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Multiple disruption of IAS Today it is obsolete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