Anal Fissure

Anal fissure is a common condition, and although most are short-lived and heal spontaneously, those that persist and require intervention cause considerable morbidity in an otherwise healthy young population. Traditionally, lateral internal sphincterotomy was the gold standard treatment for chronic fissures, but this procedure is associated with a risk of incontinence to some degree in 30% of patients. The discovery of pharmacologic agents that effectively cause a chemical sphincterotomy and heal most fissures has led to approximately two thirds of patients avoiding surgery. Topical 0.2% GTN ointment probably is the most widely used first-line treatment. Other drugs currently under investigation may offer effective treatment with fewer side effects. Another advantage of these novel treatments is that by acting through different pathways, they may be effective in the 30% of cases in which GTN fails, the risks associated with surgery may be avoided. Studies of botulinum toxin injection into the anal sphincter have reported excellent healing rates, although the procedure is more invasive, and patients may find it uncomfortable and less tolerable. Chemical sphincterotomy is particularly suitable in patients with associated inflammatory bowel disease, in whom sphincterotomy for anal fissure generally is contraindicated. When pharmacologic therapy fails or fissures recur frequently and patients have raised resting anal pressure, lateral internal sphincterotomy is the surgical treatment of choice. The results are satisfactory when patients are selected carefully and the incision is limited to the length of the fissure. When chemical sphincterotomy fails and resting anal pressures are not elevated, as is commonly the case with patients developing fissures postpartum, an advancement flap should be considered.     

Randomised controlled trial shows that glyceryl trinitrate heals anal fissures, higher doses are not more effective, and there is a high recurrence rate

BACKGROUND: Topical application of glyceryl trinitrate (GTN) ointment heals chronic anal fissures, providing an alternative to the traditional first line treatment of surgical sphincterotomy. AIMS: To determine the most effective dose of topical GTN for treatment of chronic anal fissures and to assess long term results. METHODS: Seventy consecutive patients with chronic anal fissure, were randomly allocated to eight weeks treatment with placebo, 0.2% GTN three times daily, or GTN starting at 0.2% with weekly 0.1% increments to a maximum of 0.6%, in a double blind study. RESULTS: After eight weeks fissure had healed in 67% of patients treated with GTN compared with 32% with placebo (p=0.008). No significant difference was seen between the two active treatments. Headaches were reported by 72% of patients on GTN compared with 27% on placebo (p<0.001). Maximum anal sphincter pressure reduced significantly from baseline by GTN treatment (p=0.02), but not placebo (p=0.8). Mean pain scores were lower after treatment with GTN compared with placebo (NS). Of fissures healed with placebo 43% recurred, compared with 33% of those healed with 0.2% GTN and 25% healed with escalating dose GTN (p=0.7). CONCLUSIONS: GTN is a good first line treatment for two thirds of patients with anal fissure. An escalating dose of GTN does not result in earlier healing. Significant recurrence of symptomatic fissures and a high incidence of headaches are limitations of the treatment.     

Lateral sphincterotomy compared with anal advancement flap for chronic anal fissure

PURPOSE: This study was designed to assess differences between lateral internal anal sphincterotomy and anal advancement flap for chronic anal fissure. METHODS: Forty patients with chronic anal fissure were prospectively studied. Patients randomized to the sphincterotomy group (n=20; median age, 34 (range, 16–61) years) underwent lateral internal anal sphincterotomy. Patients randomized to the flap group (n=20; median age, 32 (range, 20–44) years) had an anal advancement flap. RESULTS: All fissures in the sphincterotomy group healed following surgery compared with three patients that failed to heal in the flap group (P = 0.12). No patient in either group was incontinent to any degree following surgery. Patient satisfaction with surgery was similar in both groups. CONCLUSION: Anal advancement flap is an alternative to lateral sphincterotomy for chronic anal fissure.     

Clinical, Manometric, and Ultrasonographic Results of Pneumatic Balloon Dilatation vs. Lateral Internal Sphincterotomy for Chronic Anal Fissure: A Prospective, Randomized, Controlled Trial

Purpose This prospective, randomized, controlled trial was designed to compare the clinical, functional, and morphologic results of pneumatic balloon dilatation with lateral internal sphincterotomy for the treatment of chronic anal fissure. Methods All patients with symptomatic chronic anal fissure were randomly assigned to pneumatic balloon dilatation or lateral internal sphincterotomy and invited to complete a standardized questionnaire inquiring about their symptoms. Anal ultrasonography and anal manometry were performed before and six months after surgery. A proctologic examination was performed between the fifth and sixth postoperative weeks. Anal continence, scored by using a validated continence grading scale, was evaluated preoperatively at 1 and 6 weeks and at 12 and 24 months. Results Fifty-three patients, who satisfied selection criteria, were enrolled in the trial. Four patients (7.5 percent) were lost to follow-up. Twenty-four patients (11 males; mean age, 42 ± 8.2 years) underwent pneumatic balloon dilatation and 25 patients (10 males; mean age, 44 ± 7.3 years) underwent lateral internal sphincterotomy. Fissure-healing rates were 83.3 percent in the pneumatic balloon dilatation and 92 percent in the lateral internal sphincterotomy group. Recurrent anal fissure was observed in one patient (4 percent) after lateral internal sphincterotomy. At anal manometry, mean resting pressure decrements obtained after pneumatic balloon dilatation and lateral internal sphincterotomy were 30.5 and 34.3 percent, respectively. After pneumatic balloon dilatation, anal ultrasonography did not show any significant sphincter damage. At 24-month follow-up, the incidence of incontinence, irrespective of severity, was 0 percent in the pneumatic balloon dilatation group and 16 percent in the lateral internal sphincterotomy group (P < 0.0001). Conclusions As lateral internal sphincterotomy, pneumatic balloon dilatation grants a high anal fissure-healing rate but with a statistically significant reduction in postoperative anal incontinence. Reprints are not available.     

Chronische Analfissur – Operative Behandlung mit Analdilatation, Exzision der Analfissur versus laterale Sphinkterotomie

Background: Up to now there are no prospective randomized trials to compare the results of operative treatment of chronic anal fissure by excision of the fissure and anal dilatation in comparison to additional internal lateral sphincterotomy.The aim of the investigation was to study the efficacy of the two different treatments in a prospective randomized trial. Patients and Methods: 60 patients with age of 17 to 77 years who did not respond to medical treatment (at least 8 weeks) subjected to operative treatment were assigned by randomization to two different groups, each group with 15 men and 15 women, mean age of 44,8 (17–72) vs 46,8 (22–77) years. Not included in the trial were patients with Crohn's disease, ulcerative colitis, anal stenosis, fecal incontinence,HIV-infection. Operative methods in group 1: anal dilatation and excision of the anal fissure, operative methods in group 2: anal dilatation, excision of the anal fissure and internal lateral sphincterotomy. Criteria for treatment: postoperative pain, amount of medication to relief pain, length of hospital stay, postoperative residual symptoms, anal resting pressure, postoperative fecal incontinence. Results: There were no complications like bleeding, urinary retention or infection immediately after the operations in both groups.There were no significant differences in both groups concerning the degree of postoperative pain after the first bowel movement (mean group 1: 2.5 vs group 2: 2.5), amount of medication to relief pain (tablets ibuprofen 400: median three vs 1.5) and the length of hospital stay (median 2 vs. 2 days). After a follow-up of 3 months there were no significant differences between the two treated groups.Wounds were healed in 22/30 cases (73%) after anal dilatation and excision of the anal fissure vs 24/30 cases (80%) after anal dilatation, excision of the anal fissure and additional sphincterotomy (p = 0.761). Occasional symptoms of pain, pruritus, bleeding persisted within 3 months postoperatively in 15/30 (50%) vs 11/30 (37%). The resting pressure was reduced from 85 mm Hg (median) to 75 mm Hg vs 92.5 to 77.5 mm Hg. Symptoms of minor fecal incontinence like discharge of flatus or soiling were noted in 3/27 (11%) in group 1 vs 6/30 (20%) in group 2 (p = 0.476). Conclusion: Rates of healing and complications are similar when chronic anal fissure is treated by anal dilatation and excision of the anal fissure compared to anal dilatation, excision of the anal fissure and additional internal lateral sphincterotomy. It is concluded that anal dilatation and excision of the anal fissure is sufficient to treat the chronic anal fissure.The is no need to do an internal lateral sphincterotomy which can lead to fecal incontinence.     

Histopathology of the internal anal sphincter in chronic anal fissure

A prospective study of 18 consecutive patients undergoing unilateral, partial-thickness, distal, internal sphincterotomy for the treatment of chronic anal fissure was performed. Biopsies were taken from the base of the fissure and from the lateral muscle before division. Normal specimens were taken from the internal anal sphincter of patients undergoing abdominoperineal resection. Specimens confirmed the presence of fibrosis throughout the internal anal sphincter in patients with anal fissures, but none in controls.     

Botulinum toxin injection versus lateral internal sphincterotomy for chronic anal fissure: a meta-analysis of randomized control trials

Background

Although surgery is the gold standard treatment for anal fissure, the main concern remains its side effects and complications. Botulinum toxin injection and lateral internal sphincterotomy are technical options for patients suffering from chronic anal fissure. However, little is known about the efficacy of these two techniques. The aim of this meta-analysis was to compare the outcomes of botulinum toxin injection versus lateral internal sphincterotomy for chronic anal fissure.

Methods

Original studies in English were searched from the MEDLINE database, PubMed, Web of Science, and the Cochrane Library database. Randomized control trials that compared botulinum toxin injection with lateral internal sphincterotomy were identified. Data were independently extracted for each study, and a meta-analysis was performed using fixed and random effects models.

Results

Four hundred and eighty-nine patients from seven trials met the inclusion criteria. Patients undergoing lateral internal sphincterotomy had a higher-healing and incontinence rate. No statistically significant differences were noted in total complications between botulinum toxin injection and lateral internal sphincterotomy. Patients treated with lateral internal sphincterotomy had a significantly lower recurrence rate than the patients treated with botulinum toxin injection.

Conclusions

Our meta-analysis shows that lateral internal sphincterotomy was superior to botulinum toxin injection in terms of healing rate and lower recurrence rate. Botox, however, is safe associated with a lower rate of incontinence and could be used in certain situations. Further studies with a long-term follow-up are required to confirm our observations.     

Botulinum toxin injection versus lateral internal sphincterotomy in the treatment of chronic anal fissure: a non-randomized controlled trial

Background

Although lateral internal sphincterotomy is the gold-standard treatment for chronic anal fissure, intrasphincteric injection of botulinum toxin seems to be a reliable new option. The aim of this non-randomized study is to compare the effect of lateral internal sphincterotomy and botulinum toxin injection treatments on the outcome and reduction of anal sphincter pressures in patients with chronic anal fissure.

Methods

Patients with chronic anal fissure were treated with either botulinum toxin injection or lateral internal sphincterotomy by their own choice. Maximal resting pressure and maximal squeeze pressure measurements were performed before and 2 weeks after treatments by anal manometry. Patients were followed for fissure relapse during 14 months.

Results

Twenty-one consecutive outpatients with posterior chronic anal fissure were enrolled. Eleven patients underwent surgery and ten patients received botulinum toxin injection treatment. Before the treatment, anal pressures were found to be similar in both groups. After the treatment, the maximal resting pressures were reduced from 104 ± 22 mmHg to 86 ± 15 mmHg in the surgery group (p < 0.05) and from 101 ± 23 mmHg to 83 ± 24 mmHg in the botulinum toxin group (p < 0.05). The mean maximal squeeze pressures were reduced from 70 ± 27 mmHg to 61 ± 32 mmHg (p > 0.05) in the surgery group, and from 117 ± 62 mmHg to 76 ± 34 (p < 0.01) in the botulinum toxin group. The fissures were healed in 70 percent of patients in the botulinum group and 82 percent in the surgery group (p > 0.05). There were no relapses during the 14 months of follow up.

Conclusion

Lateral internal sphincterotomy and botulinum toxin injection treatments both seem to be equally effective in the treatment of chronic anal fissure.

     

Glyceryl trinitrate is an effective treatment for anal fissure

PURPOSE: It has been suggested that chronic anal fissure is ischemic in origin because of poor blood supply and spasm of the internal anal sphincter. Nitric oxide donors such as glyceryl trinitrate (GTN) cause a chemical sphincterotomy leading to healing of the fissure. This study addresses the hypothesis that topical GTN ointment may be an effective nonsurgical treatment for chronic anal fissure. METHODS: Thirty-nine consecutive patients (23 women; median age, 34 (range, 16–54) years) with chronic anal fissure presenting to the surgical outpatient department were treated for four to six weeks with 0.2 percent GTN ointment applied twice daily to the anoderm. Maximum anal resting pressure was measured at steady state before and after application of the ointment at the first visit. Patients were assessed at two weekly intervals. RESULTS: Previous surgery for fissure had been performed in seven patients. There were 30 posterior and 9 anterior fissures. Resting maximum anal resting pressure fell from 122.1 ± 44 to 72.5 ± 33.3 cm of water (mean ± standard deviation) by 20 minutes after application of ointment (P <0.0001; paired t-test). Healing was complete in 14 patients at four weeks and in 33 patients at six weeks. Fissures recurred in five patients after treatment had been stopped. Four recurrences were successfully treated by further GTN ointment and one by sphincterotomy. CONCLUSIONS: This study shows that most anal fissures can be treated nonsurgically with topically applied 0.2 percent GTN ointment. Prospective, randomized controlled trials are now needed, because nonsurgical treatment of anal fissure avoids permanent division of part of the sphincter and the consequent disturbance of continence mechanisms.Supported by a grant from the Wellcome Foundation, London, United Kingdom.Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

Internal sphincterotomy is superior to topical nitroglycerin in the treatment of chronic anal fissure: results of a randomized, controlled trial by the Canadian Colorectal Surgical Trials Group

PURPOSE: This was a multicenter, randomized, controlled trial to compare the effectiveness of topical nitroglycerin with internal sphincterotomy in the treatment of chronic anal fissure. METHODS: Patients with symptomatic chronic anal fissures were randomly assigned to 0.25 percent nitroglycerin tid or internal sphincterotomy. Both groups received stool softeners and fiber supplements and were assessed at six weeks and six months. RESULTS: Ninety patients were accrued, but 8 were excluded from the analysis because they refused internal sphincterotomy after randomization (6), the fissure healed before surgery (1), or a fissure was not observed at surgery (1). There were 38 patients in the internal sphincterotomy group (22 males; mean age, 40.3 years) and 44 patients in the nitroglycerin group (15 males; mean age, 38.7 years). At six weeks 34 patients (89.5 percent) in the internal sphincterotomy group compared with 13 patients (29.5 percent) in the nitroglycerin group had complete healing of the fissure (P = 5x10(-8)). Five of the 13 patients in the nitroglycerin group relapsed, whereas none in the internal sphincterotomy group did. At six months fissures in 35 (92.1 percent) patients in the internal sphincterotomy group compared with 12 (27.2 percent) patients in the nitroglycerin group had healed (P = 3x10(-9)). One (2.6 percent) patient in the internal sphincterotomy group required further surgery for a superficial fistula compared with 20 (45.4 percent) patients in the nitroglycerin group who required an internal sphincterotomy (P = 9x10(-6)). Eleven (28.9 percent) patients in the internal sphincterotomy group developed side effects compared with 37 (84 percent) patients in the nitroglycerin group (P<0.0001). Nine (20.5 percent) patients discontinued the nitroglycerin because of headaches (8) or a severe syncopal attack (1). CONCLUSIONS: Internal sphincterotomy is superior to topical nitroglycerin 0.25 percent in the treatment of chronic anal fissure, with a high rate of healing, few side effects, and low risk of early incontinence. Thus, internal sphincterotomy remains the treatment of choice for chronic anal fissure.     

Open lateral internal anal sphincterotomy under local anesthesia as the gold standard in the treatment of chronic anal fissures. A prospective clinical and manometric study.

BACKGROUND: Chronic anal fissure is one of the most frequent proctological disorders in Western populations. Open lateral internal sphincterotomy is one of the therapeutic options accepted as the treatment of choice for chronic anal fissure, since it reduces the hypertonia of the internal anal sphincter (the main etiopathogenic mechanism of fissures), decreases anal pain, and allows the fissure to heal. MATERIAL AND METHODS: We carried out a prospective study of 120 patients operated on for chronic anal fissure with open sphincterotomy under local anesthesia at our Proctology Outpatient Unit from 1998 to 2001. No preoperative studies, bowel preparation, or antibiotic prophylaxis were carried out. All patients were followed up after 1 week, 2 months, 6 months, and 1 year, and underwent an anal manometry before and after surgery. RESULTS: Early complications: 3 hematoma-ecchymosis of the wound (2.5%), 3 self-limited hemorrhage events (2.5%). No hemorrhoidal thrombosis, fistulas, or perianal abscesses occurred. Fissures recurred in nine patients (7.5%) within one year. The initial rate of incontinence of 7.5% at two months dropped down to 5% at six months. The mean resting pressure (MRP) in incontinent patients was lower than in continent patients (55 +/- 7 mmHg versus 80.7 +/- 21 mmHg). The difference in mean squeeze pressure (MSP) between incontinent patients and continent patients was not statistically significant. CONCLUSIONS: Open sphincterotomy under local anesthesia has a long-term rate of healing and a morbidity rate similar to other techniques. It may therefore be considered an effective treatment for chronic anal fissure.     

Total lateral sphincterotomy for anal fissure

Background and aims Initial experience with the posterior sphincterotomy for treating anal fissures was unsatisfactory, with a significant rate of recurrences and anal incontinence. This report describes the lateral approach to complete section of the internal sphincter.Patients and methods Between 1997 and 2001 we surgically treated 164 patients for anal fissure. Preoperative and postoperative anal manometries were recorded. Postoperative course and early and long-term results were recorded.Results No fissure failed to heal. Early complications included bleeding, hematoma, and pain. A transient, variable degree of incontinence occurred in 15 patients and persistent incontinence to flatus and soiling in 5. After total sphincterotomy no long-term complication was observed. Patient satisfaction was 96%.Conclusion Total subcutaneous, internal sphincterotomy is a safe, effective procedure for the treatment of chronic anal fissure.     

Performing internal sphincterotomy with other anorectal procedures

PURPOSE: A study was conducted to compare the outcome of combined anorectal procedures involving lateral internal sphincterotomy with lateral internal sphincterotomy alone to determine if the former results in increased complications. METHODS: Complications and anal function of 57 patients who underwent lateral internal sphincterotomy for chronic anal fissure in conjunction with another anorectal procedure (combined group) between April 1989 and June 1992 were compared with 57 other age- and sex-matched patients who underwent lateral internal sphincterotomy alone (control group). RESULTS: There was no statistical difference in the incidence of incontinence in the combined group (8.7 percent) and the control group (7 percent). None of the cases in either group had permanent incontinence. There were also no statistical differences in the incidence of postoperative bleeding, pruritus ani, mucus discharge, abscess formation, fistulation, and rates of fissure recurrence. CONCLUSIONS: Additional anorectal procedures performed at the same time as internal sphincterotomy do not increase the incidence of postoperative complications.Dr. Husain is a World Health Organization Fellow Cantonment Military Hospital Dhaka Cantonment, Bangladesh.     

Incontinence After Lateral Internal Sphincterotomy: A Prospective Study and Quality of Life Assessment

PURPOSE: Lateral internal sphincterotomy is an effective treatment for chronic anal fissures; however, the risk of "incontinence" has generated interest in pharmacologic approaches that are far less effective and may be poorly tolerated. This study was designed to objectively define the risk of incontinence with sphincterotomy using the Fecal Incontinence Severity Index and assess the implications for quality of life using the Fecal Incontinence Quality of Life Scale. METHODS: A prospective study was undertaken on all patients undergoing lateral internal sphincterotomy for a chronic anal fissure by a single surgeon at a university teaching hospital from January 1, 2000 to September 30, 2002. All patients had failed at least six weeks of nonoperative management. Patient demographics and use of nitroglycerin were noted. The Fecal Incontinence Severity Index was measured preoperatively and at a six-week postoperative visit when fissure healing and postoperative complications were assessed. The Fecal Incontinence Quality of Life Scale was administered to patients with an incontinence score>0. RESULTS: Thirty-five patients (15 males) underwent sphincterotomy during the study period. Thirty-one of 35 had failed nitrates: 10 because of unacceptable side effects, and 21 because of lack of efficacy. Thirty-two patients returned for their six-week postoperative visits, and two completed their questionnaires by telephone. One patient was lost to follow-up. Mean age was 41.2 (range, 21-67) years. Thirty of 32 (94 percent) evaluable fissures had healed by six weeks, one healed by three months, and the other required V-Y anoplasty. There were two minor complications. Three patients had postoperative deterioration in their continence score. Quality of life deteriorated in only one patient. CONCLUSIONS: Lateral internal sphincterotomy is a safe and effective treatment for chronic anal fissures that only occasionally impairs continence and rarely diminishes quality of life.     

Prospective study of the extent of internal anal sphincter division during lateral sphincterotomy

PURPOSE: The aim of lateral internal anal sphincterotomy when treating anal fissure is to divide the distal one-third to one-half of the internal anal sphincter. This study aimed to evaluate prospectively the extent of disruption to the internal anal sphincter following lateral anal internal sphincterotomy and also to establish the prevalence of symptoms of anal incontinence in these patients. METHODS: Fifteen patients with anal fissure (ten females and five males) had bowel symptoms assessed and anal endosonography performed preoperatively and two months after lateral internal anal sphincterotomy. RESULTS: Anal endosonography was normal preoperatively in all but two females who had anterior external sphincter defects (presumedly from previous obstetric trauma). Postoperatively, apart from one male in whom no defect could be identified, all had an internal anal sphincter defect corresponding to the site of lateral internal anal sphincterotomy. In nine of the ten females, the defect involved the full length of the internal anal sphincter, but in the other four males, the defect involved the distal internal anal sphincter only. All were continent preoperatively, but after lateral internal anal sphincterotomy, three females became incontinent to flatus (two of whom had a preoperative external sphincter defect). CONCLUSION: In contrast to lateral internal anal sphincterotomy in males, division of the internal anal sphincter in most females tends to be more extensive than intended. This is probably related to their shorter anal canal. In some females, lateral internal anal sphincterotomy may compromise sphincter function and precipitate anal incontinence, particularly in the presence of other sphincter defects. Care should be exercised especially in the presence of previous obstetric trauma, as internal anal sphincter division may further compromise sphincter function.     

Comparison of Botulinum Toxin Injection and Lateral Internal Sphincterotomy for the Treatment of Chronic Anal Fissure

PURPOSE: Botulinum toxin injection into the internal anal sphincter has been shown to be an effective treatment for chronic anal fissure. A randomized, prospective trial was conducted to compare botulinum toxin with lateral internal anal sphincterotomy as definitive management for chronic anal fissure. METHODS: Patients diagnosed as having chronic anal fissure were randomly assigned to one of the two treatment arms. In the botulinum toxin group (n = 61), 20 to 30 U (approximately 0.3 U/kg) of type A botulinum toxin (Botox®) was injected into the internal anal sphincter. The injection was repeated two months later if complete healing was not accomplished. Patients in the sphincterotomy group (n = 50) underwent lateral internal anal sphincterotomy. The same investigators evaluated the patients on postoperative/postinjection days 7 and 28, and then in a blinded manner at 2, 6, and 12 months. RESULTS: In the botulinum group, single injection resulted in complete healing in 45 of the 61 patients (73.8 percent) at the second month. Of the 16 failures, 6 patients refused further treatment, and 10 were treated with a second injection, which resulted in an overall healing rate of 86.9 percent (53/61) at 6 months. In the sphincterotomy group, the success rate was 82 percent (41/50) at day 28 and 98 percent (49/50) at the second month (P = 0.023 and P < 0.0001, respectively, compared with the botulinum group—single injection). At 6 months, 2 patients in the LIS group developed recurrences, and the healing rate was similar to that of the botulinum group (86.9 vs. 96.4 percent; P = 0.212). At 12 months, the success rate of the Botox® group fell to 75.4 percent (46/61) with 7 recurrences, whereas it remained stable in the sphincterotomy group (94 percent, P = 0.008). Sphincterotomy was associated with a significantly higher complication rate (8 cases of anal incontinence vs. none in the botulinum toxin group; P < 0.001). Full return to daily activities took significantly less time in the botulinum group (1 vs. 14.8 ± 5.7 days; P < 0.0001). CONCLUSION: Although the healing rate of chronic anal fissure is considerably high with botulinum toxin injection with earlier recovery and less complications compared with sphincterotomy, it occasionally requires a repeat injection, and the healing is slower. The early (two months) and late (one year) healing rates are significantly higher in the sphincterotomy group, the two groups reaching similar healing rates only at six months.     

Concepts in pathogenesis and treatment of chronic anal fissure--a review of the literature

OBJECTIVE: Chronic anal fissures are associated with a persistent hypertonia and spasm of the internal anal sphincter. Classic treatment is surgical sphincterotomy to reduce the anal tone and eliminate sphincteric spasm. However, concerns have been raised about the incidence of fecal incontinence after surgery. Therefore, pharmacological means to treat chronic anal fissures have been explored. METHODS: We conducted a literature review on MEDLINE database. RESULTS: All treatments address the anomaly of a high anal pressure. Several studies have investigated the effect of topical glyceryl trinitrate ointment. Healing rates range from 30% to 86%. Therapy is limited because of a high incidence of moderate to severe headaches in up to 84% of patients. Comparable results are observed after injection of botulinum toxin into the anal sphincter (43-96%). Minor incontinence for flatus and soiling has been reported in up to 12% of patients. Further pharmacological approaches including treatment via calcium channel blockade and treatment with alpha-adrenoceptor antagonists are still at a developmental stage. CONCLUSIONS: Topical glyceryl trinitrate ointment and injection of botulinum toxin into the anal sphincter are advocated as the first-line treatment for chronic anal fissure. Lateral sphincterotomy should be offered to patients with relapse and therapeutic failure of prior pharmacological treatment.     

Glyceryl trinitratevs. lateral sphincterotomy for chronic anal fissure

INTRODUCTION: Glyceryl trinitrate has been shown to be an effective treatment for chronic anal fissure. It decreases anal tone and ultimately heals anal fissures. The aim of this trial was to compare glyceryl trinitrate with lateral sphincterotomy (current standard treatment) as definitive management for chronic anal fissure. METHODS: All patients with symptoms of chronic anal fissure were randomly assigned to one of two treatment arms. The glyceryl trinitrate group applied 0.2 percent paste to the perianal area three times a day for eight weeks. Patients in the lateral sphincterotomy group underwent surgery on the next available operating list. Patients were reviewed at two weekly intervals until the fissure healed. RESULTS: Sixty-five patients were enrolled in the trial, with 31 in the lateral sphincterotomy group and 34 in the glyceryl trinitrate group. Five patients were excluded after randomization. Twenty of 33 (60.6 percent) glyceryl trinitrate patients had healed fissures in eight weeks compared with 26 of 27 (97 percent) in the sphincterotomy group (P=0.001). Twelve patients in the glyceryl trinitrate group had little improvement in their symptoms and underwent lateral sphincterotomy. Poor tolerance and poor compliance with treatment were important factors in patients whose fissures did not heal with glyceryl trinitrate. Fissures healed significantly faster after sphincterotomy compared with glyceryl trinitrate treatment (P=0.0001). Nine of the 20 patients whose fissures healed with glyceryl trinitrate paste subsequently had a recurrence of their fissures. There were no long-term complications from lateral sphincterotomy. CONCLUSION: Glyceryl trinitrate paste heals the majority of chronic anal fissures. However, a significant minority have little improvement or develop side effects and require conventional surgical treatment. Poor compliance with prescribed treatment often contributes to nonhealing. In addition, some fissures which initially heal with glyceryl trinitrate paste recur and require further treatment. Glyceryl trinitrate treatment is labor intensive for patients and physicians and has not been shown to be superior to lateral sphincterotomy.Funded by the Department of Surgery, University of Adelaide.Presented in part at the Annual Scientific Meeting of the Royal Australasian College of Surgeons, Auckland, New Zealand May 10 to 14 1999.     

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

Purpose Although there is enthusiasm for nonoperative management of anal fissures, most trials have been of short duration (6–8 weeks) and long-term outcome is unknown. The purpose of this study was to assess long-term outcome in two cohorts of patients who had participated in a randomized, controlled trial to compare the effectiveness of topical nitroglycerin with internal sphincterotomy in the treatment of chronic anal fissure. Methods Between February 1997 and October 1998, 82 patients with chronic anal fissure were accrued and randomized to 0.25 percent nitroglycerin ointment t.i.d. or lateral internal sphincterotomy. In 2004, a telephone survey of trial participants was conducted to determine symptom recurrence, the need for further medical and/or surgical treatment, and patient satisfaction. Furthermore, patients were assessed for symptoms of fecal incontinence using the Jorge and Wexner Fecal Incontinence Score and the Fecal Incontinence Quality of Life questionnaire. Results Overall, 51 of the original 82 patients (62 percent, 27 nitroglycerin, 24 lateral internal sphincterotomy) completed our survey. Mean follow-up was 79 (±1) months. Sphincterotomy patients were less likely to have experienced fissure symptoms within the past year (0 vs. 41 percent; P = 0.0004) and were less likely to require subsequent surgical treatment (0 vs. 59 percent; P < 0.0001) than patients treated with nitroglycerin. Patients in the lateral internal sphincterotomy group were more likely to say that they were “very” or “moderately” satisfied with their treatment (100 vs. 56 percent; P = 0.04) and that they would choose the same treatment again (92 vs. 63 percent; P = 0.02) than patients in the nitroglycerin group. Finally, the fecal incontinence and fecal incontinence quality of life scores at six-year follow-up were similar in both groups. Conclusions After six years of follow-up, it seems that lateral internal sphincterotomy is a more durable treatment for chronic anal fissure compared with topical nitroglycerin therapy and does not compromise long-term fecal continence. Thus, sphincterotomy continues to be a good treatment for patients with chronic anal fissure. Presented as a poster at the Tripartite Colorectal Meeting, Dublin, Ireland, July 5 to 7, 2005. Presented at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005. Reprints are not available.     

Nitric oxide deficiency in the internal anal sphincter of patients with chronic anal fissure

Anal fissure is a common condition affecting young to middle-aged adults. It causes severe pain on defecation and rectal bleeding. The aetiology remains uncertain. Spasm of the internal anal sphincter is a constant feature. Nitric oxide (NO) is the major inhibitory neurotransmitter of the internal anal sphincter (IAS). In other spasmodic conditions of the GI tract a lack of normal nitric oxide synthase (NOS) activity has been reported. The aim of this preliminary study was to compare the presence of NOS in the internal sphincters of patients with and without chronic anal fissure. Internal anal sphincter biopsies were taken under general anaesthesia from patients having lateral internal sphincterotomy for chronic anal fissure and from sphincter of patients having abdominoperineal resections as controls. Sections of IAS were stained to show the presence of NADPH diaphorase (and hence presence of NOS). Internal anal sphincter was taken from 6 patients with chronic anal fissure and 6 controls. IAS taken from patients with chronic anal fissure showed little NOS presence compared with controls. It may be that there is an abnormal failure of relaxation of internal sphincter in those patients who develop chronic anal fissure caused by an intrinsic lack of neural NOS in the internal anal sphincter.