Long-term Outcome of a Fissurectomy: A Prospective Single-Arm Study of 50 Operations out of 349 Initial Patients

PURPOSE: The surgical standard of care for patients with chronic anal fissure is still disputed. We aimed to assess the natural course of idiopathic anal fissure and the long-term outcome of a fissurectomy as a surgical treatment. METHODS: All consecutive patients referred to a single expert practitioner in a tertiary centre were primarily included. A fissurectomy was proposed in cases of refractory symptoms after 4 to 6 weeks of standard medical management. Only patients with idiopathic and noninfected anal fissures were included in this second subsample to undergo surgery. Conventional postoperative management was prescribed for all patients who had undergone surgery. The main outcome measures were the success rate (defined as a combination of wound healing and relief of pain) and postoperative anal continence. RESULTS: Three hundred forty-nine patients were primarily recruited. Fifty patients finally underwent surgery for an idiopathic and noninfected fissure. Among them, 47 (94%) were cured at the end of primary follow-up, and 44 of the 47 (93.6%) could be confirmed as being sustainably cured in the longer-term follow-up. The mean time of complete healing was 10.3 weeks (range, 5.7–36.4 weeks). All patients were free of pain at weeks 42. The continence score after surgery was not statistically different from the preoperative score. CONCLUSION: A fissurectomy for the treatment of patients with an idiopathic noninfected fissure is associated with rapid pain relief and a high success rate even though complete healing may often be delayed. Moreover, it appears to have no adverse effect on continence.

Length Tension Function of Puborectalis Muscle: Implications for the Treatment of Fecal Incontinence and Pelvic Floor Disorders

BACKGROUND/AIMS: External anal sphincter (EAS) and puborectalis muscle (PRM) play important role in anal continence function. Based on length-tension measurement, we recently reported that the human EAS muscle operates at short sarcomere length under physiological conditions. Goal of our study was to determine if PRM also operates at the short sarcomere length. METHODS: Length-tension relationship of the PRM muscle was studied in vivo in 10 healthy nullipara women. Length was altered by vaginal distension using custom-designed probes of 5, 10, 15, 20, 25 and 30 mm diameters as well as by distending a polyethylene bag with different volumes of water. Probes were equipped with a reverse perfuse sleeve sensor to measure vaginal pressure (surrogate of PRM tension). PRM electromyogram (EMG) was recorded using wire electrodes. Three-dimensional ultra-sound images were obtained to determine effect of vaginal distension on PRM length. RESULTS: Ultrasound images demonstrate distension volume dependent increase in PRM length. Rest and squeeze pressures of vaginal bag increased with the increase in bag volume. Similarly, the change in vaginal pressure, which represents the PRM contraction increased with the increase in the probe size. Increase in probe size was not associated with an increase in EMG activity (a marker of neural drive) of the PRM. CONCLUSIONS: Probe size dependent increase in PRM contraction pressure, in the presence of constant EMG (neural input) proves that the human PRM operates at short sarcomere length. Surgically adjusting the PRM length may represent a novel strategy to improve treat anal continence and possibly other pelvic floor disorders.

Evaluation of Anal Continence Function by Analysis of the Rectoanal Reflex

PURPOSE: The rectoanal reflex is a response of the anal sphincter to rectal distension, reflecting the functional nature of the anal sampling mechanism of rectal discrimination. The role of this reflex in the continence mechanism is believed to be important, but it exact role still remains to be proven, and the stratification of this reflex, along to the degree of functional impairment of the anal sphincter, is rarely performed. The aim of this study was to assess the differences between various parameters of this reflex among healthy volunteers and incontinent and constipated patients. METHODS: The rectoanal contractile and inhibitory reflexes were recorded in 20 normal controls (group A) and 25 constipated (group B) and 19 incontinent patients (group C). The latencies, areas under the reflex curves, amplitudes and recovery times of each reflex were individually estimated, and differences between the groups statistically analyzed. RESULTS: The inhibitory reflex was not detected in 2 cases from group B (8.0%) and 1 from group C (5.26%). The contractile reflex was not detected in 2 cases from group A (10.0%), 8 from group B (32.0%) and 10 from group C (52.63%). There were no significant differences in any of the parameters in a comparison of the three groups. In a two group comparison, the amplitude and area under the reflex curves of the inhibitory reflex differed significantly between groups B and C (P=0.0373, 0.0238), and the latency of the contractile reflex differed significantly between groups A and C (P=0.0476). CONCLUSION: Both the rectoanal reflexes showed significant differences between the three patient groups, although this was not the case with all parameters. An analytical assessment of the various parameters of those reflexes would, therefore, make it possible to stratify the functional impairment of anal continence.