Nitroglycerin, Botox or Sphincterotomy for Anal Fissure

Associate Professor Nick Rieger

Adelaide University

Department of Surgery

Aetiology ?

Trauma Sphincter spasm Ischaemia

Typical Anal Fissure

Treatment

Relieve Sphincter spasm

Alleviate ischaemia

Healing

How to relieve spasm?

• Mechanical - Sphincterotomy, Stretch

• Chemical - GTN, Diltiazem, Nifedipine

• Neurotoxic - Botox

Botox

• Botulinum Toxin A• Prevents release of acetylcholine by

presynaptic nerve terminals.• Lasts up to 3 months• Regrowth new axon terminals• Few side effects• Cost $400.00

GTN

• Glyceryl trinitrate

• NO2 donor (inhibitory neurotransmitter in the Internal Anal Sphincter)

• 3 applications per day for 6 weeks

• Headache (dose related)

• Efficacy 47 to 86%

Sphincterotomy

• Requires anaesthesia

• Day case admission

• Very effective (90-95%)

• Incontinence; may be minor (flatus, smearing) but can be permanent

• Up to 5% of patients (some studies quote more)

SphincterotomyDefine the IASOpen or Closed?Tailored?Debride the fissure?

Adelaide study 1

• GTN vs Sphincterotomy (RCT)Evans J, Luck A, Hewett P. DCR 2001

GTN (33 pt) vs LAS (27 pt)

Healed 8 Weeks 20/33 (61%) 26/27 (97%)

Recurrence 9 patients

Sphincterotomy 12 patients

Time to healing significantly faster for sphincterotomy

No incontinence reported

Adelaide study 2

• Open vs Closed Sphincterotomy (RCT)• Wiley M, Day P, Rieger N, Stephens J, Moore J. DCR 2004

• RCT 76 patients; 36 closed:40 open• 6 weeks 96% healed• Incontinence of any grade was seen in 6.8 percent

of patients at 52-week follow-up. Three patients (4.1 percent, 1 closed, 2 open) suffered major incontinence at 52 weeks.

Adelaide study 3• Botox vs Sphincterotomy (RCT)• 38 patients; 17 Botox® ; 21 sphincterotomy• Healing at 6 weeks 7/17 (41%); 18/21 (86%) P = 0.004*• Healing at 26 Weeks 7/17 (41%); 19/21 (91%) P < 0.001†• Of the 17 patients who were treated with Botox®, 9 required

reoperation (53%) within six months, as compared to 2 of 21 cases treated with sphincterotomy (9.5%).

• Eight of the nine Botox® “failures” were cured by sphincterotomy, while 1 continued to have symptoms. One patient who had healing of the fissure by Botox® treatment, had recurrence following a vaginal delivery, some 18 months following the procedure. This was treated by sphincterotomy.

• Botox group were found to have significantly higher two-week pain scores and re-operation rates,

• Continence scores were not significantly different in the two groups.

Literature

Meta-analysis: Nelson; DCR 2004 (Cochrane)• 31 trials• Medial therapy for chronic anal fissure, acute fissure

and fissure in children may be applied with a chance of cure that is only marginally better than placebo.

• For chronic anal fissure surgery more effective than medical therapy (OR=0.12, 95% CI, 0.07-0.22)

Management Considerations

• Crohn’s disease• Patient sex• Obstetric history• Patient age• Duration of symptoms• Prior treatment

Primary FissureWhat I do

• Explanation of treatment options

• Explanation of side effects

• Analgesia (local and systemic)

• Stool softeners

• GTN

• Failure or recurrence go to sphincterotomy

Recurrent Fissure after sphincterotomy

• GTN first line• Consider Botox• Anal ultrasound• Redo sphincterotomy

Other Alternatives?

• Fissure excision and primary closure

• Flap repair - V/Y flap

- Island flap

Incontinence Post Sphincterotomy

• Diet modification

• Physiotherapy

• Imodium

• Sphincter injection - PTP

- EVOH

Summary

• Sphincterotomy remains the best “curative” procedure for anal fissure (incontinence)

• GTN has a role in the initial management (failure and headache)

• Botox may be useful in selected patients (failure)

Conclusions

No perfect management for anal fissure

Informed consent paramount

Tailor the treatment to the individual