+Model JVS-415; No. of Pages 7

ARTICLE IN PRESS

Journal of Visceral Surgery (2014) xxx, xxx—xxx

Available online at

ScienceDirect www.sciencedirect.com

REVIEW

Update on the management of anal fissure T. Higuero 11, boulevard du Général-Leclerc, 06240 Beausoleil, France

KEYWORDS Anal fissure; Medical treatment; Chemical sphincterotomy; Fissurectomy; Lateral internal sphincterotomy; Anoplasty

Summary Anal fissure is an ulceration of the anoderm in the anal canal. Its pathogenesis is due to multiple factors: mechanical trauma, sphincter spasm, and ischemia. Treatment must address these causative factors. While American and British scientific societies have published recommendations, there is no formal treatment consensus in France. Medical treatment is nonspecific, aimed at softening the stool and facilitating regular bowel movements; this results in healing of almost 50% of acute anal fissures. The risk of recurrent fissure remains high if the causative factors persist. If non-specific medical treatment fails, specific medical treatment can be offered to reversibly decrease hypertonic sphincter spasm. Surgery remains the most effective long-term treatment and should be offered for cases of chronic or complicated anal fissure but also for acute anal fissure with severe pain or for recurrent fissure despite optimal medical treatment. Surgical treatment is based on two principles that may be combined: decreasing sphincter tone and excision of the anal fissure. Lateral internal sphincterotomy (LIS) is the best-evaluated technique and remains the gold standard in English-speaking countries. Since LIS is associated with some risk of irreversible anal incontinence, its use is controversial in France where fissurectomy combined with anoplasty is preferred. Other techniques have been described to reduce the risk of incontinence (calibrated sphincterotomy, sphincteroplasty). The technique of forcible uncalibrated anal dilatation is no longer recommended. © 2014 Published by Elsevier Masson SAS.

Introduction Anal fissure (AF) is an ulcer situated in the mucosa and the lower part of the anal canal from the anoderm up the dentate line. Clinical history and physical examination help to differentiate AF from hemorrhoidal disease, anoperineal Crohn’s disease, various sexuallytransmitted infections, and fissure due to underlying cancer. AF is the second most common reason for proctologic consultation after hemorrhoidal disease. It occurs more commonly in young adults with similar incidence in either sex. Its occurrence is less common beyond age 65 when other associated diseases must be considered [1,2]. It is particularly common after childbirth affecting 15% of women [3].

E-mail address: [email protected] http://dx.doi.org/10.1016/j.jviscsurg.2014.07.007 1878-7886/© 2014 Published by Elsevier Masson SAS.

Please cite this article in press as: Higuero T. Update on the management of anal fissure. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.07.007

+Model JVS-415; No. of Pages 7

ARTICLE IN PRESS

2

T. Higuero

Anal fissure is considered acute when it is of recent onset (less than six weeks), and chronic if it has been present for a longer period, taking on a characteristic aspect that includes perianal skin tag, fibrotic edges, and a proximal papilla. A fissure may cause severe pain or be essentially asymptomatic depending on the degree of anal sphincter spasm. There is often associated low volume rectal bleeding. Secondary reflex constipation is very common due to the fear of pain associated with bowel movements. The fissure is located posteriorly in 85% of cases and anteriorly in 15% of cases. When rectal bleeding is a presenting symptom, the presence of a fissure should not preclude full colonoscopy to rule out other colorectal lesions.

Pathophysiology Anal fissure has multiple pathogenic factors, which form the basis for therapeutic approaches. The initial event is triggered by the passage of hard and bulky stools (or the sudden evacuation of liquid stool) resulting in a tear the anoderm. Two other factors account for the persistence of the fissure. Hypertonia or spasm of the internal sphincter can be primary or a secondary reflex to the pain caused by the raw ulceration, resulting in a vicious circle of repeated anal trauma due to reflex sphincter spasm caused by fear of defecation. This primary role of spasm has been demonstrated by anal manometry of patients with chronic anal fissure: the resting tone of the internal anal sphincter is high with little relaxation [4]. The second predisposing factor is local ischemia of the anoderm, which impairs the healing of the fissure. The anoderm is vascularized by branches of the inferior rectal artery. These arterioles reach the mucosa after piercing through the internal anal sphincter. Studies have shown that the area of the posterior commissure is less well vascularized and therefore at risk of ischemia [5,6]. Sphincter spasm promotes mucosal ischemia by reducing the blood flow through the arteries as they pass through the internal anal sphincter [7,8]. Post-partum anal fissure, which often involves the anterior anal commissure, is usually not associated with sphincter spasm, having a different mechanism related to constipation, hormonal levels and perineal dynamic changes that impair healing.

Non-specific medical treatment The lack of prospective studies with extended follow-up of acute and chronic anal fissure has made it difficult to understand the natural history of anal fissure. The healing rate of chronic anal fissure with medical management ranges from 8 to 31% (estimated by analyzing the placebo arm in controlled trials) [9—13]. Medical management is the standard first-line of therapy due to its safety and simplicity of implementation. It aims to regularize bowel movements and improve patient comfort. Bowel regulation is enhanced by a high fiber diet and mild laxatives chosen according to the quality and intensity of constipation (stool softeners, osmotic laxatives, mineral oil). A study from the 1980s showed the effectiveness of high fiber diet in the treatment of acute anal fissure. It resulted in healing in 87% of cases within 3 weeks [14].

Continuation of a high fiber diet for one year (at least 5 g/day) prevented the recurrence of the fissure, with only 16% recurrence compared to 68% for patients taking placebo [15]. Two large retrospective series (876 and 393 patients) reported a healing rate of about 45% at 5 years [16]. Topical medications, consisting of local anesthetics, vitamins or anti-inflammatory agents, are often used but no study has proven their superiority over simple topical lubricants. The use of anesthetic-containing lubricants is considered no better than placebo [17]. Suppositories are often used to lubricate the anal canal and facilitate the passage of stool. Analgesics are often required for patient comfort. NSAIDs, tylenol, and opioid analgesics are used. Conservative medical treatment for 3 weeks results in healing in almost 50% of acute anal fissures. The risk of recurrence remains high if the underlying cause (such as anal sphincter spasm) persists or if stool softeners are prematurely discontinued; such treatment should be continued for long periods.

Specific medical treatment Specific medical treatment is aimed at reversible reduction of anal sphincter tone (since sphincter spasm is responsible for persistence and/or appearance of anal fissure) thereby also promoting improved vascularization of the anoderm, which is essential to the healing process. A recent Cochrane Collaboration reviewed the medical management of acute and chronic anal fissure in adults and children; this included 75 randomized controlled trials in the analysis and 5031 patients [17].

Topical nitrates Dilute nitroglycerin (NTG) ointment (0.05—0.4%) has proved its effectiveness in the control of sphincter spasm-related pain and the healing of chronic anal fissure compared to placebo (48.9% versus 35.5%) [17]. Two applications per day for 6 to 8 weeks should be prescribed [18]. The most common side effect of NTG is headache, which occurs in 20—30% of cases and may require discontinuation of treatment in one out of five cases. Headache is dose-dependent and can be prevented by oral analgesics and by gradually increasing the NTG dosage over four to five days [19,20]. The healing rate is similar to that obtained with injection of botulinum toxin or topical application of calcium channel blockers, but it is significantly less than after LIS or use of anal dilators at home. There is no significant difference between intra-anal application at the dentate line or at some distance therefrom [17]. The rate of long-term recurrence ranges from 51 to 67% [18,21—23]. The use of topical NTG has decreased the need for surgery in some practices [24], while others find that it only delayed eventual surgery [25]. While the Cochrane study did not note an influence of the NTG concentration (0.2 and 0.4%), one group reported higher healing rates (40.4% versus 54.1%) at higher concentrations (0.2% versus 0.4%) [19]. In France, only one form (Rectogesic® , a 0.4% preparation of NTG) is approved by the French marketing authority (Autorité de mise sur le marché [AMM]) and it is not reimbursable.

Please cite this article in press as: Higuero T. Update on the management of anal fissure. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.07.007

+Model JVS-415; No. of Pages 7

ARTICLE IN PRESS

Update on the management of anal fissure

Calcium channel blockers Diltiazem and nifedipine, applied topically as a 2% ointment, are the two most studied agents. Two applications per day for 6 to 8 weeks are prescribed. They result in healing of the anal fissure in 65 to 94.5% of cases [26—28]. Side effects include headache and pruritus ani in about 10% of cases [29,30]. Some authors have reported effectiveness in 50% of cases after failure of NTG [31]. Topical calcium channel blockers are more effective and better tolerated than oral medication [32,33]. Calcium channel blockers (CCB) appear to be as effective as nitrates but with fewer side effects [32,33]. However, the rate of healing is much higher after LIS [17]. Few trials have follow-up beyond one-year, making the assessment of recurrence difficult. A recurrence rate of 59% in the two years after treatment has been reported [34]. While topical calcium channel blocker preparations are marketed in England (diltiazem 2%) and Italy (nifedipine 2%), none have been approved in France for this indication by the AMM.

Botulinum toxin A Botulinum toxin is a neurotoxin that inhibits pre-synaptic re-uptake of acetylcholine. Injection results in sustained relaxation of the internal sphincter, treating both the painful sphincter spasm and the vascular component and promoting healing of the fissure. Two commercial formulations exist: Botox® and Dysport® . There is no consensus as to the dose, the site or the number of injections; usually 30—50 units of botulinum toxin are injected into the internal anal sphincter in the posterior commissure on either side of the fissure. Numerous reviews and meta-analyses have evaluated botulinum toxin [17,35]. Botox® has proven more effective than placebo in one study with a healing rate of 73% [13] and of similar efficacy in another with 32% healing in either arm [36]. The latest Cochrane meta-analysis shows efficacy similar to NTG [17]. Lateral internal sphincterotomy is more effective with 1.3 greater chance of healing and a recurrence rate six times less frequent than with Botox treatment. However, the risk of anal incontinence for gas is nine times more common with sphincterotomy [37]. Overall, botulinum toxin results in an average healing rate of 67.5% with a recurrence rate of 50% at one year [17]. The healing rate appears to be better for higher doses [32], with no difference between Botox® and Dysport® . Few side effects are reported. The most common is transient anal incontinence of gas and stool in 10—18% and 5% of cases, respectively [13,32,38]. Besides the absence of marketing authorization for this indication in France, the availability of botulinum toxin is limited and its cost is high.

Summation of medical treatments In France, there is no consensus regarding medical treatment. Non-specific medical treatment is always offered first-line. If this fails, the only specific treatment recognized by the AMM is Rectogesic® , 0.4% NTG. Because of its safety, this can be tried in patients who refuse surgery. Our Italian colleagues propose topical treatment with 0.4% NTG as first-line medical treatment. They do not recommend botulinum toxin [20]. The Association of

3 Coloproctology of Great Britain and Ireland (ACPGBI) recommends non-specific medical treatment for both acute and chronic anal fissure, in combination with 2% preparations of CCB for 6—8 weeks; in case of failure, they recommend the injection of 20 to 25 units of Botox® [33]. The American Society of Colon and Rectal Surgeons (ASCRS) recommends first-line NTG or CCB treatment for both acute and chronic anal fissure and for fissure in children; if this fails or is poorly tolerated, botulinum toxin is recommended for patients who refuse surgery [32].

Surgical treatment Surgery remains the most effective long-term treatment of chronic anal fissure. It is based on two principles that may be associated: decreasing sphincter tone and excision of the anal fissure.

Fissurectomy Fissurectomy consists of resection of the fissure with its lateral edges (tissue should be sent for histologic examination), replacing poor quality tissues that heal poorly with a clean wound that will heal. For posterior midline fissure, the defect may be resurfaced by an anoplasty, advancing a rectal mucosal flap into the anal canal. The systematic performance of internal sphincterotomy in the bed of the fissure remains useful when there is associated infection or anal fistula. This technique can be complicated in a third of patients by keyhole deformity of the anal canal with fecal soiling. Other complications are rare: local secondary infection, delayed healing, which is generally obtained by 6—8 weeks. A recent French multicenter prospective evaluation of 264 patients followed for one year found that healing occurred in all patients within an average of 7.5 weeks. Complications were rare (4%): urinary retention, urinary and local infections, and fecal impaction. The risk of anal incontinence was increased in patients at risk: prior history of diarrhea, cholecystectomy, multiparity and perineal laceration. Patient satisfaction was 91% [39]. The effectiveness of fissurectomy seems to persist in the long-term with only an 11.6% rate of recurrence after a mean follow-up of 8.2 years (5.5 to 12.2) and a minimal impact on fecal continence [40]. Fissurectomy has been combined with ‘‘chemical sphincterotomy’’ in order to promote healing by resecting fibrosis and decreasing anal hypertonia while avoiding risks of incontinence. Results reported in the literature (80 to 100% healing) should be interpreted with caution due to the low level of evidence of these studies [41,42]. The British recommendations include the possibility of fissurectomy with ‘‘chemical sphincterotomy’’ [33]. Fissurectomy has been compared to LIS in a prospective trial (mean follow-up of 22 months) that showed sphincterotomy to be superior with 3.1% recurrence rate and a 6.3% incidence of incontinence of flatus after fissurectomy versus 0% after sphincterotomy [43]. The most recent Cochrane Collaboration meta-analysis found LIS to be superior in terms of healing with no significant increased risk of anal incontinence [44]. The combination of anoplasty with fissurectomy should reduce sphincter spasm without taking risks on continence [45]. In a retrospective study, the healing rate was higher in the fissurectomy group compared to the LIS group (96% versus 88%) [46]. In the U.S. recommendations, fissurectomy

Please cite this article in press as: Higuero T. Update on the management of anal fissure. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.07.007

+Model JVS-415; No. of Pages 7

ARTICLE IN PRESS

4

T. Higuero

with anoplasty is a preferable alternative to LIS in patients who do not have sphincter hypertonia and in those who are at increased risk of anal incontinence [32].

Sphincterotomy Lateral internal sphincterotomy (open or close) is the bestevaluated surgical technique and remains the gold standard method in the Anglo-Saxon literature. Its use has been controversial in France because of the risk of irreversible disturbance of anal continence [47]. Its effectiveness for healing anal fissure has been evaluated at 91 to 100% [44]. LIS consists of transection of a portion of the internal anal sphincter, performed in a quadrant remote from the fissure, to relieve anal sphincter spasm with secondary ischemia and poor healing of the anoderm. When performed by the closed technique, it results in a minimal incision that heals in a few days. Patient satisfaction is higher when sphincterotomy is combined with debridement of the base and edges of the fissure [20,44]. The open technique seems to increase the risk of incontinence for flatus with no benefit for healing [44,48]. After sphincterotomy by the open approach, wound closure allows healing two times faster (15 days versus 30 days) with less infection [44]. LIS is more effective than specific medical treatment, forcible dilatation and fissurectomy in terms of healing and risk of recurrence, albeit at the price of some risk of impaired continence [44]. Reported complications of LIS include bleeding, hematoma, local infection, but most particularly anal incontinence in 3—45%. This risk was assessed in 585 patients followed for a mean of 72 months [6—45]. Postoperative continence disorders were noted in 45% of patients, mostly women. Incontinence to flatus, fecal soiling, and stool incontinence occurred in 31, 39 and 23% of patients, respectively. At a mean follow-up of five years after surgery, incontinence for flatus, fecal soiling and solid stool incontinence persisted in 6, 8 and 1% of patients, respectively [49]. This risk appears to be lower in the most recent published trials. The risk may have been overestimated due to difficulty in perfectly standardizing the technique with regard to the height and thickness of internal sphincter to be divided.

Calibrated lateral internal sphincterotomy (‘‘tailored sphincterotomy’’) In order to reduce the risk of post-sphincterotomy incontinence, two techniques have been described: a sphincterotomy extending to the apex of the anal fissure but not beyond the dentate line and sphincterotomy calibrated dilatation to allow dilatation of the anal canal to a diameter of 3 cm. The first open studies reported a healing rate similar to LIS (90%) with less than 10% incidence of anal incontinence. Efficacy for the first technique has not been confirmed in controlled trials [50] but was demonstrated for the second technique [51,52].

Anoplasties Anoplasties are performed to provide resurfacing of the floor of the debrided fissure with a flap of skin or rectal mucosa. Several techniques have been described. The mucosal anoplasty can be performed in association with V-Y cutaneous advancement flap or rotation flap to bring skin up

to the pectineal line. Observational series have shown good results for healing without disturbance of continence. The few controlled trials comparing anoplasty to LIS are encouraging but are not sufficient to decide in their favor [44]. Anoplasties have the advantage of not injuring the internal anal sphincter and therefore are particularly useful in patients at high risk of anal incontinence after sphincterotomy.

Anal dilatation The objective of anal dilatation is to reduce sphincter spasm by deliberate rupture of the internal sphincter. Uncontrolled anal dilatation (manual or using dilators) is no longer recommended since it is three times less effective than LIS with a 51% risk of permanent anal incontinence [33,44]. In recent years, techniques have emerged based on the same principle but using a more controlled and standardized approach to anal dilatation. ‘‘Sphincterolysis’’, consisting of rupture of the internal sphincter fibers by firm finger pressure within the anal canal, results in a healing rate of 96.5% with a 3.5% incidence of anal incontinence that recovers in 97% of cases [53]. Controlled sphincteric dilatation using a progression of anal dilators up to a diameter of 48 mm [54] or using a pneumatic balloon [55] were compared with LIS. The results are encouraging, similar to sphincterotomy in terms of healing but with a lesser tendency to produce anal incontinence.

Summation of surgical treatment American and British surgical societies agree in recommending against uncontrolled manual dilatation. The ASCRS feels that calibrated sphincterotomy may also be offered as firstline therapy without prior medical treatment in order to decrease internal sphincter tone [32]. The ACPGBI states that LIS is indicated in cases of failed medical treatment, or of chronic anal fissure with hypertonic anal sphincter. Fissurectomy is an alternative that can be optionally associated with botulinum toxin injection. If the anal sphincter is hypotonic, anoplasty is recommended [33].

Indications for surgery in practice First-line surgery Surgery is indicated for cases of infected anal fissure, suspicion of malignancy, acute fissure with severe pain uncontrolled by medical treatment, or chronic fissure after failure of medical management for at least six to eight weeks (Figs. 1 and 2). The choice of surgical technique depends on several factors. An anal fissure with sphincter spasm but without significant fibrosis is best treated by LIS, which is the most effective treatment, although the patient must be informed of the risk of complications including anal incontinence. Infected anal fissure be treated with sphincterotomy, fissurectomy and laying the intersphincteric collection open. For anal fissure with important elements of fibrosis, fissurectomy with anoplasty is a treatment alternative, particularly in patients at high risk of anal incontinence or who refuse the risk of incontinence associated with LIS.

In case of failure After failure of medical treatment, treatment can be optimized by changing or increasing the strength or dose of sphincter-relaxing medications, or by proceeding to

Please cite this article in press as: Higuero T. Update on the management of anal fissure. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.07.007

+Model JVS-415; No. of Pages 7

ARTICLE IN PRESS

Update on the management of anal fissure

Figure 1.

Management of acute anal fissure.

surgical therapy which must then address the problem as one of primary chronic anal fissure. If surgical treatment fails, further efforts must be guided by the wishes of the patient and possibly by the results of anorectal manometry and endoanal ultrasound. If sphincter spasm persists after simple fissurectomy, LIS is the next appropriate step. If the patient has risk factors for developing anal incontinence, anoplasty with or without topical application of 0.4% NTG may be proposed. If LIS fails, a repeat internal sphincterotomy can be proposed if the amount of sphincter divided at the initial procedure was inadequate, or contralateral LIS can be performed, although this increases the risk of anal incontinence. When risk factors for anal incontinence are present, anoplasty with or without fissurectomy, eventually combined with topical 0.4% NTG, is the preferred approach.

Figure 2.

5

Special cases During pregnancy, anal fissure often occurs due to constipation, high hormonal levels, and altered perineal dynamics that impede healing. Hypertonic sphincter spasm is usually not present. Treatment here should be medical with local topical agents and stool softeners. Contraindications to the use of analgesics, particularly NSAIDs, must be respected. Delayed surgery may be indicated after failure of medical treatment for at least six months. Anal fissure occurs commonly in the post-partum period (15%). It can be prevented by the early use of laxatives and a high fiber diet. In children, non-specific medical treatment should be the rule for initial treatment. It is important to eliminate any factors favoring severe constipation or encopresis. Medical therapy results in healing within 10 to 14 days in most cases.

Management of chronic anal fissure.

Please cite this article in press as: Higuero T. Update on the management of anal fissure. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.07.007

+Model JVS-415; No. of Pages 7

ARTICLE IN PRESS

6

T. Higuero

Fissures that persist beyond eight weeks can be treated with topical NTG and/or CCBs. Surgery is rarely needed and should be discussed only if medical treatment fails (LIS).

Conclusion As a rule, anal fissure causes painful ulceration associated with spasm of the internal sphincter. While the pain of acute anal fissure is usually controlled with analgesics and heals with conservative treatment including topical agents and regularization of bowel movements, chronic fissure can sometimes develop. Specific medical treatment to decrease sphincter spasm should be proposed if first-line medical treatment fails or as an immediate treatment if the fissure is associated with severe pain. Surgical therapy remains the most effective treatment: fissurectomy with or without anoplasty (mainly in France) or lateral internal sphincterotomy (mainly in Anglo-Saxon countries).

KEY POINTS • Non-specific medical treatment (high fiber diet, medications to regulate bowel movements, topical agents and analgesics) is always proposed as first-line therapy. • Nitrate derivatives (0.4% NTG) for topical application can be proposed initially or used in case of failure of non-specific medical treatment. Topical calcium channel blockers and botulinum toxin have not been approved in France by the AMM for the treatment of anal fissure. • Surgery remains the most effective long-term treatment of chronic anal fissure • Surgery should be proposed for complicated or chronic anal fissure, for acute anal fissure with severe pain, and for recurrent fissure despite optimal medical treatment. • Surgical treatment is based on two principles that may be simultaneously addressed: to decrease hypertonic sphincter spasm and to excise the fissure itself. • Forcible uncontrolled sphincter dilatation is no longer recommended. • Fissurectomy with anoplasty should be preferred to sphincteroplasty if the patient has risk factors for anal incontinence. • The objective of sphincteroplasty is to decrease the resting tone of the internal anal sphincter, thereby improving blood flow to the anoderm and wound healing. • The effectiveness of lateral internal sphincterotomy increases with the amount of sphincter divided and should allow the sphincter to dilate to a diameter of 3 cm. Rigorous attention to technique is necessary to diminish the risk of anal incontinence.

Disclosure of interest Continuing medical education financed by Bayer, congress trip financed by JJSF.

References [1] Hananel N, Gordon PH. Re-examination of clinical manifestations and response to therapy of fissure-in-ano. Dis Colon Rectum 1997;40(2):229—33. [2] American Gastroenterological Association. American Gastroenterological Association medical position statement: diagnosis and care of patients with anal fissure. Gastroenterology 2003;124(1):233—4. [3] Abramowitz L, Sobhani I, Benifla JL, et al. Anal fissure and thrombosed external hemorrhoids before and after delivery. Dis Colon Rectum 2002;45(5):650—5. [4] Farouk R, Duthie GS, MacGregor AB, et al. Sustained internal sphincter hypertonia in patients with chronic anal fissure. Dis Colon Rectum 1994;37(5):424—9. [5] Lund JN, Binch C, McGrath J, et al. Topographical distribution of blood supply to the anal canal. Br J Surg 1999;86(4):496—8. [6] Klosterhalfen B, Vogel P, Rixen H, et al. Topography of the inferior rectal artery: a possible cause of chronic, primary anal fissure. Dis Colon Rectum 1989;32(1):43—52. [7] Schouten WR, Briel JW, Auwerda JJ. Relationship between anal pressure and anodermal blood flow. The vascular pathogenesis of anal fissures. Dis Colon Rectum 1994;37(7):664—9. [8] Schouten WR, Briel JW, Auwerda JJ, et al. Ischaemic nature of anal fissure. Br J Surg 1996;83(1):63—5. [9] Lund JN, Scholefield JH. A randomised, prospective, doubleblind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure. Lancet 1997;349(9044):11—4. [10] Kennedy ML, Sowter S, Nguyen H, et al. Glyceryl trinitrate ointment for the treatment of chronic anal fissure: results of a placebo-controlled trial and long-term follow-up. Dis Colon Rectum 1999;42(8):1000—6. [11] Carapeti EA, Kamm MA, McDonald PJ, et al. Randomised controlled trial shows that glyceryl trinitrate heals anal fissures, higher doses are not more effective, and there is a high recurrence rate. Gut 1999;44(5):727—30. [12] Siproudhis L, Sébille V, Pigot F, et al. Lack of efficacy of botulinum toxin in chronic anal fissure. Aliment Pharmacol Ther 2003;18(5):515—24. [13] Maria G, Cassetta E, Gui D, et al. A comparison of botulinum toxin and saline for the treatment of chronic anal fissure. N Engl J Med 1998;338(4):217—20. [14] Jensen SL. Treatment of first episodes of acute anal fissure: prospective randomised study of lignocaine ointment versus hydrocortisone ointment or warm sitz baths plus bran. Br Med J (Clin Res Ed) 1986;292(6529):1167—9. [15] Jensen SL. Maintenance therapy with unprocessed bran in the prevention of acute anal fissure recurrence. J R Soc Med 1987;80:296—8. [16] Shub HA, Salvati EP, Rubin RJ. Conservative treatment of anal fissure: an unselected, retrospective and continuous study. Dis Colon Rectum 1978;21:582—3. [17] Nelson RL, Thomas K, Morgan J, et al. Non surgical therapy for anal fissure. Cochrane Database Syst Rev 2012;2. [18] Gagliardi G, Pascariello A, Altomare DF, et al. Optimal treatment duration of glyceryl trinitrate for chronic anal fissure: results of a prospective randomized multicenter trial. Tech Coloproctol 2010;14(3):241—8. [19] Scholefield JH, Bock JU, Marla B, et al. A dose finding study with 0.1%, 0.2%, and 0.4% glyceryl trinitrate ointment in patients with chronic anal fissures. Gut 2003;52(2):264—9. [20] Altomare DF, Binda GA, Canuti S, et al. The management of patients with primary chronic anal fissure: a position paper. Tech Coloproctol 2011;15(2):135—41. [21] Jonas M, Lund JN, Scholefield JH. Topical 0.2% glyceryl trinitrate ointment for anal fissures: long-term efficacy in routine clinical practice. Colorectal Dis 2002;4(5):317—20. [22] Graziano A, Svidler López L, Lencinas S, et al. Long-term results of topical nitroglycerin in the treatment of chronic anal fissures are disappointing. Tech Coloproctol 2001;5(3):143—7. [23] Fruehauf H, Fried M, Wegmueller B, et al. Efficacy and safety of botulinum toxin A injection compared with

Please cite this article in press as: Higuero T. Update on the management of anal fissure. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.07.007

+Model JVS-415; No. of Pages 7

ARTICLE IN PRESS

Update on the management of anal fissure

[24]

[25]

[26]

[27]

[28]

[29]

[30]

[31]

[32]

[33]

[34]

[35]

[36]

[37]

[38]

[39]

topical nitroglycerin ointment for the treatment of chronic anal fissure: a prospective randomized study. Am J Gastroenterol 2006;101:2107—12. Sinha R, Kaiser AM. Efficacy of management algorithm for reducing need for sphincterotomy in chronic anal fissures. Colorectal Dis 2012;14(6):760—4. Lysy J, Israeli E, Levy S, et al. Long-term results of ‘‘chemical sphincterotomy’’ for chronic anal fissure: a prospective study. Dis Colon Rectum 2006;49:858—64. Perrotti P, Bove A, Antropoli C, et al. Topical nifedipine with lidocaine ointment vs. active control for treatment of chronic anal fissure: results of a prospective, randomized, double-blind study. Dis Colon Rectum 2002;45(11):1468—75. Carapeti EA, Kamm MA, Phillips RK. Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects. Dis Colon Rectum 2000;43(10):1359—62. Jonas M, Neal KR, Abercrombie JF, et al. A randomized trial of oral vs. topical diltiazem for chronic anal fissures. Dis Colon Rectum 2001;44(8):1074—8. Bielecki K, Kolodziejczak M. A prospective randomized trial of diltiazem and glyceryltrinitrate ointment in the treatment of chronic anal fissure. Colorectal Dis 2003;5(3):256—7. Kocher HM, Steward M, Leather AJ, 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(4):413—7. Jonas M, Speake W, Scholefield JH. Diltiazem heals glyceryl trinitrate-resistant chronic anal fissures: a prospective study. Dis Colon Rectum 2002;45(8):1091—5. Perry WB, Dykes SL, Buie WD, et al. Practice parameters for the management of anal fissures (3rd revision). Dis Colon Rectum 2010;53(8):1110—5. Cross KL, Massey EJ, Fowler AL, et al. The management of anal fissure: ACPGBI position statement. Colorectal Dis 2008;10(Suppl. 3):1—7. Nash GF, Kapoor K, Saeb-Parsy K, et al. The long-term results of diltiazem treatment for anal fissure. Int J Clin Pract 2006;60(11):1411—3. Yiannakopoulou E. Botulinum toxin and anal fissure: efficacy and safety systematic review. Int J Colorectal Dis 2012;27(1):1—9. Daniel F, de Parades V, Siproudhis L, et al. Botulinum toxin and chronic anal fissure. Gastroenterol Clin Biol 2006;30(5):687—95. Shao WJ, Li GC, Zhang ZK. Systematic review and meta-analysis of randomized controlled trials comparing botulinum toxin injection with lateral internal sphincterotomy for chronic anal fissure. Int J Colorectal Dis 2009;24(9):995—1000. Brisinda G, Maria G, Sganga G, et al. Effectiveness of higher doses of botulinum toxin to induce healing in patients with chronic anal fissures. Surgery 2002;131(2):179—84. Abramowitz L, Bouchard D, Souffran M, et al. Sphincter-sparing anal fissure surgery: a 1-year prospective, observational,

7

[40]

[41]

[42]

[43]

[44] [45]

[46]

[47] [48]

[49]

[50]

[51] [52]

[53] [54]

[55]

multicentre study of fissurectomy with anoplasty. Colorectal Dis 2013;15(3):359—67. Schornagel IL, Witvliet M, Engel AF. Five-year results of fissurectomy for chronic anal fissure: low recurrence rate and minimal effect on continence. Colorectal Dis 2012;14(8):997—1000. Lindsey I, Cunningham C, Jones OM, et al. Fissurectomybotulinum toxin: a novel sphincter-sparing procedure for medically resistant chronic anal fissure. Dis Colon Rectum 2004;47(11):1947—52. Scholz T, Hetzer FH, Dindo D, et al. Long-term follow-up after combined fissurectomy and Botox injection for chronic anal fissures. Int J Colorectal Dis 2007;22(9):1077—81. Mousavi SR, Sharifi M, Mehdikhah Z. A comparison between the results of fissurectomy and lateral internal sphincterotomy in the surgical management of chronic anal fissure. J Gastrointest Surg 2009;13(7):1279—82. Nelson R. Operative procedures for fissure in ano. Cochrane Database Syst Rev 2011:CD002199. Patti R, Territo V, Aiello P, et al. Manometric evaluation of internal anal sphincter after fissurectomy and anoplasty for chronic anal fissure: a prospective study. Am Surg 2012;78(5):523—7. Patel SD, Oxenham T, Praveen BV. Medium-term results of anal advancement flap compared with lateral sphincterotomy for the treatment of anal fissure. Int J Colorectal Dis 2011;26(9):1211—4. Lund JN, Scholefield JH. Aetiology and treatment of anal fissure. Br J Surg 1996;83(10):1335—44 [Review]. Garcia-Aguilar J, Belmonte C, Wong WD, et al. Open vs. closed sphincterotomy for chronic anal fissure: long-term results. Dis Colon Rectum 1996;39(4):440—3. Nyam DC, Pemberton JH. Long-term results of lateral internal sphincterotomy for chronic anal fissure with particular reference to incidence of fecal incontinence. Dis Colon Rectum 1999;42(10):1306—10. Elsebae MM. A study of fecal incontinence in patients with chronic anal fissure: prospective, randomized, controlled trial of the extent of internal anal sphincter division during lateral sphincterotomy. World J Surg 2007;31:2052—7. Cho DY. Controlled lateral sphincterotomy for chronic anal fissure. Dis Colon Rectum 2005;48:1037—41. Mentes BB, Guner MK, Leventoglu S, et al. Fine-tuning of the extent of lateral internal sphincterotomy: spasm-controlled vs. up to the fissure apex. Dis Colon Rectum 2008;51:128—33. Gupta PJ. Closed anal sphincter manipulation technique for chronic anal fissure. Rev Gastroenterol Mex 2008;73(1):29—32. Yucel T, Gonullu D, Oncu M, et al. Comparison of controlledintermittent anal dilatation and lateral internal sphincterotomy in the treatment of chronic anal fissures: a prospective, randomized study. Int J Surg 2009;7(3):228—31. Renzi A, Izzo D, Di Sarno G, et al. Clinical, manometric, and ultrasonographic results of pneumatic balloon dilatation vs. lateral internal sphincterotomy for chronic anal fissure: a prospective, randomized, controlled trial. Dis Colon Rectum 2008;51(1):121—7.

Please cite this article in press as: Higuero T. Update on the management of anal fissure. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.07.007

Update on the management of anal fissure.

Anal fissure is an ulceration of the anoderm in the anal canal. Its pathogenesis is due to multiple factors: mechanical trauma, sphincter spasm, and i...
1MB Sizes 0 Downloads 6 Views