x2 APME-310; No. of Pages 4 Please cite this article in press as: Agarwal N. Current status of various treatment modalities in the management of Fissure-in-ano, Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.07.014

4. perianal infection, Fournier's gangrene, bacteremia, and rectal procidentia associated with it, though the pain relief may be complete and immediate. There is uncontrolled stretching and subsequent tearing of both the internal and external sphincter at various locations causing temporary paralysis of both the muscles. Recurrence rate of 6–7% has been observed. Sohn and colleagues (1992), described anorectal sphincter dilation with a Parks retractor opened to 4.8 cm or with a 40 mm balloon. The dilatations were sustained for exactly 5 min. The cure rates were 93% and 94%, respectively. Post-op assessment with endoanal ultrasound and anal manometry showed significant reduction in mean resting pressure (MRP). Contraindication to anal stretching includes short anal canal, Straight AR angle, Old age with lax sphincters, and large internal piles. 4.4. V-Y mucosal advancement flap It is indicated in low-pressure sphincters where sphincter- otomy is less beneficial10 e.g. obstetric related chronic fissure- in-ano. It can be done as a 2nd procedure if the initial wound of previous fissure surgery does not heal. 4.5. Internal Anal Sphincterolysis A procedure where the sphincter is fragmented by finger has shown 91% healing rate and 6% recurrence.25 Experience is limited with other interventions like con- trolled sphincterotomy using pneumatic dilatation, ablative procedures involving energy sources like cryotherapy, laser, radiofrequency, etc. 5. Recurrence Recurrence could be because of recurrent disease or incom- plete procedure (LIS). Medical treatment can be tried. If it fails, the patient should be evaluated by digital examination under anesthesia or endoanal ultrasound. If LIS was found incom- plete, it should be completed on the same side or can be done freshly on the opposite side. If initial sphincterotomy was complete, it can be repeated on the other side. 6. Specific causes Fissure with specific causes is treated by eliminating the underlined diseases. Conservative medical therapy is the treatment of choice. If it fails, LIS can be tried. Repeat surgical intervention may be necessary and rates of anal incontinence may be higher. Recent studies have shown benefits with conservative lateral anal sphincterotomy.26 Anal fissure in HIV patients may benefit from limited sphincterotomy.27 7. Associated pathologies 1. Anal stenosis – anoplasty with advancement flap along with LIS. 2. Grade I or II piles – LIS and sclerotherapy or rubber band ligation. 3. III degree piles – LIS and haemorrhoidectomy. Conflicts of interest The author has none to declare. r e f e r e n c e s 1. Zaghiyan KN, Fleshner P. Anal Fissure. Clin Colon Rectal Surg. 2011;24(1):22–30. 2. Madalinski MH. Identifying the best therapy for chronic anal fissure. World J Gastrointest Pharmacol Ther. 2011;2(2):9. 3. Jensen SL. Maintenance therapy with unprocessed bran in the prevention of acute anal fissure recurrence. J R Soc Med. 1987;80(5):296–298. 4. Dodi G, Bogoni F, Infantino A, et al. Hot or cold in anal pain? A study of the changes in internal anal sphincter pressure profiles. Dis Colon Rectum. 1986;29(4):248–251. 5. Gupta PJ. Treatment of fissure in ano- revisited. Afr Health Sci. 2004;4(1):58–62. 6. Kennedy ML, Sowter S, Nguyen H. Glyceryl trinitrate ointment for the treatment of chronic anal fissure: results of a placebo-controlled trial and long-term follow-up. Dis Colon Rectum. 1999;42(8):1000–1006. 7. Nelson RL, Thomas K, Morgan J, et al. Non surgical therapy for anal fissure. Cochrane Database Syst Rev. 2012;2:. CD003431. 8. Bailey Hr. Beck DE, Billingham RP, et al. A study to determine the nitroglycerin ointment dose and dosing interval that best promote the healing of chronic anal fissures. Dis Colon Rectum. 2002;45:1192–1199. 9. Knight JS, Birks M, Farouk R. Topical diltiazem ointment in the treatment of chronic anal fissure. Br J Surg. 2001;88 (4):553–556. 10. Jonas M, Neal KR, Abercrombie JF, et al. A randomized trial of oral vs. topical diltiazem for chronic anal fissures. Dis Colon Rectum. 2001;44(8):1074–1078. 11. Antrapoli C, Perrotti P, Robino M, et al. Nifedipine for local use in conservative treatment of anal fissure: preliminary results of a multicentre study. Dis Colon Rectum. 1999;42:1011–1015. 12. Carapeti EA, Kamm MA, Phillips RK, et al. Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects. Dis Colon Rectum. 2000;43 (10):1359–1362. 13. Minguez M, Melo F, Espi A, et al. Therapeutic effects of different doses of botulinum toxin in chronic anal fissure. Dis Colon Rectum. 1999;42:1016–1021. 14. Minguez M, Herreros B, Espi A, et al. Long-term follow-up (42 months) of chronic anal fissure after healing with botulinum toxin. Gastroenterology. 2002;123(1):112–117. 15. Brisinda G, Maria G, Sganga G, et al. Effectiveness of higher doses of botulinum toxin to induce healing in patients with chronic anal fissures. Surgery. 2002;131:179–184. 16. Wiley M, Day P, Rieger N. Open vs. closed lateral internal sphincterotomy for idiopathic fissure-in-ano: a prospective, randomized, controlled trial. Dis Colon Rectum. 2004;47 (6):847–852. 17. Casillas S, Hull TL, Zutshi M, et al. Incontinence after a lateral internal sphincterotomy: are we underestimating it? Dis Colon Rectum. 2005;48(6):1193–1199. a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x 3 APME-310; No. of Pages 4 Please cite this article in press as: Agarwal N. Current status of various treatment modalities in the management of Fissure-in-ano, Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.07.014

5. 18. Fleischer M, Marini CP, Statman R, et al. Local anesthesia is superior to spinal anesthesia for anorectal surgical procedures. Am Surg. 1994;60(11):812–815. 19. Garcea G, Sutton C, Mansoori S. Results following conservative lateral sphincteromy for the treatment of chronic anal fissures. Colorectal Dis Off J Assoc Coloproctology G B Irel. 2003;5(4):311–314. 20. Hyman N. Incontinence after lateral internal sphincterotomy: a prospective study and quality of life assessment. Dis Colon Rectum. 2004;47(1):35–38. 21. Saad AM, Omer A. Surgical treatment of chronic fissure-in- ano: a prospective randomised study. East Afr Med J. 1992;69 (11):613–615. 22. Brown CJ, Dubreuil D, Santoro L, et al. Lateral internal sphincterotomy is superior to topical nitroglycerin for healing chronic anal fissure and does not compromise long- term fecal continence: six-year follow-up of a multicenter, randomized, controlled trial. Dis Colon Rectum. 2007;50 (4):442–448. 23. Abcarian H. Surgical correction of chronic anal fissure: results of lateral internal sphincterotomy Vs fissurectomy- midline sphincterotomy. Dis Colon Rectum. 1980;23:31–36. 24. Isbister WH, Prasad J. Fissure in ano. Aust N Z J Surg. 1995;65 (2):107–108. 25. Gupta PJ. Internal anal sphincterolysis for chronic anal fissure: a prospective, clinical, and manometric study. Am J Surg. 2007;194(1):13–16. 26. Fleshner PR, Schoetz Jr DJ, Roberts PL, et al. Anal fissure in Crohn's disease: a plea for aggressive management. Dis Colon Rectum. 1995;38(11):1137–1143. 27. Abramowitz L, Benabderrahmane D, Baron G, Walker F, Yeni P, Duval X. Systematic evaluation and description of anal pathology in HIV-infected patients during the HAART era. Dis Colon Rectum. 2009;52(6):1130–1136. a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x4 APME-310; No. of Pages 4 Please cite this article in press as: Agarwal N. Current status of various treatment modalities in the management of Fissure-in-ano, Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.07.014

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