Manejo Clínico ­ Quirúrgico de pacientes con Fisura Anal en la Unidad de Coloproctología del HECAM / Clinical-Surgical Management of patients with Anal Fissure in the Unit HECAM Coloproctology

La fisura anal es una de las enfermedades más antiguamente descritas, la misma que, ha tenido hasta el momento múltiples tratamientos tanto médicos como quirúrgicos, existiendo controversias en su algoritmo terapéutico. Constituye una de las patologías cuyo diagnóstico y tratamiento corresponde a la Especialidad de Coloproctología, afecta a ambos sexos y a cualquier edad y puede ser aguda o crónica. Proponemos el presente Protocolo para un adecuado manejo de la patología, de manera que sirva de guía en la toma correcta de decisiones basadas en la evidencia y el consenso de quienes integramos la Unidad Técnica de Coloproctología del Hospital de Especialidades Carlos Andrade Marín.

Anal fissure is one of the oldest described diseases, which has so far had multiple medical and surgical treatments, with controversies in its therapeutic algorithm. It is one of the pathologies whose diagnosis and treatment corresponds to the Coloproctology Specialty, it affects both sexes and any age and can be acute or chronic. We propose the present Protocol for an adequate management of the pathology, so that it serves as a guide in the correct decision making based on evidence and consensus of those who integrate the Technical Unit of Coloproctology of the Hospital de Especialidades Carlos Andrade Marín.

Effect of Yashtimadhu Suppository with Cocoa Butter Base in the Pain Management of Parikartika

Parikartika is one of the common ano-rectal anomalies observed in clinical practise. In Ayurveda Samhitas, this condition is mostly mentioned as an Upadrava of Grahani, Atisara, Arshas and as Vamanavirechanavyapat. ‘Kartanavatvedhana’ is described as predominant symptom of Parikartika which means cutting type of pain in the anus. As per the description of signs and symptoms, Parikartika can be co-related to fissure-in ano in modern contexts. Yashtimadhu is the most widely used drug for Parikartika. Acharya Susruta has mentioned the drug Yashtimadhu in Trividhakarma Adhyaya in post-operative pain management and in treatment for Parikartika in Vamana virechana vyapat. Yashtimadhu in the form of Thaila and Ghrita are commonly used. Here, Yashtimadhuchurna was used to prepare a suppository with cocoa butter as its base for the management of Parikartika. Objectives: The objective of the clinical study is to evaluate any difference in the efficacy of Yashtimadhu suppository in treating Parikartika. Materials and Methods: The study was conducted as an open labelled, randomized, single arm clinical study. 40 Patients who are fulfilling the inclusion, exclusion, diagnostic criteria and complying with the informed consent was selected from OPD and IPD of Sri Jayendra Saraswathi Ayurveda College and Hospital [IEC NO- IEC/ SJSACH/ 09/2021, CTRI NO- CTRI/2021/07/035252]. Case proforma was prepared with all the appropriate details of the patient along with history and physical, rectal examination was done to diagnose Parikartika. Relevant laboratory investigations were performed. Yashtimadhu suppository was given twice per day for about 14 days to 40 patients along with 4 follow-ups once a week for one month after the treatment i.e., 7th, 14th, 21st, 28th day. The subjective parameter was pain and objective parameter were ulceration, sphincter tone. Grading was done according to the specified assessment criteria and was statistically analysed. Results: On completion of the study, statistical analysis was done on the data collected. The intervention, Yashtimadhu suppository showed significant difference in the outcome.

ANALYSIS AND COMPARATIVE STUDY OF TOPICAL CONSERVATIVEMEDICATION VERSUS OPERATIVE MANAGEMENT IN PATIENTS OFANAL FISSURE

Introduction:Anal fissures or anal ulcers are considered one of the commonest causes of severe analpain. Surgical techniques like manual anal(lords) dilatation or lateral internalsphincterotomy, effectively heal most fissures within a few weeks, but mayresult in permanently impaired anal continence. This has led to the research foralternative non-surgical treatmentAIMS AND OBJECTIVES:The present study comprises the comparative study of 2% Diltiazem gel,0.2% Glyceryl Nitrate,2%lignocaine jelly application and need of surgical intervention in the treatment of chronic fissure inano.MATERIALS AND METHODS: This is a prospective study of fissure in ano during the period from September 2020 to September2021 in Sheth Lallubhai Gordhandas Municipal General Hospital, Ahmedabad. Clinical Data ofadmitted patient were collected by their detail history after stabilizing the patient, clinicalexamination with appropriate investigations.OBSERVATION AND DISCUSSION:Anal fissure is a very common problem across the world. It causes considerablemorbidity and adversely affects the quality of life. Therefore appropriate treatment ismandatory.In this study the commonest age group affected was 31-40 years agegroup (40%) and least affected were 51-60 years age groupThe incidence of fissure in males was slightly greater than females with MaleFemale ratio being 2.2: 1 in our study.CONCLUSION:Propper clinical examination and appropriate investigations helps in management of patient eitheroperative or non-operative which leads successful treatment in these patients.

Effect of Yashtimadhu Ghrita Gudapurana on Post Operative Pain Management in Patients of Haemorrhoids and Fissure-in-ano with Special Reference to Shastranipataja Vedana: A Randomized Controlled Trial.

Modern medical Science has offered many surgical procedures like open and closed haemorrhoidectomy, anal dilatation, Sphincterotomy etc for haemorrhoides and fissure in ano. These operative procedures are associated with unavoidable sequel of symptoms like Pain, Discharge and Inflammation etc. Role of analgesia is vital in the treatment of post-operative pain. The mode of analgesia depends on degree or level of pain which is a subjective criteria. Analgesics routinely used are NSAIDs, opioids and corticosteroids. Side effects includes like Gastritis, Gastrointestinal bleeding etc. Hence, Analgesia has to be supplemented with antacids or H2 Receptor Agonists. Here, quest for knowledge for an alternative treatment to analgesics starts. According to Sushrutacharya, these diseases like Arsha and Parikartika are termed as Chhedya, i.e., treatable by surgery and he has indicated Yashtimadhu Ghrita in Shastranipataja Vedana. Methodology- In present study, total 100 postoperative patients of haemorrhoids and fissure in ano, randomly allocated into two groups (50 in each group). In Group A (n = 50), Yashtimadhu Ghrita Gudapurana was done every day after sitz bath for 5 days. In Group B (n = 50), local application of lignocaine jelly every day after sitz bath for 5 days. Result- Yashtimadhu Ghrita as a local application is clinically as effective as lignocaine jelly in the management of post operative pain in patients of hemorrhoids and fissures in ano. Conclusion- it was concluded that Yashtimadhu Ghrita is helpful in the management of pain in the post operative patient of haemorrhoids and fissure in ano

Analgesic effectiveness and improvement in quality of life after using topical sevoflurane for an extremely painful anal fissure / Eficácia analgésica e melhoria da qualidade de vida com o uso tópico de sevoflurano em fissura anal extremamente dolorosa

Painful anal fissures could be distressing conditions that severely impair the patients' quality of life. The analgesic effectiveness of topical drugs, such as calcium-antagonists and nitrates is quite variable. The inhalational anesthetic sevoflurane is being repurposed as a topical analgesic for painful chronic wounds.We report a pioneer experience treating a painful chronic anal fissure with topical sevoflurane. A young adult male was suffering from an extremely painful chronic anal fissure, which severely affected his quality of life. The topical treatment with nitroglycerine and diltiazem gels failed. The patient agreed to the treatement with topical sevoflurane as an off-label medication, and it produced an immediate, intense, and long-lasting analgesic effect. An intense but rapidly transient burning sensation, as well as persistent but well-tolerated flatulence were the only adverse effects. The quality of life was greatly improved, and the cost of the treatment was affordable. Therefore, the off-label use of topical sevoflurane appears to be an effective alternative for the symptomatic treatment of painful anal fissures (AU)

As fissuras anais dolorosas podem ser condições angustiantes que prejudicam gravemente a qualidade de vida dos pacientes. A eficácia analgésica de medicamentos tópicos, como antagonistas de cálcio e nitratos, é bastante variável. O anestésico inalatório sevoflurano está sendo reaproveitado como analgésico tópico para feridas crônicas dolorosas. Relatamos uma experiência pioneira de tratamento com sevoflurano tópico em fissura anal crônica dolorosa. Umjovemadulto do sexomasculino sofria de uma fissura anal crônica extremamente dolorosa, que afetava gravemente sua qualidade de vida. O tratamento tópico com nitroglicerina e géis de diltiazem foi ineficaz. O paciente concordou com o tratamento com sevoflurano tópico como medicamento off-label, ou seja, com uso diferente do aprovado embula. O sevoflurano tópico produziu um efeito analgésico imediato, intenso e duradouro. Uma sensação de ardência intensa, mas transitória, e flatulência persistente, embora bem tolerada, foram os únicos efeitos adversos. A qualidade de vidamelhorou significativamente, e o custo do tratamento revelou-se acessível. Portanto, o uso off-label de sevoflurano tópico pode ser uma alternativa analgésica eficaz em casos de fissuras anais dolorosas. (AU)

Analyzing the prevalence of proctological diseases in HIV-positive and -negative patients / Análise da prevalência de doenças proctológicas em pacientes HIV positivo e negativo

ABSTRACT Objective: To compare proctological diseases in HIV-positive and -negative patients. Method: Prospective study conducted in the proctology outpatient clinic at Instituto de Infectologia Emílio Ribas from 2013 through 2019. All of them underwent anamnesis and proctological examination and were divided into two groups (HIV+ and HIV−). The groups were then compared with regard to age, sex, diagnosis, and whether or not there was any indication for surgery. Results: 485 HIV + patients (41.9%) (Group I) and 672 HIV− (58.1%) (Group II). The mean age in Group I was 42.8 years, and 404 (83.3%) of the patients were males. In Group II, the mean age was 48.3 years, and 396 (59%) patients were females. In comparing the groups, a statistically significant difference was found regarding sex, age, and diagnosis. The incidence of hemorrhoid and anal skin tags was higher in group II and that of condyloma acuminata was higher in in Group I (p < 0.001). In Group I, condyloma acuminata was more prevalent, but in those with CD4 levels above 500 cells/mm3, the diagnoses were more similar to those in the population without HIV. Conclusions: Proctological diseases were found to be similar but have different incidences. The incidences of diseases in HIV− and + patients tend to approach each other as CD4 level increases.

RESUMO Objetivo: Comparar as doenças proctológicas nos pacientes HIV positivos e negativos. Método: Estudo prospectivo realizado no ambulatório de proctologia do Instituto de Infectologia Emílio Ribas de 2013 a 2019. Todos foram submetidos a anamnese e exame proctológico, e divididos em dois grupos (HIV+ e HIV−) sendo comparados em relação a idade, sexo, diagnóstico e se havia ou não indicação cirúrgica. Resultados: 485 pacientes HIV+ (41.9%) (Grupo I) e 672 HIV negativos (58.1%) (Grupo II). A média de idade do Grupo I foi 42.8 anos sendo 404 (83.3%) do masculino. No grupo II, a média de idade foi de 48.3 anos, sendo 396 (59%) do sexo feminino. Comparando os grupos, houve diferença estatisticamente significante em relação ao sexo, idade e diagnóstico. Houve maior incidência de hemorróida e plicoma no Grupo II e condilomas acuminados no Grupo I (p < 0.001). No Grupo I, o condiloma acuminado foi mais prevalente, porém naqueles com CD4 acima de 500 células/mm3, os diagnósticos se aproximaram da população sem HIV. Conclusão: As doenças proctológicas foram semelhantes, com incidências diferentes. A incidências das doenças de pacientes HIV− e + tendem a se aproximar na medida que o nível do CD4 aumenta.

La esfinterotomía lateral interna subcutánea cerrada en pacientes con fisura anal crónica / The closed subcutaneous internal lateral sphincterotomy in patients with chronic anal fissure diagnosis

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.

Use of diclofenac suppositories in pain management in acute fissure in ano in outpatient department care

Background: Per anal diseases and the pain management in such cases have always been a problematic solution for surgeons. There are various pain management methods for per anal cases, however we wanted a cheaper yet effective way and patient friendly method for pain management where no expertise would be required, hence we opted to see results of diclofenac suppositories which were easily available, patient could insert it without anyone’s help or assistance and hence need not be hospitalized for any intravenous analgesics.Methods: A study was conducted over 2000 cases over a span of 6 years in a tertiary centre. A control group A of 1000 patients was made where, oral (tablet diclofenac) plus local analgesics (xylocaine gel) were opted for whereas the other group B of 1000 patients was treated with diclofenac suppository 100 mg twice a day with glycerin as lubricant at anal verge. The pain score was noted in both the groups. All acute fissure in ano cases, we included in this study.Results: The pain score of the group B cases was much lower than the group A cases, and also the duration of results acquired was much lesser than group A.Conclusions: Diclofenac suppository 100 mg twice a day proved to be an excellent pain management method for acute fissure in ano cases in outpatient department care.

Anoplastia com plicoma sentinela para o tratamento de fissura anal crônica / Anoplasty with skin tag flap for the treatment of chronic anal fissure

RESUMO Objetivo: avaliar os resultados de longo prazo da correção de fissuras anais crônicas em pacientes sem hipertonia anal usando a técnica de anoplastia com o plicoma sentinela. Métodos: estudo prospectivo de pacientes com fissura anal crônica refratários ao tratamento conservador e sem hipertonia anal, submetidos à operação de anoplastia com utilização do plicoma anal para cobrir a área cruenta. Foi confirmada a ausência de hipertonia anal através do toque retal e da eletromanometria. Foi aplicado um questionário de dor visual e o escore de incontinência fecal da Cleveland Clinic, antes e após a cirurgia. Resultados: quinze pacientes com fissura anal crônica foram acompanhados por um período médio de 29 meses (12 a 56). A média de idade foi 41 anos (29 a 69) e a duração dos sintomas variou entre seis meses e cinco anos. A cicatrização ocorreu entre três e seis semanas para 13 pacientes (86,7%). Os outros dois pacientes foram submetidos a desbridamento e nova anoplastia, com sucesso. Em nenhum paciente ocorreu necrose do plicoma ou estenose anal. O escore de incontinência anal não se alterou após o procedimento e todos os pacientes referiram melhora da dor. Após 12 meses de seguimento, nenhum paciente apresentou recorrência ou incontinência anal e 93,3% (14/15) dos pacientes responderam estar muito satisfeitos. Conclusão: fissurectomia e anoplastia com o uso do plicoma sentinela é uma técnica segura que resulta em melhora da dor sem alterações da continência fecal e com altas taxas de satisfação.

ABSTRACT Objective: to evaluate the long-term results of the correction of chronic anal fissures (CAF) in patients without anal hypertonia using the technique of anoplasty with skin tag flap. Methods: we conducted a prospective study of CAF patients refractory to conservative treatment without anal hypertonia, subjected to anoplasty with the use of anal plicoma to cover the bloody area. We confirmed the absence of anal hypertonia through rectal exam and electromanometry. We applied a visual pain questionnaire and the Cleveland Clinic fecal incontinence score before and after surgery. Results: we followed 15 patients with chronic anal fissure for a mean period of 29 months (12-56). The mean age was 41 years (29-69) and the duration of symptoms ranged from six months to five years. Healing occurred between three and six weeks for 13 patients (86.7%). The other two patients underwent debridement and new anoplasty successfully. No plicoma necrosis or anal stenosis occurred in any patient. The anal incontinence score did not change after the procedure, and all patients reported reduced pain. After 12 months of follow-up, none of the patients presented recurrence or anal incontinence, and 93.3% (14/15) of the patients were very satisfied. Conclusion: fissurectomy and anoplasty with the use of sentinel plie is a safe technique that results in improvement in pain without change of fecal continence and with high satisfaction rates.

Study Of Chronic Fissure–In–Ano At Our Institute:

Anal fissure is common cause of anal pain. Exact aetiology of anal fissure is not known, but it is commonly seen due to constipation and hypertonic anal sphincter conditions. Studies on the method of treatment of anal fissure ranges from medical application to surgery. We have study of 200 cases of fissure in Ano for comparing in between treatment options of anal dilatation (AD) and lateral anal sphincterotomy (LAS). Patients were divided in two groups by randomly. In our study it has been shown that all the patients after anal dilatation significantly reduces the anal pain and provide symptomatic relief that is slightly better than lateral anal sphincterotomy

Implementación de un programa de cirugía proctológica en régimen de cirugía mayor ambulatoria: experiencia inicial / Early results of an ambulatory surgery programme for benign anorectal disorders

Introducción: La realización en régimen de cirugía mayor ambulatoria (CMA) de procedimientos proctológicos complejos es aún infrecuente en nuestro medio. El objetivo del presente trabajo es presentar los resultados iniciales de un programa de cirugía proctológica en régimen de CMA que incluye procedimientos complejos tales como esfinteroplastias o colgajos de avance rectal. Material y métodos: Se realizó un estudio descriptivo retrospectivo en el que se incluyeron 186 pacientes intervenidos de patología proctológica en un programa de CMA. El programa se basó en la unión de una Unidad de Coloproctología con amplia experiencia en cirugía proctológica y una Unidad de CMA ya establecida en el centro. Se analizaron los resultados tanto de ingreso como de reintervención en el postoperatorio inmediato y precoz. Resultados: Entre enero de 2014 y diciembre de 2015 se realizaron un total de 197 intervenciones, destacando 105 (53,3%) cirugías de fístula anal, 33 (16,8%) hemorroidectomías y 11 (5,6%) esfinteroplastias. De los pacientes intervenidos por fístula perianal, en 25 (23,8%) se realizó un colgajo de avance rectal. Una paciente (0,5%) requirió ingreso tras la cirugía por haberse realizado un proceso más complejo del inicialmente programado, todos los demás pacientes pudieron ser dados de alta sin complicaciones. Tres pacientes (1,5%) reingresaron en el postoperatorio precoz y fueron reoperados debido a una hemorragia poshemorroidectomía, un absceso perianal y dolor anal. Conclusiones: La implementación de un programa de patología proctológica en régimen de CMA que incluya procedimientos complejos como el colgajo de avance endorrectal o la esfinteroplastia es factible, con una baja tasa de ingresos en hospitalización y reingresos posteriores.

Introduction: Complex procedures for anorectal disorders are uncommonly performed as Ambulatory Surgery (AS). The aim of this study was to describe the early results of an AS program that included complex procedures such as advancement rectal flaps for fistula repair. Material and methods: A retrospective descriptive study was performed with 186 patients who were submitted to AS because of benign anorectal disorders. The AS program for anorectal disorders started when a Colorectal Surgery Unit with broad experience in anorectal surgery joined an AS Unit that was already working in the hospital. Hospital admissions and need of early reoperation were analyzed. Results: One hundred and ninety seven procedures were performed between January 2014 and December 2015. One hundred and five (53.3%) fistula repair surgeries were performed, as well as 33 (16.8%) hemorrhoidectomies and 11 (5.6%) anal sphincter repairs. Among the patients who were operated because of an anorectal fistulae, 25 (23.8%) were submitted to advancement rectal flap. One patient (0.5%) could not be discharged after the surgery because the procedure performed was more complex than previously expected. All other patients were discharged. Three patients (1.5%) were addmited during early postoperative course, all of them had to undergo revisional surgery because of hemorrhage, pain and anorectal abscess respectively. Conclusions: Anorectal procedures, including complex procedures such as advancement rectal flap and sphincter repair, can be performed as AS with a low percentage of patients addmited before or after discharge.

The effect observation of comprehensive intervention on postoperative pain of patients with rectal disease / 中国实用护理杂志

Objective To explore the effect of comprehensive intervention on postoperative pain of patients with rectal disease. Methods A total of 200 patients with postoperative pain after the treatment of anorectal perianal disease from May 2015 to May 2016 were randomly divided into two groups with 100 cases each. The control group was treated with drugs and usual nursing, the observation group were adopted drugs and comprehensive nursing intervention. The improvement of pain, psychological states and the quality of sleep were compared between two groups. Results The VAS pain scores at 4, 6, 12, 24, 48 h after treatment was (2.1 ± 0.6), (3.3 ± 0.4), (3.5 ± 0.3), (2.3 ± 0.5), (1.9 ± 0.5) points in the observation group, and (3.0 ± 0.5), (5.1 ± 0.6), (6.2 ± 0.6), (5.7 ± 0.8), (5.8 ± 0.5) points in the control group, and the difference was statistically significant (t=8.539-38.806, P < 0.05). The Self-rating Anxiety Scale was (20.32 ± 6.16) points in the observation group, and (35.58 ± 7.43) points in the control group, and the difference was statistically significant (t=41.188, P<0.05). The sleep quality, the amount of sleep , sleep time, sleep efficiency of Pittsburgh Sleep Quality Index Questionnaire scores was (0.91±0.28), (0.86±0.2), (0.83±0.27), (0.59±0.31), (0.62±0.27), (0.58±0.41), (4.39±1.79) points in the observation group, and (1.61± 0.88), (1.32 ± 0.75), (1.59 ± 0.89), (1.34 ± 0.58), (1.36 ± 0.45), (1.29 ± 0.86), (8.51 ± 3.55) points in the control group, and the difference was statistically significant (t=4.557-17.740, all P<0.05). Conclusions The comprehensive intervention on postoperative pain relief in patients with anal disease is significant, it is beneficial to relieve the pain response, improve sleep quality, and achieve physical and psychological comfort, and has a positive effect to clinical.

Comparative Study of Lateral Internal Sphincterotomy and Diltiazem 2% Topical Ointment in the Treatment of Chronic Fissure in Ano: A Prospective Study.

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.

Segmental Lateral Internal Sphincterotomy: A New Technique for Treatment of Chronic Anal Fissure - Clinical Outcome and Review of Literature.

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.

The feasibility and effectiveness of the interspincterotomy combined with PPH in the treatment of severe mixed hemorrhoids and anal fissure / 中国基层医药

Objective To explore the feasibility and effectiveness of the interspincterotomy combined with PPH in the treatment of severe mixed hemorrhoids and anal fissure.Methods 116 cases of glioma patients with post-operative residual lesions were treated.The observation group of 58 patients were treated with internal sphincterotomy combined with PPH resection,while 58 cases in the control group were treated by traditional external dissection and internal ligation plus resection of anal fissure.The efficacy and safety of treatment of the two groups of patients were evaluated.Results The operation time,hospitalization time,healing time,postoperative curative effect evaluation score of the observation group were (22.5 ±5.3)min,(2.1 ±0.9)d,(9.6 ±2.1)d and (9.8 ±1.6)points,respec-tively,which of the control group were (35.2 ±6.7)min,(9.1 ±2.5)d,(18.4 ±3.7)d and (5.3 ±1.2)points, there were significant differences between the two groups(t =5.68,4.95,6.33,1.35,all P 0.05),but seventh days after the operation,the pain,edema,hemorrhage control scores of the observation group were significantly better those of the control group(all P <0.05).The complication rate of the observation group was 5.17%,which of the control group was 17.24%,there was significant difference between the two groups(χ2 =4.25, P <0.05).Conclusion The interspincterotomy combined with PPH is an operation that meeting the requirements of modern hemorrhoid treatment.It is a safe and effective treatment.It is worthy of further promotion in the treatment of severe mixed hemorrhoid and anal fissure.

Sphincter-Preserving Therapy for Treating a Chronic Anal Fissure: Long-term Outcomes

PURPOSE: To estimate the risk of recurrent fissure in ano after sphincter preserving treatments. METHODS: A retrospective case note review, combined with a telephone survey was conducted for all patients treated for a chronic anal fissure between 1998 and 2008. RESULTS: Six hundred and twelve patients (303 women: mean age, 39 years; range, 16-86 years) were treated for chronic anal fissure between 1998 and 2008. Topical diltiazem 2% was initially prescribed for 8 weeks. The fissure did not heal in 141 patients. These patients (61 women: mean age, 30 years; range, 15-86 years) were treated with 100 IU botulinum A toxin (Botox) injection combined with a fissurectomy under general anaesthesia. Thirty eight patients suffered a recurrence of their fissure within two years. Thirty-four healed with further medical or sphincter conserving surgical therapy while four required a lateral internal sphincterotomy. CONCLUSION: The vast majority of patients with chronic anal fissure can be treated with sphincter conserving treatments. This may require several interventions before healing can be achieved. Assessment for recurrence after 'conservative' treatments requires a minimum of two-year follow-up.

Avaliação do tratamento de fissura anal crônica com isossorbida tópica a 1 por cento / Evaluation of the treatment of chronic anal fissure with topical isosorbide 1 percent

INTRODUÇÃO: Fissuras anais crônicas são úlceras benignas, dolorosas, profundas. Ocorrem devido a trauma das fezes, hipertonia esfincteriana e pobre vascularização. Cirurgia é mais efetiva, porém com efeitos adversos (incontinência anal). Terapia conservadora consegue decréscimo transitório da pressão de repouso, cicatrizando muitas lesões, sem dano muscular. MÉTODOS: Objetivando avaliar tratamento de fissuras crônicas com isossorbida (ISO) a 1 por cento tópica, foi realizado um ensaio clínico, duplo-cego em pacientes do Serviço de Coloproctologia da Universidade Federal de Sergipe (UFS) - Aracaju, Sergipe, durante um ano. Foram estudados 24 pacientes: 14 no Grupo 1 - creme com ISO, e 10 no Grupo 2 - placebo. Avaliaram-se comportamento da pressão de repouso, melhora da dor e grau de cicatrização das feridas com e sem ISO. RESULTADOS: Resultados mostraram que a fissura acometeu mais mulheres, a constipação foi observada em 58,3 por cento. Quanto à dor, obteve-se menor intensidade no Grupo 2, mas sem significância. A cicatrização ao fim de 60 dias foi igual nos dois grupos (50 por cento). Quanto às médias de pressão de repouso com 30 e 60 dias, houve queda no padrão em ambos os grupos, porém sem significância. Observou-se que pacientes curados foram os de maior redução de pressão de repouso. CONCLUSÃO: Concluiu-se que a ISO não modificou o padrão de resposta manométrica; todavia, houve melhora clínica importante nos dois grupos, cuja taxa de cicatrização foi equivalente.

INTRODUCTION: Chronic anal fissures are deep, benign and painful ulcers. The involved factors are local trauma, sphinter hypertonia and poor blood flow. Surgery is gold standard treatment, but it causes fecal incontinence. Medical non-surgical therapy gets transitory resting pressure reduction and cure of lesions, without muscular damage. METHODS: In order to evaluate the treatment of chronic anal fissures using topical isossorbide (ISO) 1 percent, a randomizated and double-blind study twas carried out in Coloproctology Section of Universidade Federal de Sergipe (UFS), Sergipe, Brazil, during one year. Twenty-four patients were evaluated: 14 in Group 1 - ISO cream, and 10 in Group 2 - placebo. Resting pressure profile, improvement of painful symptoms and degree of scaring of the fissure were evaluated. RESULTS: Ulcer was more prevalent in women, constipation was present in 58.3 percent. The evacuatory pain was less common in Group 2, but without statistical significance. After 60 days, the healing was equal in the both groups (50 percent). There was a small reduction of resting pressure means at the end of 30 and 60 days, without statistical significance. Healing patients presented more resting pressure reducing. CONCLUSION: ISO cream did not influence the manometric response standard; otherwise it offered clinical improvement in both groups, whose scarring index was similar.

Análise das complicações tardias em operações anorretais: experiência de um serviço de referência em coloproctologia / Analysis of late complications of anorectal procedures: experience of a referral coloproctology unit

INTRODUÇÃO: as operações anorretais correspondem a 80 por cento do movimento do coloproctologista. O índice de complicações tardias após estas operações é indefinido, e varia de acordo com o tipo de operação e serviço onde estas são realizadas. OBJETIVO: estabelecer a taxa de complicações tardias decorrentes das operações anorretais e fatores de risco que pudessem estar associados a estas complicações. MÉTODO: estudo retrospectivo (série de casos) dos pacientes submetidos a operações anorretais entre janeiro de 2007 e julho de 2009. Variáveis estudadas: sexo, idade, operação, sistema de saúde, técnica de anestesia, complicações tardias, além da taxa de reoperações realizadas. RESULTADOS: foram avaliados 430 pacientes (234 mulheres - 54,4 por cento), submetidos a 453 operações anorretais. A hemorroidectomia foi o mais freqüente procedimento realizado: 50,3 por cento das operações. Encontrou-se 102 complicações tardias pós-operatórias, representando 22,52 por cento dos casos. A fissura anal residual foi a complicação mais freqüente (54 por cento/ n=55). Somente 38 pacientes necessitaram de reintervenção cirúrgica (8,83 por cento). Não houve diferença significativa em relação ao sexo, idade, sistema de saúde e ao tipo de operação realizada com as complicações encontradas. CONCLUSÕES: a taxa de complicações tardias foi de 22,52 por cento, com reintervenções cirúrgicas em 8,83 por cento dos pacientes. Não houve fator de risco para complicações identificado nesta série de casos.

INTRODUCTION: anorectal procedures consist 80 percent of surgical cases in colorectal surgery practice. The exact rate of long-term complications after anorectal surgery is unknown. This number is variable according to the medical centres and the type of procedures. OBJECTIVE: to evaluate the long-term complications secondary to anorectal procedures, as well as the risk factors that might be associated with these complications. METHOD: retrospective analysis, including anorectal procedures performed between January 2007 and July 2009. The characteristics analyzed were: sex, age, type of surgery, health system, long-term complications and reoperations performed. RESULTS: 430 patients submitted to 453 anorectal procedures were studied (54,4 percent female). Hemorrhoidectomy was the most common procedure (50,3 percent of all operations). The mean period of follow-up was 164,7 days and 102 long-term complications were identified, occurring in 22,52 percent of all procedures. Residual fissure in ano was the most frequent complication (54 percent, n=55). Only 38 patients needed reoperation (8,83 percent of all cases). There was no statistical significance between sex, age, health system and type of surgery in relation to the complications found. CONCLUSIONS: the long-term complication rate was 22,52 percent, with reoperations performed in 8,83 percent of all patients. There was no risk factor for long-term complications identified in this case series.

Unilateral versus bilateral sphincterotomy:A randomized chronic fissure in ano.

Background: Standard treatment for Chronic Anal Fissure (CAF) is unilateral Internal Sphincterotomy (UIS). Still there is recurrence and the risk of of incontinence. Bilateral Internal Sphincterotomy (BIS) as a treatment for CAF has not been adequately evaluated. Methods: A prospective randomized controlled trial of UIS at 3 o clock compared with BIS at 3 and 9 ‘O’ clocks. The outcome variables were : post operative pain, recurrence and incontinence. Result: There was 104 and 107 cases in UIS and BIS group respectively with similar age and sex. There were 12 recurrences in UIS and only one in the BIS group (p< 0.001) with no change in the continence. BIS group had less pain (p<0.001). Conclusion: BIS for CAF resulted in less postoperative pain, lower recurrence with no increase in the incontinence. However, further study is required with pre and post operative anal manometry.

Study of efficacy and safety of a new local cream ("healer") in the treatment of chronic anal fissure: a prospective, randomized, single-blind, comparative study / Estudo da eficácia e segurança de novo creme cicatrizante para o tratamento da fissura anal crônica: estudo prospectivo, randomizado, simples-cego e comparativo

OBJECTIVES: To determine the efficacy and safety of "healer" cream as monotherapy in the treatment of acute and chronic anal fissure. STUDY DESIGN: A prospective, randomized, single blinded, comparative trial. METHODS: Sixty patients suffering from anal fissure were included in the study. Patients were randomly divided into three groups: group A: treated with "healer" local cream application 3 times daily; group B: treated with nitroglycerine 0.25 percent local cream 3 times daily; group C: treated with a lidocaine 2 percent cream applied locally 3 times daily. All the followings were followed up and compared between groups. (1) Visual pain analogue score after defecation; (2) severity of straining and discomfort during defecation; (3) frequency of ulcer healed at 30 days; (4) any side effects or complications. RESULTS: The pain scoring after defecation was significantly reduced in the three treatment groups. The group treated with "healer" isosorbide-di-nitrate showed the greatest reduction of the visual pain analogue score median from 9 before treatment to 3 & 1 after 10 and 20 days respectively, while the median visual pain analogue score in group B treated with nitroglycerine cream was 9 reduced to 4 & 2 after 10 and 20 days respectively, and the median visual pain analogue score in lidocaine group only dropped from 9 to 6 and 4, respectively. The reduction of both pain scoring and defecation scoring with "healer" was statistically significantly greater than the other two treatments by Kruskal-Wallis test, P<0.001. The number of patients experiencing complete relief and passing stools easily after 10 days was significantly higher in "healer" group, by Pearson Chi square = 22.94, P<0.001. After 30 days, the fissures were healed in 18 (90 percent) of 20 patients in the "healer" group and in 12 (60 percent) of 20 in the nitroglycerin group, while only 6 (30 percent) of patients treated with lidocaine cream had their fissures healed by ...

OBJETIVOS: Determinar a eficácia e segurança de "creme cicatrizante" (dinitrato de isosorbida 1 por cento; lidocaína 2 por cento; rutosídios 5 por cento em base de creme anti-séptico) como monoterapia no tratamento da fissura anal aguda ou crônica. METODOLOGIA: Estudo prospectivo, randomizado, simples-cego, comparativo. Foram incluídos 60 pacientes com fissura anal. Foram divididos randomicamente em três grupos: grupo A: tratados com "creme cicatrizante", grupo B: tratados com creme de nitroglicerina 0,25 por cento e grupo C: tratados com creme de lidocaína 2 por cento aplicado. Em todos foi feita aplicação local 3 vezes ao dia. Os seguintes parâmetros foram aferidos: 1) escore analógico visual de dor após defecação, 2) severidade de esforço e desconforto para evacuar, 3) frequência da cicatrização após 30 dias, 4) presença de efeitos colaterais ou complicações. RESULTADOS: O escore de dor após a defecação foi reduzido significativamente nos três grupos. O grupo tratado com creme cicatrizante mostrou grande redução do escore médio de 9 para 3 e 1 após 10 e 20 dias de tratamento, respectivamente, enquanto que a média do grupo B foi reduzida de 9 para 4 e 2 e do grupo C de 9 para 6 e 4 após 10 e 20 dias de tratamento, respectivamente. A redução tanto da dor como do desconforto evacuatório com o uso de "creme cicatrizante" foi significativo em comparação com os outros cremes pelo teste de Kruskal-Wallis, P<0,001. O número de pacientes que referiram alívio completo e passagem fácil da fezes após 10 dias de tratamento foi maior e significativo no grupo A pelo teste Pearson, P<0,001. Após 30 dias, as fissuras estavam cicatrizadas em 18 (90 por cento) pacientes do grupo A, em 12 (60 por cento) do grupo B e em apenas 6 (30 por cento) do grupo C. Qui ao quadrado = 15 (P = 0,001). CONCLUSÃO: O "creme cicatrizante" é um tratamento que promete ser promissor e seguro na fissura anal aguda ou crônica. A característica farmacocinética do creme leva ...