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)

Role of micronize purified flavonoid fraction and ethanol Graptophyllum pictum extract on experimental anal ulcer healing. Study on Wistar rat / Papel da fração flavonoica purificada micronizada e do extrato etanólico de Graptophyllum Pictum em experimento de cicatrização de úlcera anal. Estudo com ratos Wistar

ABSTRACT Aim of the study To evaluate the role of micronized purified flavanoid fraction and ethanol Graptophyllum pictum extract in the treatment of anal ulcer. Method Twenty-eight Wistar rats were randomly allocated into four groups. Groups 2, 3 and 4 the anus were induced with croton oil, but was not induced on group 1. Groups 1 and 2 were treated with normal saline, while groups 3 and 4 were treated with micronized purified flavanoid fraction, and ethanol G. pictum extract, respectively. On 9th days blood sample were taken from the retro-orbital region, and Wistar was killed by cervical dislocation under ether anesthesia. The anal canal was resected up 2 cm from anal opening, weighted, photographically taken to measure the percentage of residual ulcer, and then prepared for microscopic examination. Elisa methods were done for superoxide dismutase and malondialdedhyde. The total leukocyte in the anal specimen was counted under 400 magnification power. superoxide dismutase, anal coefficient, and total leukocyte for statistical analysis were using ANOVA and LSD, while malondialdedhyde and percentage of ulcers were using Kruskal-Wallis and Mann-Whitney. Result Treatment with ethanol G. pictum extract dose of 100 mg/kg BW significantly reduces the percentage of anal ulcer, the edema, leukocyte infiltration, and malondialdedhyde, and increase the superoxide dismutase in comparison without treatment. Treatment with micronized purified flavanoid fraction did not reduce the leukocyte, anal coefficient, and percentage of anal ulcer, only increase malondialdedhyde and decrease superoxide dismutase significantly.

RESUMO Objetivo do estudo Avaliar o papel da Fração Flavonoica Purificada Micronizada e do Extrato Etanólico de Graptophyllum pictum no tratamento de úlcera anal. Método Vinte e oito ratos Wistar foram randomicamente alocados em quatro grupos. Nos grupos 2, 3 e 4, indução com óleo de cróton foi realizada no ânus, excetuando-se o Grupo 1. Os grupos 1 e 2 foram tratados com solução salina normal, enquanto os grupos 3 e 4 foram tratados com fração flavonoica purificada micronizada e extrato etanólico de Graptophyllum pictum, respectivamente. No nono dia, amostras de sangue foram colhidas da região retroorbital, e o rato Wistar sofreu eutanásia por deslocamento cervical sob anestesia com éter. O canal anal foi ressecado até 2 cm da abertura anal, ponderado e fotografado para medir a porcentagem de úlcera residual e, em seguida, preparado para exame microscópico. Os métodos superoxide dismutase e malondialdedhyde do ensaio Elisa foram realizados. A contagem total de leucócitos foi realizada na amostra anal com ampliação de 400 vezes. ANOVA e LSD foram utilizados para a análise estatística de superoxide dismutase, coeficiente anal e número total de leucócitos, enquanto os testes de Kruskal-Wallis e Mann-Whitney foram utilizados para a análise de malondialdedhyde e porcentagem de úlceras. Resultado O tratamento com o extrato etanólico de Graptophyllum pictum (100 mg/kg de peso corporal) reduz de modo significativo a porcentagem de úlceras anais, o edema, a infiltração de leucócitos e o malondialdedhyde e aumenta a superoxide dismutase, comparado ao não tratamento. O tratamento com a fração flavonoica purificada micronizada não reduziu os leucócitos, o coeficiente anal e a porcentagem de úlceras anais, apenas aumentou o malondialdedhyde e diminuiu significativamente a superoxide dismutase.

Tratamiento médico de la fisura anal con tadafilo tópico como principio activo / Medical treatment of chronic anal fissure with topical tadalafil

Introducción: La fisura anal es una úlcera lineal dolorosa que generalmente, aparece en la línea media posterior del canal anal, extendiéndose desde la línea dentada hasta el margen del ano. Su persistencia se debe al espasmo anómalo del músculo del esfínter interno. Hasta hace poco, la curación definitiva de las fisuras solo se logró mediante procedimientos quirúrgicos dirigidos a la ablación del espasmo esfinteriano. Diseño: Estudio prospectivo, controlado y aleatorio para comprobar la hipótesis de que la aplicación tópica de una preparación de Tadalafilo es un método efectivo y seguro para relajar el músculo liso y promover la cicatrización de la fisura anal. Población y métodos: Se seleccionaron los pacientes que acudieron a la consulta de coloproctología del HCC con diagnóstico de fisura anal (726). Todos fueron sometidos a una historia clínica y examen físico, antes del comienzo del tratamiento y seguimiento por 1 año. Los pacientes fueron divididos en tres grupos: Grupo A: tratados de forma médica con AINES por via oral, sediluvios y pomadas tópicas de esteroides 3 veces al dia. Grupo B: tratados con nitroglicerina 0,25% locales crema 3 veces al día. Grupo C: tratados con toxina botulínica inyectada 1 sola dosis en el espesor del esfínter interno del ano. Grupo D: tratados con formula magistral crema tópica de Tadalafilo aplicada 3 veces al día. Grupo E: pacientes a quienes se les realiza la Esfinterotomía Lateral Interna una vez que se considera ha fracasado el manejo médico y tratamiento farmacológico. Resultados: Se encontró predominio del sexo femenino con 370 pacientes (50.97%). Las edades en las cual se agrupó mayor cantidad de individuos fue entre los 26 a 35 años con 218 pacientes (30,02%). Predominó el diagnóstico de fisura crónica con 382 casos (52,61 %). El tratamiento inicial que se utilizó más frecuentemente fue el quirúrgico con 270 pacientes (37,19%), seguido de Tadalafilo tópico con 196 pacientes (26,99%)...

Introduction: Anal fissure is a painful linear ulcer usually appears in the posterior midline of the anal canal, extending from the dentate line to the margin of the anus. Its persistence is due to spasm abnormal internal sphincter muscle. Until recently, a definitive cure was achieved only cracks by surgical procedures aimed at ablation of the sphincter spasm. Design: Prospective. controlled trial to test the hypothesis that topical application of a preparation of Tadalafil is a safe and effective method to relax the smooth muscle and promote healing of anal fissure. Population and methods: We selected patients who attended the consultation of Coloproctology of HCC diagnosed with anal fissure (726). AIl underwent a medical history and physical examination before starting treatment and followed for 1 year. The patients were divided into three groups: Group A: treated medical oral NSAlDs, topical ointments sediluvios and steroids 3 times a day. Group B: treated with local nitroglycerin cream 0.25% 3 times a day. Group C: treated with botulinum toxin injection 1 dose in the thickness of the internal anal sphincter. Group D: treated with topical cream formulation TadalafiI masterfully applied 3 times a day. Group E: patients who underwent lateral internal sphincterotomy is considered after failed medical management and pharmacological treatment. Results: There was a predominance of females with 370 patientes (50.97%). The ages at which more individuals grouped was between 26 to 35 years with 218 patients (30.02%). The predominant diagnosis of chronic fissure with 382 cases (52.61%). The initial treatment was most frequently used surgical treatment of 270 patients (37.19%), followed by topical Tadalafil 196 patients (26.99%). The initial treatment had less failure was the use of topical Tadalafil 10 cases (1.37%), which required surgery...

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 ...

Long-term clinical and manometric comparison between surgical and chemical sphincterotomy for treatment of chronic anal fissure

Comparison between surgical and chemical sphincterotomy for treatment of chronic anal fissure. 160 patients were equally randomly divided into 4 groups treated by: lateral internal sphincterotomy [Group], local Diltiazem ointment [Group[22]], local Glyceryl trinitrate ointment [Group[222]], or injection of Botulinum toxin into the internal anal sphincter [Group 2V]. Anal manometry was measured before and 3 months after treatment. Patients were followed up for 5 years. Mean time for complete pain relief was 5.68 +/- 7.77 days [Group I], 15.7 +/- 5.87 days [Group II], 15.6 +/- 5.90 days [Group III] and 2.67 +/- 3.60 days [Group IV]. Mean healing time was 4.48 +/- 1.20 weeks [Group I], 5.12 +/- 1.13 weeks [Group II], 5.00 +/- 1.12 weeks [Group III] and 5.06 +/- 1.31 weeks [Group IV]. Mean resting and squeeze anal pressures decreased significantly after sphincterotomy. Recurrence rate was 10% in Group I, 65% in Group II, 57.5% in Group III and 52.5% in Group IV. Lateral internal sphincterotomy is easy and satisfactory, with minimal complications and recurrence. Medical sphincterotomy is safe, and easy, with mild complications. Its effect is reversible. Relapse after it is common. It is worth trial before surgery or in patients that cannot or unwilling to undergo surgery

Consumption of red-hot chili pepper increases symptoms in patients with acute anal fissures. A prospective, randomized, placebo-controlled, double blind, crossover trial / Efeito da pimenta vermelha nos sintomas de pacientes com fissuras anais agudas

BACKGROUND: Red-hot chili pepper and other spices have been blamed for causing or exacerbating symptoms of anal pathologies like anal fissure and hemorrhoids. AIM: To determine if consumption of chilies increases symptoms of acute anal fissures. METHODS: Individual patients were randomized to receive capsules containing chili or placebo for one week in addition to analgesics and fiber supplement. Patients were asked to note score for symptoms like pain, anal burning, and pruritus during the study period. After 1 week, cross over treatment was administered to the same group of patients with the same methodology and results were noted at the end of 2 weeks. RESULTS: Fifty subjects were recruited for this study. Forty three of them completed the trial (22 in the chili group and 21 in the placebo group). The daily mean pain score was significantly lower in the placebo group in the study period. Score 2.05 in chili group and 0.97 in placebo group. There was a significant burning sensation experienced by the patients in the chili group (score 1.85 for the chili group vs 0.71 for the placebo group). Patient’s mean recorded improvement score was significantly higher after taking placebo. Eighty one point three percent patients preferred placebo while 13.9 percent preferred chilies. Two patients had no preference. CONCLUSION: Consumption of chili does increase the symptoms of acute anal fissure and reduces patient compliance.

RACIONAL: A pimenta vermelha e outras especiarias têm sido responsabilizadas por agravar a sintomatologia das doenças anais, tais como fissuras e hemorróidas. OBJETIVO: Determinar se o consumo de pimentas vermelhas aumentaria os sintomas em fissuras anais agudas. MÉTODOS: Pacientes foram recrutados e randomizados para receber cápsulas contendo pimenta ou placebos por 1 semana, somadas a analgésicos e suplementos de fibras. Foi solicitado que anotassem um escore de sintomas, tais como dor, queimação anal, prurido durante o período de estudo. Após 1 semana o tratamento foi cruzado e administrado ao mesmo grupo de pacientes com a mesma metodologia e os resultados foram anotados ao final de duas semanas. RESULTADOS: Cinqüenta pacientes foram selecionados e 43 completaram o estudo (22 no grupo pimenta e 23 no grupo placebo). O escore médio diário de dor foi significativamente mais baixo (2,05 no grupo pimenta e 0,97 no grupo placebo). A sensação de queimação foi sentida de modo significativo no grupo pimenta (1,85 para o grupo pimenta vs 0,71 para o grupo placebo). O escore de melhora dos sintomas foi significantemente alto após tomar o placebo. Oitenta e um virgula três porcento dos pacientes preferiram tomar placebo contra 13,9 por cento que preferiram pimenta. Dois pacientes não referiram preferências. CONCLUSÃO: O consumo de pimentas agrava os sintomas de fissuras anais agudas.

Comparative study of lateral internal sphincterotomy versus local 0.2% glyceryl trinitrate ointment for the treatment of chronic anal fissure.

The gold standard surgical treatment of chronic anal fissure is lateral internal sphincterotomy which lowers the resting anal pressure and effectively heals the majority of fissures. Local application of 0.2% glyceryl trinitrate ointment has been used as an agent for chemical sphincterotomy, causing temporary alleviation of sphincter spasm and allowing the fissure to heal without compromising the anal continence. The aim of the present study was to compare the results of surgical sphincterotomy with that of local 0.2% glyceryl trinitrate ointment in the treatment of chronic anal fissure. Seventy adult patients between the age of 18 and 50 years with chronic anal fissure were randomized in a prospective trial to receive either surgical sphincterotomy or 0.2% glyceryl trinitrate ointment locally. Patients were followed up at 2 weeks' interval for 10 weeks. Symptom relief, fissure healing and continence scores were the outcomes assessed. Six patients were excluded for protocol violations. Surgical sphincterotomy was significantly more effective in providing pain relief and was associated with significantly better fissure healing rates at 6 weeks and 10 weeks (both p < 0.001). There were substantial problems with compliance in ointment group related to slow healing and longer time needed for symptomatic relief. Minor incontinence was 6% in sphincterotomy group and none in ointment group (p > 0.05). Considering early symptomatic relief, rapid fissure healing and better patient compliance surgical sphincterotomy is the treatment of choice for chronic anal fissure.

Fisura anal, opciones terapéuticas actuales: [revisión] / Anal fissure, actually treatment options: [review]

La fisura anal es una patología frecuente y probablemente la causante de la mayor parte de las proctalgias agudas severas. Esta revisión tiene por objetivo, evaluar los procedimientos actualmente utilizados para el tratamiento de esta enfermedad. En principio se describen algunos aspectos ligados a la etiopatogenia y a la evolución natural con la intención de comprender la utilización de las distintas modalidades terapéuticas. Posteriormente se analizan las características de cada método en particular, como así también sus beneficios, efectos adversos y resultados. Al final del trabajo, se expone el algoritmo de tratamiento seguido por los autores.

The anal fissure is a frequent pathology and probably the cause of most of the severe acute proctalgias. This revision has by objective, to evaluate the procedures at the moment used for the treatment of this disease. In principle some aspects related to etiopatogenia are described and to the natural evolution, with the intention to understand the use of different therapeutic modalities. Later the characteristics of each method in individual are analyzed, like thus also their benefits, adverse effects and results. At the end of the work, the algorithm of treatment followed by the authors is exposed.

Fisura anal aguda. Tratamiento convencional versus trinitrato de glicerilo / Acute anal fissure. Standard versus glyceryl trinitrate treatment

Antecedentes: El tratamiento no quirúrgico de la fisura anal aguda sigue siendo objeto de múltiples estudios. Quisimos conocer como podíamos mejorar los resultados añadiendo un donante de óxido nítrico al tratamiento convencional. Objetivo: Comparar dos tratamientos médicos para la fisura anal aguda, el tratamiento convencional versus trinitrato de glicerilo (TNG). Lugar de aplicación: Consultorios externos de coloproctología de hospitales privados. Diseño: Prospectivo, comparativo, aleatorio, multicéntrico. Población: 167 pacientes mayores de 18 años con fisura anal aguda. Método: Grupo I (TNG), n = 78. La dosis se calculó en 0,8 mg. Evaluamos efectos colaterales de la medicación y tasa de éxito. Grupo II (tratamiento convencional), n= 89. Se evaluó el dolor mediante una escala numérica al momento de la consulta y a los 3, 7 y 10 días. Resultados: El tratamiento fue insuficiente (necesidad de medicación agregada, benzodiacepinas) en 15 pacientes del grupo I y 1 paciente de este grupo necesito cirugía. Mientras que en el grupo II el tratamiento fue insuficiente en 8 pacientes (8,9 por ciento) y requirieron cirugía 12 pacientes (13 por ciento). No hubo que suspender en ningún paciente el TNG. Dentro de la evaluación del dolor vimos que gran parte del grupo I a los 3 días se situaba en el punto de menor dolor mientras que en el grupo II no hubo cambios. Conclusiones: El tratamiento con TNG es más eficaz en la tasa de curación, y es más efectivo en calmar el dolor que el tratamiento convencional.

Cost effectiveness of topical glyceryl trinitrate versus lateral internal sphincterotomy for chronic anal fissure

To compare the cost effectiveness of initial use of topical glyceryl trinitrate [GTN] before lateral internal sphyncterotomy against the sphincterotomy as primary treatment modality for chronic anal fissure. This prospective randomized study was conducted at Isra University Hospital, Hyderabad between November 2004 and October 2005. Fifty patients fulfilling the criteria were randomized into two equal groups. One group was treated with topical GTN ointment and other group with lateral internal sphincterotomy. Patients were followed up for one year. In case of failure of treatment or recurrence in GTN group, the patients were subjected to lateral sphincterotomy. The total expenditures of treatment in both groups were separately calculated and compared. Pain relief was observed in 92% of the patients in both the groups after 6 weeks. Complete healing of fissure was observed in 92% and 88% of the patients in GTN group and sphincterotomy group respectively after 6 weeks. Recurrence was observed in 16% of the patients in GTN group and non in sphincterotomy group after one year. The sphincterotomy was avoided in 76% of the patients in GTN group during one year. The total expenditure of GTN group was Pakistani Rupeed [PKR] 139500 and of sphincterotomy group was PKR 387500; about 2.8 time the expenditure of GTN group. The initial use of topical GTN before sphincterotomy against the sphincterotomy as primary treatment modality for chronic and fissure is cost effective and provides substantial monetary benefit

Nitroglycerine ointment for anal fissure

To determine long term effectiveness of glyceryl trinitrate [GTN] for treatment of anal fissure and to find out its side effects. This study was done on patients who presented with symptoms of anal fissure in colorectal clinic surgical ward 2 JPMC. Total 498 patients were included out of which 237 had acute anal fissure while 261 patients had chronic fissure. All patients received 8 weeks treatment with 0.2% GTN ointment three times daily applied over perianal area. Those patients who developed side effects i.e. headache were offered treatment with 2% diltiazem. After 8 weeks treatment 228 patients of acute anal fissure had complete healing and 9 patients had partial response. In chronic anal fissure, 229 patients completely healed after 8 weeks of treatment while 32 patients were advised further 4 weeks treatment of GTN due to partial healing and out of them 22 patients had complete healing. Thirteen patients had to undergo lateral sphincterotomy. Five patients complained of headache that settled after shifting to treatment with diltiazem ointment. Ten patients developed recurrence of symptoms. GTN proved to be good first line treatment for most of patients with anal fissure. Small group of patients experience recurrence of symptoms and most of them respond to prolong duration of treatment

Comparison between the therapeutic effects of internal sphincterotomy and diltiazem gel in chronic anal fissure

Surgery is now the [treatment of choice] for chronic anal fissure. However, considering the pathogenesis of this disease and the tendency for noninvasive and economical procedures, more attention is growing towards the non surgical treatments. Oral or topical nitroglycerin, isosorbide, bethanechol, L-Arginine, nifedipine, diltiazem, adrenergic -antagonists and botulinum toxin have been used to treat chronic anal fissure. In this study, we compared the surgical sphincterotomy and topical diltiazem gel for the treatment of anal fissure. This clinical trial study was performed on two groups of 35 patients. The first group was treated by surgical sphincterotomy and the second group received the topical diltiazem gel. Both groups were examined 2, 4 and 6 weeks after the onset of the treatment and, the findings were recorded and statistically analyzed by SPSS, t-test and X to determine the relation between parameters and p<0.05 was considered to be significant. Two weeks after the onset of treatment, the rate of complete pain relief in the sphincterotomy group and in the diltiazem group was 75% and 45% respectively [p<0.005]. Although this value was the same in both groups 4 weeks after treatment [p=0.357], the wound healing process observed in the first group was significantly higher than the second group [85% VS 40%, p<0.0001]. Both groups had a similar wound healing rate in the 6th week [p=0.0351]. According to our findings, both the surgical sphinctorotomy and the topical diltiazem gel had a similar therapeutic effect on the chronic anal fissure. However, the topical diltiazem gel has shown to have several advantages such as lower complication rates, greater convenience, noninvassivess, [no hospitalization] and lower cost. Therefore this type of treatment considered to be more appropriate for chronic anal fissure, and the surgery should be used as an alternative option for special cases

Treatment of anal fissures using a combination of minoxidil and lignocaine: a randomized, double-blind trial.

AIM : Anal fissures are associated with hypertonia of the internal anal sphincter and pain. We evaluated the efficacy of local application of a combination of minoxidil and lignocaine in healing anal fissures. METHODS: In this prospective, randomized, double-blind study, 90 patients with anal fissure were recruited. Patients received local applications of ointments containing 5% lignocaine (n=28), 0.5% minoxidil (n=36), or both (n=26). Healing of anal fissure at 6 weeks was used as the primary end-point. RESULTS: Rates of complete healing of fissure were similar in the three groups (lignocaine alone 8/27, minoxidil alone 10/34, combination 7/22; p=ns). Mean (SD) time taken for complete healing with combination treatment [1.9 (0.6) weeks] was significantly shorter than that with minoxidil alone (3.1 [1.7] weeks; p=0.001) or with lignocaine alone (3.3 [0.8] weeks; p=0.002). Rates of pain relief were similar in the three groups. Stoppage of bleeding occurred more often with combination treatment than with lignocaine alone. No patient had systemic or local side effects. CONCLUSION: Combination treatment with minoxidil and lignocaine helps in faster healing of anal fissures and provides better symptomatic relief than either drug alone.

Chemical sphincterotomy--first line of treatment for chronic anal fissure.

Anal fissure is a common disorder which may cause symptoms at any age. Internal anal sphincterotomy is the gold standard surgical treatment which lowers the resting anal pressure and effectively heals the majority of fissures. However the post operative period may be marked by surgical risks, complications and late incidence of incontinence that is some times permanent. These complications has led to a search for alternative therapies for the treatment of chronic anal fissure. Chemical sphincterotomy has been tried using a variety of novel agents including topical glyceryl trinitrate (GTN), calcium channel blockers such as nifedipine or diltiazem and botulinum toxin. Some of these agents were found to be effective in healing chronic anal fissure with negligible side effects and are now considered as first line treatment for chronic anal fissure.

Tratamiento de la fisura anal / Treatment of the anal fissure

La fisura anal es una lesión que aparece en la porción epidérmica del canal anal, con sintomatología muy florida de dolor y sangrado defecatorio. Existen dos formas típicas, la primaria o idiopática, relacionada con la isquemia relativa del anodermo debida al incremento del tono basal esfintérico interno, y la secundaria a patologías infecciosas o del tubo digestivo. Objetivo y diseño: En los últimos años surgió el concepto de esfinterotomía química. El motivo de este trabajo es la comparación entre estas técnicas incruentas y la esfinterotomía quirúrgica, evaluando en forma prospectiva randomizada los pacientes tratados con diltiazem al 2 por ciento en vaselina sólida, trinitrato de glicerilo aplicados tópicamente y la esfinterotomía lateral interna.Material y Métodos: Durante el período comprendido entre el 31 de diciembre de 2002 y el 31 de diciembre de 2004 se trataron 174 pacientes; 56 con diltiazem al 2 por ciento, 60 con trinitrato de glicerilo y 58 por medio de esfinterotomía lateral interna 10 abierta y 48 cerrada, (Nottaras). La ubicación de la fisura fue en el 76.8 por ciento o 134 pacientes en hora VI, y en el 23.2 por ciento o 40 en hora XII. La distribución según sexo fue 96 (55.3 por ciento) varones y 78 ( 44.7 por ciento) mujeres. Resultados: Luego de una media de seguimiento de 87 días (7 a 330 días), en el grupo tratado con diltiazem, 33 pacientes presentaron la desaparición de los síntomas en la primer semana, con una curación y epitelización, sin recidiva, en 38 pacientes a las 6 semanas. 7 pacientes evolucionaron mal y necesitaron cirugía, y 9 no se presentaron al control y seguimiento.En el grupo tratado con trinitrato de glicerilo, 36 pacientes tuvieron una buena evolución, 5 necesitaron cirugía, 10 no volvieron a control y 9 suspendieron el tratamiento por reacciones adversas. El grupo de 58 pacientes tratado quirúrgicamente evolucionó favorablemente excepto 2 de ellos que necesitaron una anoplastía con deslizamiento de colgajo. Conclu...

Randomized, double-blind trial comparing topical nitroglycerine with xylocaine and Proctosedyl in idiopathic chronic anal fissure.

OBJECTIVE: To compare symptomatic relief, healing, and changes in maximal anal resting pressure with the use of topical formulations in patients with chronic anal fissure. METHODS: Sixty-four consecutive patients with chronic anal fissure were randomized into 4 groups that received, in a double-blind manner, a topical ointment that contained 0.2% nitroglycerine (GTN), 5% xylocaine, Proctosedyl (hydrocortisone acetate, heparin, framycetin sulfate, esculoside, ethoform, butoform) or petroleum jelly (Vaseline), to be applied twice daily. Patients were reviewed at 2-week intervals for 6 weeks. Anal manometry was done before, and 20 minutes after, the first application of the ointment. RESULTS: There was significant (p < 0.0001) reduction in mean anal resting pressure after application of GTN, but not any other ointment. Of 16 patients receiving GTN, complete pain relief occurred in 6 and 15 patients after 2 and 4 weeks of treatment, respectively; this was more frequent than in the other 3 groups. At 6 weeks also, complete pain relief occurred more often with GTN than with Vaseline or xylocaine. After 4 weeks of treatment, 3 patients on GTN had complete healing of fissure as compared to one each in the xylocaine and Proctosedyl groups and none in the Vaseline group. At 6 weeks, healing of fissure had occurred in 15 of 16 patients receiving GTN as compared to 4 receiving Vaseline, 11 receiving xylocaine, and 12 on Proctosedyl. CONCLUSIONS: Topical nitroglycerine produces 'chemical sphincterotomy' with reduction in mean anal resting pressure. Pain relief and healing of fissure occurred earlier with GTN than with other treatments. GTN should be considered as the treatment of choice for the non-surgical management of patients with chronic anal fissure.

Treatment of chronic anal fissure with topical glyceryl trinitrate: a double-blind, placebo-controlled trial.

BACKGROUND: Topical glyceryl trinitrate (GTN) may produce healing of anal fissure by decreasing the high resting anal sphincter pressure in these patients. The present study assessed the efficacy of GTN in chronic anal fissure in a double-blind placebo-controlled trial. METHOD: Patients with chronic anal fissure (for more than 8 weeks) underwent measurement of maximum anal resting pressure (MARP) before and 12 minutes after application of either 0.2% GTN or placebo ointment in a randomized manner. They then received twice-daily local application of their respective ointment for 6 weeks. Symptoms and healing of fissure were assessed; patients were evaluated at 3 months for evidence of relapse. RESULTS: 19 adult patients (12 men) were studied; 10 received GTN and 9 placebo. Mean (SD) MARP decreased from 131.0 (32.3) cm H2O to 93.5 (28.4) cm H2O (p<0.05) with GTN and from 150.5 (36.9) cm H2O to 142.8 (35.0) cm H2O (p=ns) with placebo. Fissure healed in 7 of 10 patients treated with GTN and 2 of 9 patients treated with placebo (p<0.05). There was no relapse of fissure in either group. CONCLUSION: Local application of GTN was effective in healing chronic anal fissure.

La esfinterotomía medicamentosa / Medicamentous sphinterectomy

Aunque la mayoría de las fisuras agudas cicatrizan con tratamiento conservador, algunas evolucionan a la cronicidad requiriendo cirugía. Para estos casos, la esfinterotomía lateral interna es el tratamiento de elección. El principio que fundamenta esta técnica es reducir la hipertonía anal y aumentar la irrigación local. Si bien las series, analizando los resultados con la ELI comunican índices de curación de hasta el 97 por ciento, el índice de incontinencia observado alcanza hasta el 35 por ciento. Esto motivó el uso de nuevas alternativas con el fin de producir el mismo efecto que la cirugía pero en forma reversible. De ellas, la que cuenta con mayores evaluaciones, es la crema de nitroglicerina con índices de curaciones que van del 46 al 68 por ciento. El índice de efectos adversos alcanza al 85 por ciento, siendo la cefalea el más común. A pesar de los resultados menos óptimos y los efectos adversos más frecuentes en relación al tratamiento quirúrgico, la crema de nitroglicerina debería ser utilizada antes del mismo, ya que si bien la esfinterotomía lateral interna es un procedimiento seguro, el riesgo de incontinencia está presente