The management of patients with primary chronic anal fissure: a position paper.

Anal fissure is one of the most common and painful proctologic diseases. Its treatment has long been discussed and several different therapeutic options have been proposed. In the last decades, the understanding of its pathophysiology has led to a progressive reduction of invasive and potentially invalidating treatments in favor of conservative treatment based on anal sphincter muscle relaxation. Despite some systematic reviews and an American position statement, there is ongoing debate about the best treatment for anal fissure. This review is aimed at identifying the best treatment option drawing on evidence-based medicine and on the expert advice of 6 colorectal surgeons with extensive experience in this field in order to produce an Italian position statement for anal fissures. While there is little chance of a cure with conservative behavioral therapy, medical treatment with calcium channel blockers, diltiazem and nifepidine or glyceryl trinitrate, had a considerable success rate ranging from 50 to 90%. Use of 0.4% glyceryl trinitrate in standardized fashion seems to have the best results despite a higher percentage of headache, while the use of botulinum toxin had inconsistent results. Nonresponding patients should undergo lateral internal sphincterotomy. The risk of incontinence after this procedure seems to have been overemphasized in the past. Only a carefully selected group of patients, without anal hypertonia, could benefit from anoplasty.

[Our experience with emergency surgical treatment of acute cholecystitis]. / La nostra esperienza nel trattamento chirurgico d'ungenza delle colecistiti acute.

A clinical series of 580 patents (318, F, 199 M) personally observed at the Emergency Surgery and First Aid Division of the Fatebenefratelli and Ophthalmic Hospital Board of Milan between 1975 and 1980, and suffering from acute inflammation of the bile ways (gall bladder empyemas, acute cholecystitis, gangrene of the gall bladder, haemobilia due to gall bladder puncture), has been examined. Of these patients, 558 were subjected to surgery between 12 hours and 6 days after admittance. Operated patients are subdivided into 4 groups on the basis of their anatomo-pathological form and the average time interval between admittance and intervention. Critical examination shows that their behaviour with respect to acute inflammatory forms of the gall bladder can be split up as follows: 1) immediate surgery (within 12 hours) for empyematous and/or punctured forms; 2) emergency surgery (within 2 days of admittance) for cases with certain diagnosis backed up by historical and X-ray data pointing to calculosis of the gall bladder; 3) early surgery (within 3 days) for cases with certain diagnosis but without prior X-ray documentation; 4) deferred surgical intervention (within 6 days) for patients without X-ray documentation and in whom immediate medical treatment leads to a rapid improvement in the clinical picture. The very good clinical results obtained and the observation of a low mortality and morbility index (comparable to those of surgery of choice) suggest that early surgery is certainly the therapy of choice when dealing with acute cholecystitis.