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Anal Fissure What? When? Why?

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

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Anal Fissure What? When? Why?

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  1. Miklós Kassai MD EBSQ colo Anal Fissure What? When? Why?

  2. AnalFissure • Acutefissure • Papercut • Spontaneoushealinglikely • Chronicfissure • Underminededges • Sentinelpile • Anal papilla • Treatmentneeded • Comeswithincreasedanaltone

  3. Medlinesearch • FissureinAnoHeading • 1696 hits

  4. Anal resting pressure

  5. Internal Anal Sphincter Physiology

  6. The viciouscircle of analfissure Microinjury Ulcer formation Pain Increased anal tone Inadequate healing Ischaemia of the anoderm

  7. Treatment • Excludeothercauses • IBD, HIV, AnalCa • Breakthecircle • Regulatebowel • Fibre • Fluid • Decreasepain • Local anaesthetics • Decreasespasm • Surgicalinterventions • Chemicalsphincterotomy

  8. Surgicaltreatment

  9. Surgicaloptions • Analdilatation • Sphincterotomy • Fissurectomy • Advancementflaps

  10. Anal dilatation • 4 fingers 2-4 minutes • Veryeffective, 90% healingrate • Recurrence 2% - 57% • Incontinence 50% • Multipledisruption of IAS • Todayit is obsolete Jensen SL, Lund F, Nielsen OV, Tange G (1984) Lateral subcutaneoussphincterotomyversus anal dilatation in the treatment of fissure in ano in outpatients: a prospective randomisedstudy. 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 anal endosonography. Br J Surg 78:1429–1430

  11. SphincterotomyPosteriorMidline • Posteriorly, inthefissure • Effective, but • Prolongedhealing • Keyholedeformity • Incontinence • IAS defect • Deformity Nelson R (2005) Operative procedures for fissure in ano. Cochrane Database Syst Rev:CD002199

  12. SphincterotomyLateralInternalSphincterotomy • Awayfromfissure • Open – Closetechnique • Partialdivision • Todentate line • „Tailored” (Less incontinence) • Healingrates 95% • Incontinence 0% - 50% • Getsbetterwithtime • Dependentonfollowuptechniques • Womenare more atrisk • Preop US and manometrymay be necessary

  13. Fissurectomy • Excision of thefissure • Withorwithoutclosure • Aloneorincombinationwith • Botulinum toxin • Local Nitrates • Healing 90% - 100% • But no RCTs! Engel AF, Eijsbouts QA, Balk AG (2002) Fissurectomyandisosorbidedinitrate for chronic fissure in ano not responding to conservative treatment. Br J Surg 89:79–83 Lindsey I, Cunningham C, Jones OM, Francis C, MortensenNJ (2004) Fissurectomy-botulinum toxin: a novel sphinctersparingprocedure for medically resistant chronic anal fissure. Dis Colon Rectum 47:1947–1952

  14. Modifiedfissurotomy • Deroofing a narrowsubcutaneoustract • Caudaltothefissure • Providescleaning • 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

  15. Advancementflaps • Skingraft • Infection – failure • Successinnormal, lowpressurecases • Healingcomparableto LIS • Recommendedinselectedcasesonly Nyam DC, Wilson RG, Stewart KJ, Farouk R, BartoloDC(1995) Island advancement flaps in the management of analfissures. Br J Surg 82:326–328

  16. Internal Anal Sphincter Physiology

  17. Non-surgicaltreatment • Nitrates • Cachannelblockers • Neurotoxins • L-Arginine • K channelopeners • Alpha-1 adrenoceptorblockers • Phosphodiesterase-5 inhibitors • Angiotensine-convertingenzymeinhibitors

  18. Nitrates • NO donors • Relaxsmoothmuscles • Variablepharmacokinetics • Effectivebothsystemically and topical • Prospective, randomised, doubleblind, placebo controlledtrialshowed • 66% successin GTN arm • 8% in placebo arm • Initially 0.2%, now 0.4% ointment • Works asdermal patch too Lund JN, Scholefield JH (1997) A randomised, prospective,double-blind, placebo-controlled trial of glyceryltrinitrate ointment in treatment of anal fissure. Lancet 349:11–14

  19. 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 superior • But incontinence

  20. Ca channel blockers • Nifedipine 0.2% - 95% Healingrate • Diltiazem 0.2% - 75% Healingrate • Oraltreatmenteffectivebut • Sideeffects 60% • Headaches • Flushing • Ankleoedema Antropoli C, Perrotti P, Rubino M et al (1999) Nifedipine forlocal use in conservative treatment of anal fissures: preliminaryresults of a multicenter study. Dis Colon Rectum 42:1011–1015 Jonas M, Speake W, Scholefield JH (2002) Diltiazemhealsglyceryltrinitrate-resistant chronic anal fissures: a prospectivestudy. Dis Colon Rectum 45:1091–1095

  21. Neurotoxins • Inhibitneurotransmitters • Resultsinrelaxation • PRCT withsaline • Healingrate → → → → → • Recurrence 55% at 3y • Sideeffects • Incontinence • Haematomas • Infections • Long term? Maria G, Cassetta E, Gui D, Brisinda G, Bentivoglio AR,Albanese A (1998) A comparison of botulinum toxin and saline for the treatment of chronic anal fissure. N Engl J Med338:217–220

  22. Non-surgical treatment • Nitrates • Cachannelblockers • Neurotoxins • L-Arginine • K channelopeners • Alpha-1 adrenoceptorblockers • Phosphodiesterase-5 inhibitors • Angiotensine-convertingenzymeinhibitors

  23. What is thecurrentguideline? • ASCRS revisedin2004 • Orsay C, Rakinic J, Perry WB et al (2004) Practice parametersfor the management of anal fissures (revised). DisColonRectum 47:2003–2007 • PRODIGY revisedinNov2005 • CKS (2005) Anal Fissure (PRODIGY guidance). ClinicalKnowledge Summaries Service.ww.cks.library.nhs.uk/anal_fissure • European cliniciansin2006 • Lund JN, Nystrom PO, Coremans G et al (2006) An evidencebasedtreatment algorithm for anal fissure. Tech Coloproctol10:177–180

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