Efficacy of diltiazem 2% rectal gel in the treatment of chronic anal fissure: a retrospective observational study.

OBJECTIVE: The aim of this study is to describe the effectiveness and safety of a magistral formulation of diltiazem 2% rectal gel as a treatment for chronic anal fissure. MATERIAL AND METHODS: A retrospective observational study of all patients that began treatment with diltiazem 2% gel during 2019. The primary endpoint of the study was anal fissure healing. We also looked for differences in effectiveness between those initiating treatment and those who had been previously treated, long-term effectiveness through a 2-year follow-up and frequency of adverse effects. RESULTS: Of the 166 patients included in the study, anal fissure healed in 72.9%. We detected adverse effects in 12 patients, the most common was local irritation. After 2 years of follow-up, 88% of patients did not relapse. CONCLUSION: In this study, use of topical diltiazem 2% has been shown to be effective and safe in the treatment of anal fissure and should be considered as the first line of therapy.

OBJETIVO: El objetivo de este estudio es describir la efectividad y la seguridad de una fórmula magistral de diltiazem 2% gel rectal, como tratamiento de la fisura anal crónica. MATERIAL Y MÉTODOS: Un studio observacional retrospectivo de todos los pacientes que comenzaron a ser tratados con diltiazem 2% gel durante el año 2019. La variable principal del estudio fue la cicatrización de la fisura anal. También se buscaron diferencias de efectividad entre aquellos que iniciaban el tratamiento y los que ya habían sido tratados previamente, efectividad a largo plazo mediante un seguimiento de 2 años y frecuencia de aparición de efectos adversos. RESULTADOS: De los 166 pacientes incluidos en el estudio, el 72,9% cicatrizaron la fisura anal. No detectamos diferencias estadísticamente significativas de efectividad entre los pacientes naive y aquellos que ya habían sido tratados. Detectamos efectos adversos en 12 pacientes, siendo el más frecuente la irritación local. Tras 2 años de seguimiento, el 88% de los pacientes no presentaron ninguna recaída. CONCLUSIÓN: En este estudio, el uso de diltiazem 2% tópico ha mostrado ser efectivo y seguro en el tratamiento de la fisura anal y debería considerarse como primera línea terapéutica.

Outcomes Following Intrasphincteric Injection of Botulinum Toxin for Treatment of Anal Fissures.

Background Intrasphincteric injection of botulinum toxin is an alternative treatment for anal fissures, which may present less risk of fecal incontinence than more invasive procedures, such as lateral internal sphincterotomy. The aim is to compare cure and complication rates between these two treatments. Methods We conducted a retrospective audit of patients who underwent treatment of anal fissures with intrasphincteric botulinum toxin or lateral internal sphincterotomy from 2016 to 2020 at the Colorectal Surgery Unit of Monash Health, Melbourne, Australia, excluding those who had previously had either procedure. Results Fifty-one patients received intrasphincteric botulinum toxin, and 40 patients underwent lateral internal sphincterotomy. Most patients in the botulinum group had a total dose of either 80 (53%; n=27) or 100 units (37%; n=19) and had the dose administered bilaterally at the 3 o'clock and 9 o'clock positions (n=41; 80%). Thirty-one patients in the botulinum group (61%) had complete resolution of symptoms, with a mean time to cure of two months, compared to 36 patients (90%) in the sphincterotomy group with a mean time to cure of 1.5 months. In most cases, postoperative incontinence was transient, although one patient in the botulinum group had persistent incontinence of flatus, and two patients in the sphincterotomy group had persistent fecal incontinence. Conclusion Intrasphincteric botulinum injection is an effective, less-invasive alternative to sphincterotomy for the treatment of anal fissures, with incontinence usually temporary when it occurs. Further research is needed to optimize the dose and location of injection and guide future recommendations.

Toxicidad muco-cutánea: un desafío en el tratamiento oncológico / Mucocutaneous toxicity: a challenge in oncological treatment

El tratamiento combinado con inhibidores de tirosina quinasa e inmunoterapia en el cáncer de pulmón avanzado con mutación del EGFR es un enfoque emergente en la investigación clínica. Algunos estudios preliminares han mostrado resultados prometedores, con mejorías en la respuesta tumoral y la supervivencia global en comparación con la monoterapia. Sin embargo, esta combinación puede aumentar el riesgo de eventos adversos, por lo que se requiere un se-guimiento estrecho y una atención médica especializada. Se presenta el caso de un varón de 57 años con adenocarcinoma de pulmón que manifestó exantema generalizado grado 3 con lesiones pápulo-pustulosas, paroniquia y tricomegalia secundario al tratamiento con la-zertinib-amivantamab. Además, el paciente desarrolló una proctalgia crónica con mal control álgico debido a la aparición de úlceras anales e hipertonía del esfínter anal. (AU)

The combined treatment with tyrosine kinase inhibitors and immunotherapy in advanced lung cancer with EGFR mutation is an emerging approach in clinical research. Some preliminary studies have shown promising results, with improvements in tumor response and overall survival compared to monotherapy. However, this combination may increase the risk of adverse events, necessitating close monitoring and specialized medical attention. We present the case of a 57-year-old male with lung adenocarcinoma who manifested grade 3 generalized exanthema with papulopustular lesions, paronychia and trichomegaly secondary to treatment with lazertinib-amivantamab. Additionally, the patient developed chronic proctalgia with poorly controlled pain due to the presence of anal ulcers and anal sphincter hypertonia. (AU)

[Management of anal fissure]. / Prise en charge de la fissure anale.

MANAGEMENT OF ANAL FISSURE. The news in the management of the anal fissure are few but to know. The medical treatment must be well explained to the patient and optimized from the outset. Healthy bowel movements combining a sufficient fiber intake and soft laxatives must be continued for at least 6 months. Pain control is important. Topicals, specific (in case of sphincter hypertonia) or not, must be maintained for 6 to 8 weeks. Calcium channel blockers seem the most interesting with fewer side effects for similar effectiveness. Surgery is proposed (apart a no medically control of the pain or a fistula associated) in the event of failure of well-conducted medical treatment. It remains the most effective long-term treatment. Lateral internal sphincterotomy has its place in the absence of anal continence disorder, in which case fissurectomy and/or cutaneous anoplasty can be proposed.

PRISE EN CHARGE DE LA FISSURE ANALE. Les nouveautés dans la prise en charge de la fissure anale sont peu nombreuses mais à connaître. Le traitement médical doit être bien expliqué au patient et optimisé d'emblée. La régulation du transit associant un apport de fibres suffisant et des laxatifs doux doit être poursuivie au moins six mois. Le contrôle de la douleur est important. Les topiques, spécifiques (en cas d'hypertonie sphinctérienne) ou non, doivent être maintenus six à huit semaines. Les inhibiteurs calciques semblent les plus intéressants, avec moins d'effets indésirables pour une efficacité similaire. La chirurgie est proposée (sauf en cas de fistule associée ou de caractère hyperalgique non contrôlé médicalement) en cas d'échec d'un traitement médical bien conduit ; elle reste le traitement le plus efficace à long terme. La sphinctérotomie latérale interne a sa place en l'absence de trouble de la continence anale, auquel cas la fissurectomie et/ou les plasties anocutanées peuvent être proposées.

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.

Prospective, Randomized, Controlled Trial of Ultra-modified Internal Sphincterotomy vs Closed Lateral Internal Sphincterotomy for Chronic Fissure-in-Ano.

BACKGROUND: Currently, the lateral internal sphincterotomy is the treatment of choice for a chronic anal fissure (CAF). However, the length of the internal sphincter incision varies, due to lack of standardization. Insufficient length increases the risk of recurrence. To compare a new ultra-modified internal sphincterotomy (UMIS) to the closed lateral internal sphincterotomy (CLIS) for treating CAF, based on internal anal sphincter function and postoperative complications. The primary endpoint was continence after UMIS. The secondary outcomes were CAF healing complications, visual analog scale pain scores, and sphincter pressures. METHODS: This was a prospective, randomized, controlled trial (block randomization method). 200 patients with CAFs were randomly assigned to receive either UMIS (n = 100) or the closed lateral internal sphincterotomy (CLIS) (n = 100). Follow-up was 2 years. RESULTS: All (100%) patients in both groups showed clinical improvement at 1 month post-surgery. Recurrences were accompanied by deteriorations in Cleveland Clinic Florida Fecal Incontinence scores at 12 months and 2 years (P < .05). The groups showed significant differences in fissure healing rates and pain scores. After 1 and 2 years, incontinence rates were significantly higher, and patient satisfaction scores were significantly lower in the CLIS group than the UMIS group (P < .05). CONCLUSION: UMIS provided a faster healing rate and fewer side effects than the CLIS for treating CAFs. These results might lead to a standardized treatment among surgeons.

Clinical Trial of Combining Botulinum Toxin Injection and Fissurectomy for Chronic Anal Fissure: A Dose-Dependent Study.

PURPOSE: Our aim was to evaluate the effectiveness of combining a fissurectomy with a botulinum toxin A injection in treating chronic anal fissure. METHODS: A single surgeon in Saudi Arabia conducted a nonrandomized prospective cohort study between October 2015 and July 2020. The cohort included 116 female patients with chronic anal fissures with a mean age of 36.57±11.52 years who have presented to the surgical outpatient clinic and received a botulinum toxin injection A combined with fissurectomy. They were followed up with for at least 1, 2, 3, 4, and 8 weeks to evaluate the effects of the treatment, then again at 1 year. Primary outcome measures were symptomatic relief, complications, recurrence, and the need for further surgical intervention. RESULTS: Treatment with botulinum toxin A combined with fissurectomy was effective in 99.1% of patients with chronic anal fissure at 1 year. Five patients experienced recurrences at 8 weeks which resolved completely with a pharmacological sphincterotomy. Twelve patients experienced minor incontinence which later disappeared. Pain completely disappeared in more than half of the patients (55.2%) within 7 to 14 days. Pain started to improve in less than 8 days among patients treated with a dose of 50±10 IU (P=0.002). CONCLUSION: Seventy units of botulinum toxin A injection combined with a fissurectomy is a suitable second-line treatment of choice for chronic anal fissure, with a high degree of success and low rate of major morbidity.

Anal Fissure - an extensive update.

Anal fissure is one of the most common anorectal diseases resulting from a longitudinal tear in anoderm under the dentate line. It causes painful defecation and bleeding per anum. Most of the fissures heal by conservative means but a significant proportion turns chronic, leading to a negative impact upon the overall quality of life of a patient. The treatment options for chronic fissures are generally based on reducing the anal pressures and include non-surgical and surgical modalities. Lateral internal sphincterotomy still remains the gold standard for definitive management of anal fissure though anal incontinence is a serious complication of the procedure. In recent years, various modifications have evolved to minimize chances of incontinence besides the evolution of a wide range of non-surgical options of management. This review outlines the key points in the clinical presentation, etiopathogenesis, impact on the quality of life and management of anal fissure in the light of the recent updates in literature.

Minimal Lateral Internal Sphincterotomy (LIS): Is It Enough to Cut Less Than the Conventional Tailored LIS?

PURPOSE: Anal fissure is a common anorectal condition, yet its pathogenesis remains unclear. Lateral internal sphincterotomy (LIS) is the gold standard treatment for chronic anal fissures that do not respond to conservative treatment; however, it has a risk of anal incontinence. We believe that fibrosis of the internal anal sphincter is an important factor in the pathogenesis of chronic anal fissure. In this study, we describe the minimal LIS method, a minimally invasive method where only the fibrotic portion of the internal anal sphincter is cut. We also describe the outcomes of this method. METHODS: We performed a retrospective review of 468 patients (270 male and 198 female) who underwent minimal LIS for chronic anal fissure in 2017 at Seoul Song Do Hospital. We analyzed the patients' clinical characteristics, manometry data, complications, and outcomes of minimal LIS. The outcomes of the surgery were assessed via questionnaires during the postoperative outpatient visits, beginning 2 weeks postoperatively. RESULTS: The overall complication rate was 4.0% (19 patients). Delayed healing occurred in 14 patients (3.0%), perianal abscess was present in 3 patients (0.6%), and gas incontinence occurred in 2 patients (0.4%). All complications were improved with conservative treatment. Recurrence, defined as the recurrence of anal fissure more than 4 weeks after healing, was present in 6 patients (1.3%). CONCLUSION: Minimal LIS is a safe and effective treatment option for patients with chronic anal fissure. Postoperative complications, especially incontinence and recurrence, are rare.

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)

Impact of Anal Fissure on Neuroticism, Extraversion, Openness to Experience, Agreeableness, and Conscientiousness: A Case-Control Study.

INTRODUCTION: Scientific literature on determining patterns of personality traits in patients with anal fissure is limited. OBJECTIVES: To determine whether certain common psychological traits are associated with anal fissure. METHODS: A case-control study was carried out in Spain in 2016-2017. Patients with acute or chronic idiopathic anal fissure (n = 35) and controls (n = 32) were recruited. The main outcome measures were those defined in the NEO-FFI questionnaire, validated in Spain, which was administered to all the participants. This questionnaire evaluates the following traits: neuroticism, extraversion, openness, agreeableness, and conscientiousness. RESULTS: Three significant traits were noted: (1) greater neuroticism in the cases (OR 1.19, 95% CI 1.08-1.32, p < 0.001, AUC 0.77), (2) greater openness to experience in the controls (OR 0.90, 95% CI 0.83-0.98, p = 0.015, AUC 0.69), and (3) greater conscientiousness in the controls (OR 0.91, 95% CI 0.83-1.00, p = 0.049, AUC 0.69). CONCLUSIONS: The cases mainly presented higher levels of neuroticism and lower levels of openness to experience and conscientiousness. Further studies are needed to corroborate our results.

The Long-term Effect of Standardized Anal Dilatation for Chronic Anal Fissure on Anal Continence.

PURPOSE: For the past several decades, internal anal sphincterotomy has generally been considered to be the standard operation for an anal fissure. However, wound complications inherent in this operation forced surgeons to look for an alternative form of treatment. The aim of our study was to evaluate the long-term outcome of anal dilatation for chronic anal fissure, especially possible negative impact on anal sphincter function. METHODS: The study was approved by the local Institutional Review Board and given a waiver of written consent. A phone call survey was undertaken among a group of consecutive patients who had an anal dilatation by standardized technique for chronic anal fissure for the period between 2000 and 2016. The survey included medical, obstetrical and surgical-related data, Wexner fecal incontinence score, recurrence of the anal fissure, and the need for additional medical intervention. Five hundred 48 patients were identified after limitations of age, concomitant pathology, and procedures that were applied to the hospital computerized database. Eighty-five patients (group A) agreed to participate in the survey and 463 patients did not. RESULTS: There were no differences between groups in demographic information and medical records data; therefore, group A may well represent a satisfactory sample of the whole group. The interval between the procedure and the survey was 6.8 ± 2.7 years. The Wexner incontinence score was 0 in 94% of patients. CONCLUSION: Anal dilatation, performed in a systematic and standardized way, has a successful outcome with no complications and has no clear long-term negative impact on anal sphincter function.

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.

Management options for chronic anal fissure: a systematic review of randomised controlled trials.

INTRODUCTION: Anal fissure is the most common cause of severe anorectal pain in adults, contributing significantly to coloproctology workloads. There are a wide variety of management options available, including topical nitrites, calcium channel blockers, botulinum toxin injection and sphincterotomy. The aim of this study was to review current options for the treatment of chronic anal fissure. METHODS: A comprehensive search identifying randomized controlled trials comparing treatment options for anal fissure published between January 2000 and February 2020 was performed. The primary outcome assessed was healing at 8 weeks post commencing treatment. Secondary outcomes included recurrence, intolerance of treatment and complications. RESULTS: A total of 2822 studies were identified. After removal of duplicates and non-relevant studies, we identified nine randomized controlled trials which met pre-defined criteria. There was a total of 775 patients. At 8 weeks, healing rates were 95.13% in those treated with sphincterotomy, 66.7% in the botulinum toxin group, 63.8% in the nitrate group, 52.3% for topical diltiazem and 50% for topical minoxidil. Recurrence was highest amongst those treated with botulinum toxin injection (41.7%) and lowest for sphincterotomy (6.9%). Although the absolute number is low, there was a risk of permanent incontinence with sphincterotomy. CONCLUSION: This review of the randomized control data demonstrates that healing was significantly higher amongst those treated with sphincterotomy versus more conservative modalities. Topical nitrites had similar outcomes to botulinum toxin injection but were poorly tolerated in comparison to other treatments. The benefit of sphincterotomy was at a cost of increased complications, notably permanent incontinence.

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.

Comparative Study to Assess the Effectiveness of Topical Nifedipine and Diltiazem in the Treatment of Chronic Anal Fissure.

BACKGROUND: Chronic anal fissure is a common condition which is classically treated by surgery which may lead to incontinence. Recently medical treatment in form of calcium channel blockers (CCB) has gained interest. AIMS: The aim of this study is to compare the effectiveness of local Nifedipine and Diltiazem with lignocaine as control. We also aimed to observe the clinical pattern of chronic anal fissure. MATERIAL AND METHOD: Patients of chronic anal fissure were divided into three groups. First group received topical Nifedipine, second received topical Diltiazem, and the control group received only local lignocaine for 1 month. Their clinical data was recorded. The intensity of pain and bleeding was assessed from a visual analogue score (VAS). On the 4th week patients were examined for healing. STATISTICAL ANALYSIS: Statistical analysis was done by Medcalc statistical software v14. Student's t-test and Chi-square test was used accordingly. RESULTS: Mean age was 35.89 with a male female ratio of 1.7:1. Most common clinical feature was pain (100%), followed by constipation, bleeding, and pruritus. Most common location was posterior. VAS scores for pain of the Nifedipine group and Diltiazem group was significantly better than control group (P < 0.0001). VAS scores for bleeding in the Nifedipine group (P = 0.0091) and Diltiazem group (P = 0.0045) was significantly better than control group. The healing rate for NFD group was 93.33% (P < 0.0001), that of DTZ group was 86.67% (P = 0.0002), which was statistically better than control group (36.67%). There was no significant difference between the two CCBs. CONCLUSION: Adding topical Nifedipine or Diltiazem in the treatment of anal fissure is far superior to treatment with only topical Lignocaine.

Apamarga Ksharasutra application and open lateral internal sphincterotomy in the management of Parikartika (chronic fissure­in­ano): A randomized controlled clinical trial.

INTRODUCTION: Parikartika resembles fissure­in­ano which is one of the common painful disease among the anorectal disorders. Ksharasutra which is a para­surgical procedure is effective in the management of Parikartika. AIM: To compare the efficacy of Apamarga Ksharasutra and open lateral internal sphincterotomy (OLIS) in the management of Parikartika (chronic fissure­in­ano). MATERIALS AND METHODS: Total 30 patients having signs and symptoms of Parikartika (chronic fissure­in­ano) were selected and randomly divided into two groups. In Group A (n = 15), Ksharasutra ligation after anal stretching was carried out while in Group B (n = 15), OLIS with excision of skin tag was carried out under local anesthesia or spinal anesthesia. Relief in postoperative symptoms and complications if any was recorded for 4 weeks and follow­up was done for the period of 1 month. RESULTS: In both the groups, significant results were obtained, but the difference among groups was statistically insignificant. Duration required for relief in postoperative pain, bleeding, swelling, and wound healing was found to be more in Group A (Ksharasutra) than Group B (OLIS). CONCLUSION: OLIS provided better results compared to Ksharasutra ligation in the management of Parikartika (chronic fissure­in­ano).

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.

Combined treatment approach to chronic anal fissure with associated anal fistula.

BACKGROUND: Anal fistula in association with chronic anal fissure (fissure-fistula) is infrequently described. Recognizing this association and managing both components may help prevent some treatment failures seen with chronic anal fissure. This study aims to report on the outcomes of 20 consecutive patients with fissure-fistula managed with fistulotomy and injection of botulinum A toxin. METHODS: The study is a retrospective, observational study, assessing the success of symptom resolution following fistulotomy with botulinum A toxin, in patients identified as having a chronic anal fissure with associated anal fistula. The study included all patients with this condition treated with combination treatment by a single surgeon at a tertiary care hospital between January 2013 and January 2016. RESULTS: Twenty patients with fissure-fistula treated with fistulotomy and botulinum toxin A were identified. The median cohort age was 44 years (range 25-78), with a predominance of males (80%) and posterior fissure position (80%). The most common presenting symptoms were anal pain (70%), rectal bleeding (55%), anal discharge (35%) and anal pruritus (35%). Mean follow-up was 10.5 weeks and all patients who attended follow-up appointments reported resolution of symptoms. There were no cases of incontinence and none of the cohort required further surgical intervention for the condition. CONCLUSION: Chronic anal fissure with associated anal fistula can be successfully managed with fistulotomy and injection of botulinum toxin A. Further studies would be helpful in determining if recognition and management of the fistula component in isolation with fistulotomy is as effective as fistulotomy plus botulinum A toxin.

A Case Series of Anal Carcinoma Misdiagnosed as Idiopathic Chronic Anal Fissure.

Chronic anal fissure is a linear ulcer in the anal canal that has not cicatrized for more than 8-12 weeks of treatment. Most anal fissures are idiopathic and are located in the posterior midline. Squamous cell carcinoma of the anus commonly presents as bleeding and anal pain. It may also present as a mass, nonhealing ulcer, itching, discharge, fecal incontinence and fistulae. Not uncommonly, small and early cancers are misdiagnosed as benign anorectal disorders like anal fissures or hemorrhoids. The clinical suspicion of squamous cell carcinoma of the anus is of paramount importance in patients with nonhealing anal fissures, fissures in atypical positions or with indurated or ulcerated anal tags and in patients with risk factors for the development of anal squamous intraepithelial lesions that are precursors of invasive anal squamous cell carcinoma. The authors present 3 cases of squamous cell carcinoma of the anus initially misdiagnosed as benign chronic anal fissure.

A fissura anal crónica é uma úlcera linear presente no canal anal que não cicatriza após 8 a 12 semanas de tratamento. A maioria das fissuras anais são idiopáticas e localizadas na linha média posterior. O carcinoma epidermoide do canal anal apresenta-se frequentemente com proctalgia e hemorragia, podendo também manifestar-se como uma úlcera que não cicatriza, corrimento anal, incontinência fecal e fístula. Não raramente, os carcinomas pequenos e em estádios precoces podem ser diagnosticados incorretamente como patologia anorrectal benigna, como fissuras ou hemorróidas. A suspeição clínica de carcinoma epidermoide do canal anal é de enorme importância em fissuras anais que não cicatrizam, localizadas em posições atípicas, com marisca anal ulcerada ou endurecida e em doentes com fatores de risco para lesões escamosas intraepiteliais anais que são percursoras do carcinoma epidermoide anal. Os autores apresentam três casos de carcinoma epidermoide do canal anal inicialmente diagnosticados incorretamente como fissuras anais benignas.