What’s New from Down Under

1. What’s New from Down Under Jeanne Yu, M.D. Grand Rounds, Roosevelt Hospital August 31, 2005

2. New Treatments for Old Problems • Anal Fissures • Anal Fistulas • Anal Warts • Procedure of Prolapsed Hemorrhoids

3. Anal Fissures • Fissure-in-ano is a cut in the anal canal • Location is mostly posterior • Lockhart-Mummery • Sphincter structure • Klosterhalfen • Ischemia due to decreased perfusion posteriorly in 85% of postmortem specimens • Schouten • Reduced anal pressure • Acute or Chronic • Etiology • Constipation, straining, diarrhea, IBD • High fiber diet decreases risk

4. History and Physical • Symptoms • Extreme, cutting pain • Rectal bleeding • Chronic fissure • Lump or sentinel tag, drainage, pruritus • Proctosigmoidoscopy

5. Treatments • Acute fissure • High fiber diet, bulking agents, fluids • Warm baths • Topical anesthetic • Ela-Max5 • Chronic fissure (> one month) • Manometry • EUA

6. Chemical Sphincterotomy • Glyceryl Trinitrate Ointment (GTN) • Nitric oxide is a neurotransmitter that leads to relaxation of the internal sphincter • Primary side effects: Headache • 0.2% GTN (68%) vs. placebo (8%) • Diltiazem (DTZ) • Ca2+ channel blocker • Kocher found no difference in healing rates, but there was fewer side effects • Botulinum Toxin (BNT) • Inhibits neuromuscular transmission • Transient incontinence for flatus

7. Chemical Sphincterotomy • Cochrane Collaboration meta analysis (2003) • 32 randomized controlled trials, 2446 patients • Summarized results • GTN vs. placebo (OR 0.73, CI 0.50-1.07) • GTN vs. Ca2+ channel blockers (OR 0.66, CI 0.22-2.01) • Botox vs. placebo (OR 0.75, CI 0.32-1.77) • Botox vs. GTN (OR 0.48, CI 0.21-1.10) • Medical therapy for acute and chronic anal fissures may be applied with a chance of cure that is only marginally better than placebo

8. Surgical Management • Sphincter Stretch • Described in 1838 • Manual stretch • No longer done in this country

9. Surgical Management • Internal Anal Sphincterotomy Open Technique • Radial incision across intersphincteric groove • Separate internal sphincter from anoderm • More than 90% of patients who require surgery for this problem have no further trouble from fissures. • Complications: infection, incontinence, recurrence

10. Surgical Management • Cochrane meta-analysis (2002) • 24 trials, 3475 patients • Results • Anal stretch has a higher risk of fissure persistence and minor incontinence than internal sphincterotomy. • Minimal difference in fissure persistence and incontinence risk between open vs. closed lateral internal sphincterotomy.

11. Anal Fistulas • An anal fistula, almost always the result of a previous abscess, is a small tunnel connecting the anal gland from which the abscess arose to the skin of the buttocks outside the anus.

12. Anal Fistulas Intersphincteric Trans-sphincteric Suprasphincteric Extasphincteric

13. History and Physical • Symptoms • Swelling, pain, discharge • Anoscopy • Bidigital palpation for the tract • Identification • Methylene blue • Milk • Hydrogen peroxide • Fistulography • Transrectal ultrasound

14. Treatment • Fistulotomy • Seton division • Endorectal advancement flap • Fibrin Glue

15. Treatment • Fibrin Plug • Suturable biodegradable plug

16. Treatment

17. Treatment

18. Treatment

19. Anal Warts • Condyloma acuminatum • HPV • Complaints • Discharge, pruritus, pain, odor, bleeding • Anoscopy • Lesions usually confined to squamous epithelium and transitional zones

20. Treatment • Podophyllin • Bichloracetic acid • Immunotherapy • Immunomodulation • Chemotherapy • Cryotherapy • Electrocoagulation • Laser therapy • Surgical excision

21. Aldara • Imiquimod cream 5% • Induces local production of interferon and other cytokines in patients applying ALDARA cream to external genital warts

22. Aldara • In early multicenter, double-blind, trials, 311 patients (1997) • Results • Three times weekly completely cleared warts in 50% of patients • Indications • First line therapy for patients who do not demand immediate removal of warts (8weeks) • Alternative therapy for failures or recurrences • In combination therapy for patients with large/multiple

23. Hemorrhoids

24. Hemorrhoids • Fibrovascular cushions (or hemorrhoids) are part of the normal anatomy within the anal canal and are believed to be important in maintaining continence. As an individual coughs, strains or sneezes, these fibrovascular cushions engorge and maintain closure of the anal canal in order to prevent leakage of stool in the presence of increased intrarectal pressure.

25. History and Physical • Symptoms • Discomfort, bleeding, pain • Anoscopy • Consider flexible proctoscigmoidoscopy to asses for neoplasm

26. Treatment • Diet and lifestyle modification • “Get off the pot!” • Rubber band ligation • Infrared coagulation • Sclerotherapy

27. Surgical Management • Ferguson hemorrhoidectomy

28. Procedure for Prolapsed Hemorrhoids (PPH) • Transanal, circular stapling of redundant anorectal mucosa • Redundant mucosa is drawn into stapler and submucosal blood flow is interrupted by the circular staple line. • No incisions are made in the somatically innervated, highly sensitive anoderm theoretically resulting in significantly less postoperative pain.

29. PPH vs. Ferguson Hemorrhoidectomy • Prospective, Randomized, Controlled, Multicenter Trial comparing stapled hemorrhoidopexy and ferguson hemorrhoidectomy: perioperative and one year results (2004). • 156 patients • Conclusions: Stapled hemorrhoidopexy had less postop pain, less requirement of analgesics, less pain at first bowel movement, while providing similar control of symptoms and need for additional hemorrhoid treatment at one year follow-up

30. PPH vs. Ferguson Hemorrhoidectomy • Meta-analysis Nisarl’s group (2004) • 15 trials, 1,077 patients • Follow-up ranged from 6 weeks to 37 months • PPH less painful. • Shorter return to normal activity of 4.03 days (P=0.007). • Stapled hemorrhoidopexy has a higher recurrence rate (OR 3.64, P = 0.008) at a minimum follow-up of six months.

31. PPH

32. PPH • There is less postoperative pain secondary to less operative trauma to the anoderm

33. PPH

34. PPH

35. Bibliography • McLeod RS, Evans J. Symptomatic care and nitroglycerin in the management of anal fissures. J Gastrointest Surg 2002:6:278. • Kocher HM, et al. Randomized clinical trial assessing the side-effects of glyceryl trinitrate and diltiazem hydrochloride in the treatment of chronic anal fissure. Br J Surg 2002:89:413. • Nelson R. Non surgical therapy for anal fissure. The Cochrane Database of Systematic Reviews 2003, Issue 4. • Wilson MS, et al. Objective comparison of stapled anopexy and open hemorrhoidectomy: A randomized, controlled trial. Dis Colon Rectum 2002; 45(11): 1437-1444. • Palimento D, et al. Stapled and open hemorrhoidectomy: randomized controlled trial of early results. World J of Surg 2003; 27:203-207.

36. Bibliography • Sengaore AJ, et al. A prospective, randomized, controlled multicenter trial comparing stapled hemorrhoidopexy and Ferguson hemorrhoidectomy: perioperative and one-year results. Dis Colon Rectum 2004;47(11): 1824-1836. • Nisarl P, et al. Stapled hemorrhoidopexy compared with conventional hemorrhoidectomy: systematic review of randomized, controlled trials. Dis Colon Rectum 2004:47:1847. • Edwards L, et al. Comparison of results from two vehicle controlled clinical trials evaluatingtopical imiquimod for the treatment of genital/perianal warts. Clinical Derm 2000.

37. The End.