ABSTRACT
RESUMEN La fisura anal es una patología proctológica frecuente caracterizada por un desgarro oval en el anoder mo que, si bien es pequeño, puede producir mucho dolor y angustia en el paciente. La etiología exacta aún se discute, pero está relacionada con una hipertonía del esfínter anal en la mayoría de los casos. El tratamiento inicial es médico, con fármacos que disminuyen el tono del esfínter anal. Las fisuras cróni cas generalmente requieren tratamiento quirúrgico. La esfinterotomía interna lateral tiene un elevado porcentaje de éxito y se considera el tratamiento de referencia. En este artículo haremos una revisión de la anatomía, fisiopatología y opciones terapéuticas actuales de las fisuras anales.
ABSTRACT Anal fissure is a common anorectal condition. While it often presents as a small oval tear in the anoderm, it can cause significant pain and anguish to the patient. The exact etiology is still debatable but increased anal tone is associated with most fissures. The initial management is medical with agents intended to reduce the anal tone. More chronic fissures usually require surgical intervention. Lateral internal sphincterotomy has a high success rates and is considered the gold standard of interventions. In this article we review the relevant anatomy, pathophysiology and contemporary treatment options for anal fissures.
Subject(s)
Fissure in Ano/surgery , Fissure in Ano/etiology , Fissure in Ano/therapy , Anal Canal/anatomy & histology , Fissure in Ano/physiopathology , Lateral Internal SphincterotomyABSTRACT
RESUMEN Fundamento: las enfermedades benignas del recto son muy frecuentes en la práctica médica habitual en todos los niveles de atención de salud, pero en especial en los servicios especializados. Dentro de estos procesos se reconoce que la fisura anal es uno de los más comunes. En Cuba, representan alrededor de un 30-35 % de las consultas e intervenciones en los servicios de Coloproctología. Objetivo: determinar la efectividad de la esfinterotomía lateral interna subcutánea cerrada en pacientes con el diagnóstico de fisura anal crónica. Métodos: se realizó un estudio descriptivo, de corte longitudinal y prospectivo, en pacientes con el diagnóstico de fisura anal crónica, atendidos en los servicios de proctología del Hospital Universitario Manuel Ascunce Domenech de la provincia Camagüey, de septiembre 2016 a septiembre de 2017. El universo estuvo constituido por los 132 pacientes adultos que acudieron al servicio de Coloproctología de dicha institución con el diagnóstico de fisura anal crónica. A todos los pacientes se les aplicó una encuesta validada por criterios de expertos, previo consentimiento informado por parte de los mismos. Resultados: en la investigación existió una elevada incidencia de la fisura anal crónica en el grupo etareo de 40 a 49 años y en el sexo femenino, la sintomatología que predominó fue el dolor, seguido del sangramiento rectal con localización posterior, con una evaluación al final del tratamiento de curado. Conclusiones: la efectividad de la esfinterotomía lateral interna subcutánea cerrada es una técnica que tiene pocas reacciones adversas y derivación a otros tratamientos.
ABSTRACT Background: benign rectal diseases are very frequent in the usual medical practice at all levels of health care, but especially in specialized services. Within these processes it is recognized that Anal Fissure is one of the most common. In Cuba, they represent approximately 30-35 % of consultations and interventions in the services of Coloproctology. Objective: to determine the effectiveness of closed subcutaneous internal lateral sphyncterotomy in patients with chronic anal fissure diagnosis. Methods: a descriptive, longitudinal and prospective study was performed in patients with chronic anal fissure diagnosis, assisted in the services of proctology of the Teaching Hospital Manuel Ascunce Domenech from September 2016 to September 2017. The universe consisted of the 132 adult patients who came to the Coloproctology service of this institution with the diagnosis of chronic anal fissure. A validated survey was applied to all patients, based on expert criteria, with prior informed consent. Results: in the investigation there was a high incidence of chronic anal fissure in the age group of 40 to 49 years and in the female sex; the predominant symptomatology was pain, followed by rectal bleeding, located in the posterior area, with an evaluation at the end of the curing treatment. Conclusions: the effectiveness of closed internal lateral sphyncterotomy is given because this technique has few adverse reactions and referral to other treatments.
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Introduction: Anal fissure was first described by Recamier in 1829. It is a linear ulcer in the anoderm. Anal fissures are most commonly seen in young adults and have a slight female preponderance. Although a relatively minor entity, the morbidity in the general population is very large. Our knowledge of the pathophysiology and management of anal fissure has rapidly progressed over the past 15 years. All methods of treatment aim to reduce the anal sphincter spasm and aid in pain relief and healing of fissure. Aim: The main aim of this study is to compare the efficacy of topical 2% Diltiazem ointment and lateral internal sphincterotomy (LIS) in the management of chronic fissure in ano. Materials and Methods: This is a prospective study of 70 patients with chronic fissure in ano. A number of 35 patients were treated with diltiazem (2%) topical ointment and 35 patients were treated with LIS. The effectiveness of both treatment modalities was assessed on 2, 4, and 6 weeks follow-up. Result: Healing of fissure was complete in 24 (68.7%) patients of topical diltiazem group and 33 (94.28%) patients of LIS group after 6 weeks of treatment. A maximum number of patients (97.14%) achieved symptomatic relief who underwent LIS at 4 weeks follow-up. Patients who underwent LIS had an immediate pain relief when compared to those who were treated with topical diltiazem 2% ointment. Both topical diltiazem 2% ointment and LIS were equally effective in reducing bleeding per rectum in patients with chronic fissure in ano. Conclusion: Time taken for fissure healing in topical diltiazem group is long in comparison to LIS group. Surgical treatment with LIS is the treatment of choice in chronic fissure in ano.
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Introduction: Lateral internal sphincterotomy is an effective treatment for fissure in ano but carries a definite risk of incontinence. In trail to avoid this complication and to study the clinical outcomes such as the symptomatic relief, early postoperative wound healing, safety, and efficacy after segmental internal sphincterotomy, it was used to treat chronic anal fissure. Materials and Methods: This is hospital-based, cohort study was conducted at the NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, Maharashtra, India. This study was undertaken on 62 patients (35 male and 27 female, with mean age 38 years) with chronic fissure in ano from March 2012 to March 2015. Surgical intervention, i.e., lateral internal segmental sphincterotomy done in two segments under direct vision under spinal anesthesia. Post-operative course with early and long-term result was recorded. Mean follow-up was 32 weeks (ranging from 2 to 48 weeks). Results and Discussion: In all patients, the technique was done under spinal anesthesia. The fissure and anal wound were healed within 4 weeks. The pain was reduced at postoperative day 1 in all patients. There were no early complications; one male patient had an infection at anal wound site at the 4th post-operative week which was managed conservatively. No transient or any persistent degree of incontinence occurred in these patients group. Conclusion: Segmental lateral internal sphincterotomy is a safe, easy, and effective procedure and not associated with risk of incontinence for the treatment of chronic anal fissure.
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Objective: Evaluate clinical, functional and morphologic outcomes of lateral sphincterotomy for chronic anal fissure treatment, and correlate the findings with factors that influence in the anal continence. Method: In a prospective study, female patients treated by lateral sphincterotomy for chronic anal fissure were assessed using Wexner's incontinence score and grouped according to score: group I (score = 0) and group 2 (score ≥1) and evaluated with anal manometry and anorectal 3D ultrasonography. Results: Thirty-six womens were included, 33% had vaginal delivery. Seventeen patients were included in group I and 19 in group II. We found no difference in age, parity and mode of delivery between groups. A significant difference with respect to percentage reduction in resting pressures was noted, when comparing group 1 versus group 2. The anal sphincter muscle length was similar in both groups. However, the length and percentage of transected internal anal sphincter was significantly greater in group II. Conclusion: There was a correlation between fecal incontinence symptoms after sphincterotomy with the percentage of resting pressure reduction, length and percentage of transected internal anal sphincter. .
Objetivo: Avaliar os resultados clínicos, funcionais e morfológicos de pacientes submetidas à esfincterotomia para tratamento de fissura anal, correlacionando os resultados com os fatores que podem interferir com a continência fecal. Método: Foram avaliadas prospectivamente pacientes do sexo feminino submetidas à esfincterotomia lateral interna devido à presença de fissura anal crônica utilizando o escore de incontinência de Wexner e distribuídas em dois grupos. Grupo 1- Escore igual a zero e Grupo 2 - maior ou igual a 1. As pacientes foram submetidas à avaliação funcional e anatômica do canal anal utilizando manometria anorretal e ultrassonografia tridimensional anorretal. Resultados: Das 36 pacientes incluídas, 33% tinham história de parto vaginal. Dezessete pacientes foram incluídas no Grupo 1 e 19 no Grupo 2. Não houve diferença quanto à idade, paridade e tipo de parto entre grupos. Houve diferença significante em relação ao percentual de redução na pressão de repouso quando comparado o grupo 1 com grupo 2. Não houve diferença no comprimento da musculatura esfincteriana entre grupos. No entanto, o comprimento e o percentual de esfíncter anal interno seccionado foram significativamente maiores no grupo 2. Conclusão: Há correlação entre os sintomas de incontinência fecal pós esfincterotomia com o percentual de reducão das pressões de repouso, tamanho e percentual do esfíncter anal interno seccionado. .
Subject(s)
Humans , Female , Adult , Middle Aged , Fissure in Ano/complications , Fissure in Ano/diagnostic imaging , Lateral Internal Sphincterotomy/adverse effects , Anal Canal/surgery , Ultrasonography , Imaging, Three-Dimensional , Fecal Incontinence/complications , Fissure in Ano/surgery , ManometryABSTRACT
Background: The treatment of chronic anal fissure has changed greatly during the past two decades with ongoing research directed at lowering the internal anal sphincter tone and avoiding the risk of fecal continence disturbance. Glycerin trinitrate, topical calcium channel blockers and anal dilators and botulinum toxin injection alone are all known to be able to lower the internal anal sphincter tone but results have been disappointing in curing chronic anal fissure, often marginally better than to placebo. The surgical treatment in the form of lateral internal sphincterotomy is the gold standard for chronic anal fissure. Aims & Objective: The aim of this prospective study was to assess the efficacy of medical treatment in form of topical calcium channel blocker and surgery in the management of chronic anal fissure. The objective is to compare the efficacy with regard to complete healing, recurrence, incontinence and other complications after treatment with topical calcium channel blocker and lateral anal sphincterotomy. Material and Methods: From October 2010 to October 2012, 50 patients with typical chronic anal fissure completed the study. 25 patients were initially treated with topical calcium channel blocker for 8 weeks and rests 25 were treated with lateral anal sphincterotomy. During the follow-up healing rates, symptoms, incontinence scores, and therapy adverse effects were recorded. Results: Overall healing rates were 60% after 8 weeks therapy with topical calcium channel blocker. Whereas overall healing after lateral internal sphincterotomy group was 88% with no recurrence. Conclusion: Lateral internal sphincterotomy is far more effective than medical treatment, with significantly increased healing rates while avoiding risk of incontinence.
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Background: Lateral internal sphincterotomy has been accepted as the gold standard for chronic anal fissure. Despite the effectiveness, it carries a risk of fecal incontinence. Non-operative management of chronic anal fissure has been used as alternative treatment. Objectives: Evaluate the efficacy and long-term outcomes of botulinum toxin injection for the treatment of chronic anal fissure. Material and method: A prospective randomized controlled trial was conducted on 40 patients diagnosed with chronic anal fissure who were assigned to undergo either botulinum toxin injection or lateral internal sphincterotomy. Results: The wound-healing rate at 12 weeks and the reduction of post-treatment-resting pressure was significantly better in the sphincterotomy group. Complications and the continence status were not different between the two treatment groups. None of the patients in the sphincterotomy group required additional treatment, while seven patients in the botulinum toxin injection group underwent subsequent sphincterotomy within three years. Conclusion: The long-term result of botulinum toxin injection for chronic anal fissure was inferior to lateral internal sphincterotomy.
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PURPOSE: A lateral internal sphincterotomy (LIS) is a safe and effective surgical treatment that is the most commonly used one for patients with chronic anal fissure. However, reports on the recurrence rate and complications after LIS published in Korea are rare. The purpose of our study is to identify the types and rates of recurrence, the complications after LIS, and the differences in clinical outcomes between open and closed LIS. RESULTS: We used hospital records and telephone interviews to study retrospectively the rates of recurrence and complications of 898 patients who underwent a LIS for chronic anal fissure from July, 2003, to June 30, 2004. RESULTS: There were 292 male (mean age: 36.8 years, range: 16~84) and 606 female (mean age: 32.4 years, range: 1~68) patients. The preoperative mean maximum resting pressure in anal manommetry was 99.2 cmH2O in male patients and 97.7 cmH2O in female patients. Recurrence of fissure after LIS was present in five cases (0.6%). All underwent a LIS, on the same side of a previous LIS in four cases and on the opposite side in one case. Delayed healing of the fissure was present in six cases (0.7%). All of these patients were improved by conservative management. Complications of the LIS were thrombus formation, perianal abscess, fistula, and incontinence. Thrombus formation was present in eight cases (0.9%). Five patients underwent a thrombectomy and three patients were cured by conservative management. Perianal abscess or fistula was present in three patients (0.3%), who underwent incision and drainage or a simple fistulotomy. Incontinence was present in two cases (0.2%). One patient was lost to follow up, and the other patient was improved by conservative management. CONCLUSIONS: LIS is a safe and effective treatment for patients with chronic anal fissure, and recurrence and complications of LIS are rare.
Subject(s)
Female , Humans , Male , Abscess , Drainage , Fissure in Ano , Fistula , Hospital Records , Interviews as Topic , Korea , Lost to Follow-Up , Recurrence , Retrospective Studies , Thrombectomy , ThrombosisABSTRACT
PURPOSE: The aim of this study was to estimate the prevalence of anatomic anal stenosis in patients with chronic anal fissure (CAF) and ascertain the results of lateral internal sphincterotomy (LIS) using a new calibrator. METHODS: Ninety-eight adults with CAF and a control group of 40 normal adults underwent anal calibration under spinal anesthesia. The calibrator was a conical design and the diameter was scaled in increments of 1 mm. The calibration was standardized and the reliability of it was assessed by two independent examiners for the same group (n=45). Confounding effects of age, sex, body weight, and height on the anal caliber were studied. The internal sphincter was divided to the level of the dentate line during LIS. RESULTS: The anal caliber was 34.6 +/- 1.4 mm (mean +/- SD) in the control group and 28.7 +/- 3.0 mm (mean +/- SD) in patients with CAF. Excellent correlation was obtained between the two examiners (r=0.958). The confounding effects of age, sex, body weight, and height were not significant. Therefore, anal stenosis was defined as when the measurement was 31 mm or below (mean-2SD of control value). Stenosis was present in 82 of 98 patients (84%) with CAF. Patients with stenosis had an anal caliber of 27.9 +/- 2.5 mm, with a range of 21 to 31 mm. Following LIS, 91 of 98 patients (93%) with CAF attained the normal range, two patients still had stenosis, and five patients had an anal caliber exceeding the normal value. CONCLUSIONS: Anatomic anal stenosis was found in 84% of the patients with CAF. Ninety three percent of these patients attained a normal anal caliber, 2 percent of the patients still had stenosis and 5 percent of the patients had an anal caliber exceeding the normal value after LIS.