Riccardo Annibali, M.D. , M.A.S.C.R.S.Unity of Coloproctology “MILAN NORTH”

Columbus Hospital- Milan, Italy

TREATMENT OF ANAL FISSURES

ANAL FISSURE - DEFINITION

“A crack or a tear in the

vertical axis of the

squamous lining of the anal

canal between the anal

verge and the dentate line “

Fissure

Sentinel Skin Tag

Anal Polyp

ANAL FISSURE - CLASSIFICATION

• ACUTE FISSUREPainful cleft in the anoderm exposing submucosa and possibly the internal sphincter

• CHRONIC FISSUREAnodermal cleft with scarred base and surrounding inflammation. Frequentlly seen with hypetrophied anal papilla and “sentinel pile”

ANAL FISSURE - PRESENTATION

CHRONIC FISSURE• Deep indurated anal ulcer• Elevated, overhanging edges• Associated scarring• “Sentinel pile”+hypertrophied papilla• Visibile sphincter fibers• Rarely lateral• Less pain at defecation with gradually decreasing intensity (lasts from minutes to several hours). No nocturnal • Pruritus• Blood on occasion

ACUTE FISSURE• Superficial without fibrosis• Flat edges• None (unless prior surgery)• None• Not always visible• May be lateral• Severe, sudden stinging sharp pain associated with defecation (lasts only a few minutes)• No pruritus• Blood usual, bright red, stains paper or drips into the toilet

ANAL FISSURE - ETIOLOGY

• Associated with passage of hard stool

• Associated with sphincteric hypertone

• ? Most common in posterior midline

• ? Some heal spontaneously vs. become

chronic

ANAL FISSURE - PATHOGENESIS

• Abnormality of internal sphincter High resting pressures

NO: Duthie & Bennet, 1964; Braun, Raguse & Dohrenbusch, 1986 YES: Northmann & Schuster, 1974; Hancock, 1977; Abcarian, 1982 DIGITAL EXAMINATION IS UNRELIABLE: Jones OM, Ramaligam T, Lindsey I, et

al. Dis Colon Rectum 2005, 48:349-352

Abnormal reflex relaxation in response to rectal distention

• Ischemia Posterior commissure is less perfused

Klosterhalfen B, Vogel P, Rixen H, et al. Dis Colon Rectum 1989; 32:43-52 Schouten WR, Briel JW, Aurweda JJA. Dis Colon Rectum 1994; 37:664-9

ANAL FISSURE - DIFFERENTIAL DIAGNOSIS

• Intersphincteric abscess

• Pruritus ani

• Crohn’s disease

• Ulcerative Colitis

• Tuberculous anal fissures

• Syphilitic anal fissures

• AIDS

• Leukemia

• Anal Malignancy

• Previous surgery (hemorroidectomy, fistula-in-ano)

• Childbirth

Men=Women

Posterior fissure most common

Anterior fissure most common in women (10%)

Both anterior and posterior (10%)

ANAL FISSURE - TREATMENT

ACUTE FISSURE MEDICAL TREATMENT

CHRONIC FISSURE SURGICAL TREATMENT

CONSERVATIVE MEDICAL TREATMENT

• Correct precipitating cause (constipation, diarrhea)

• Increased fluid• Sitz baths, bran, bulk laxatives• Topical Steroids• Local anesthetics• (solcoderm, sodium tetradecyulfate, anal

dilators)Effective in up to 50% of cases(placebo in up to 35% of cases)

ANAL FISSURE - CONSERVATIVE TREATMENT

1 week 2 week 3 week healing

Lidocaine + + ++ 60 %

Hydro-cortisone + + ++ 82,4 %

Sitz baths

Bran++ ++ ++ 87 %

N = 103 patients

Jensen SL. BMJ 1986; 292:1167-1169

ANAL FISSURE - NEW MEDICAL TREATMENTS

• NO Donors Glycerin trinitrate-GTN; Isosorbide dinitrate-ISDN

• Calcium Channel Blockers Nifedipine, Diltiazem

• Botulinum Toxin• Gonyautoxin

Reduce MRP - Increase microcirculation

MEDICAL TREATMENT - NO DONORS(Glycerin trinitrate - Isosorbide dinitrate)

• Significant decrease in MRP• Effective at concentration from 0, 2% to 0, 5%• Immediate relief of pain that lasts for 2-6 hours• Healing 30% in 4-6 weeks, 86% in 3 months• Need for frequent application• Headache between 20 to 84% (commonly around 25%)• Discontinuation of therapy up to 20%• Recurrence rate up to 30%

MEDICAL TREATMENT CALCIUM CHANNEL BLOCKERS

• Significant decrease in MRP

• Healing from 65% to 95%

• Side effects: headache (up to 25%), flushing, hypotension

• Oral administration: lower healing rate, higher complications

• Recurrence rate: up to 42 %

MEDICAL TREATMENT - BOTULIN TOXIN

• Since 1993• Significant decrease in MRP (30%) • Two doses of 0,1 ml diluted toxin• Healing from 43% to 96% • Chemical denervation lasts 2 to 3 months• Transient incontinence: flatus 10-12%, stool 5%• Recurrence rate around 20%• Expensive

MEDICAL TREATMENT - GONYAUTOXIN

• Phytotoxin produced by microscopic planctonic algae• Stored in filter feeders like bivalves • Blocks the voltage-gated sodium channels in a reversible way• Two doses of 100 units (second one after 7 days)• Reduces both and MRP and MVCP• Immediate post injection sphincter relaxation and relief of pain• Healing rate: 98% in 28 days• Recurrence rate: ???• Further studies needed

Garrido R, Lagos N, Lattes K et al. Gonyautoxin: new treatmentfor healing acute and chronic anal fissures. Dis Colon Rectum 2005, 48:335-343

ANAL FISSURE - SURGICAL TREATMENT HISTORY

1838 Recamier - Anal stretch1835 Brodie1892 Goodsall 1930 Gabriel1934 Milligan & Morgan1939 Miles - “pectenotomy” (division of “pecten band”)1951 Eisenhammer - open lateral internal sphincterotomy1969 Notaras - closed lateral subcutaneous internal

sphincterotomy

fissurectomy

sphincterotomy

ANAL FISSURE - SURGICAL TREATMENT

• Anal Dilatation

• Fissurectomy and Posterior Sphincterotomy

• Open Lateral Internal Sphincterotomy

• Closed lateral Internal Sphincterotomy

• Anoplasty (advancement flap, V-Y flap, rotational flap, etc.)

ANAL DILATATION

• Still popular in the UK (36% of surgeons)• Sphincter damage in > 50% of patients• Incontinence to flatus 12,5 - 28.6%• Major incontinence 2 - 7,1%• Soiling up to 39.3%• 4 fingers x 4 minutes• Parks retractor at 4.8 cm• Healing rates from 43/ to 94%• Recurrence rate:10 to 30%

FISSURECTOMY-POSTERIOR SPHINCTEROTOMY

• Cure rate : 93%• “Keyhole” deformity: 5%• Incontinence to flatus: 17-34%• Incontinence to feces: 3 -15%• Soiling up to 41%• Large external wound• Prolonged time for healing•Recurrence rate: 1,3 %

Gabriel WB , 1930

LATERAL INTERNAL SPHINCTEROTOMY

OPEN - Eisenhammer S, 1951 CLOSED - Notaras MJ, 1969

LATERAL INTERNAL SPHINCTEROTOMY

No difference for persistence of symptoms, fissure recurrence or need for reoperation between open and close. Statistical significant difference for soiling of underwear (26,7% vs. 16,1%) and stool incontinence (11,8% vs. 3,1%). Almost significant for flatus incontinence (30,3% vs. 23,6%).

Garcia-Aguilar et al., 1996

No difference between the two methods.Nelson RL, 1999

Boulous PB et al., 1984Kortbeek JB et al., 1992

LATERAL INTERNAL SPHINCTEROTOMY

LATERAL INTERNAL SPHINCTEROTOMY

ANAL FISSURE - TREATMENT

“…Fully 45% of patients had some degree of fecal incontinence at some point after LIS. However, by one month after surgery, only 6% were incontinent to flatus. More importantly, 98% of patients were satisfied with the outcome of surgery, and < 1% of patients had their life affected by incontinence…”

Nyam DC, Pemberton JH, Dis Colon Rectum1999; 42:1306-10

LATERAL INTERNAL SPHINCTEROTOMY

• Forceful anal dilatation is inferior to LIS owing to a higher recurrence rate with higher rates of incontinence

Olsen J et al., 1987Weaver RM et al., 1987

• LIS is superior to fissurectomy and posterior midline sphincterotomy owing to faster healing rates, less pain and less postoperative incontinence

Abcarian H, 1980Saad AM et al., 1992

• LIS is superior to anal dilatation and posterior midline sphincterotomy

Nelson R, 2004

ANOPLASTY

AdvancementFlap

V-Y Flap Rotational Flap

ANOPLASTY

• Associated stenosis (mild, moderate, severe)• Usually postoperative (hemorrhoidectomy, fistulotomy)• In patients with normal or low MRP• In recurrences• V-Y flaps: 60-70% of donor sites break down and median

healing time of 4 months (2 - 6)• Rotational flap: lower break down rate• No incontinence• A viable alternative to LIS

Leong AF, Seow-Choen F. Dis Colon Rectum 1995;38:69-71Kenefick NJ, Gee AS, Durdey P. Colorectal Dis 2002; 4:463

Singh M et al. Int J Colorectal Dis 2005; 20:339-42

ANAL FISSURE PERSONAL SURVEY (1993-2004)

295 Pts Male:151 Female: 144Mean FU: 96 mths (18-150)Post.: 255 (87,5%) Ant.: 40 (13%) Both: 31(10%)274 (93%) operated on under local anesthesia

Open LIS: 239 (81%)Post. IS+Fissurectomy 5 (1,6%)Advancement flap 27 (9%)V-Y flap 23 (8%)Rotation Anoplasty 1 (0, 4%)Associated Excision 146 (50%)Associated pathologies 211 (70%)(hemorrhoids 62%; mucosal prolapse 19%; hemorrhoids+mucosal prolapse 11%; fistula-in-ano 1%)

ANAL FISSURE PERSONAL SURVEY (1993-2004)

LISIncont. Flatus: 21 (8,7%) Soiling: 11 (4,5%) Recurrence: 2 (0,6%)

Hematoma: 8 (3%) ; Perianal abscess: 1 (0,4%) ; Thrombosed Hemorrhoids: 1 (0,4%) ; Hemorrage: 2 (0,8%)

Post. IS1/5 not healed at 3 months (DTC); 1/5 Incont. Flatus+Soiling

Advancement Flap6/27(22%) Ant.+Post. - 3/27 (11%) Breakdown - Healing T: 7,7 wks (2-40)

V-Y Flap1 deceased - 15/22 (68%) Breakdown - Healing T: 6,5 wks (3-12)

ANAL FISSURE-COMPARISON OF TREATMENT

Nelson R. Dis Colon Rectum 2004, 47 (4):422-431

ANAL FISSURE - TREATMENT

“…first line use of medical therapy cures most chronic anal fissures cheaply and conveniently…”

Lindsey I, Jones OM, Cunningham C, Mortensen NJ. Br. J. Surg 2004;91:279-9

“…medical therapy for chronic anal fissure may be applied with a chance of cure that is only marginally better than placebo… [and] far less effective than surgery…”

Nelson R. Dis Colon Rectum 2004;47:422-31

ASCRS PRACTICE PARAMETERS

1) Conservative therapy is safe, has few side effects, and should usually be the first step

2) Anal fissures may be appropriately treated with topical nitrates because they can relieve pain; however, nitrates are only marginally associated with a healing rate superior to the placebo

3) Anal fissures may be appropriately treated with topical calcium channel blockers, which seem to have a lower incidence of adverse effects than nitrates. There is insufficient data to conclude whether they are superior to placebo in healing fissures

4) Botulinum toxin injections may be used for anal fissures that fail to respond to conservative measures and have been associated with a healing rate superior to placebo. There is inadequate consensus on dosage, precise site of administration, number of injections or efficacy

ASCRS PRACTICE PARAMETERS

5) Lateral internal sphincterotomy is the surgical treatment of choice for refractory anal fissures

6) Open and closed technique for LIS seem to yield similar results

7) Anal advancement flap is an alternative to LIS; further study is required

8) Surgery may be appropriately offered without a trial of pharmacologic treatment after failure of conservative therapy; patients should be informed about the potential complications of surgery

THANK YOU FOR YOUR ATTENTION!

“The one who knows much talks little. The one who talks much does not know”

Lao Tse