Annals of Coloproctology

Technical Note

Botulinum injection technique to reduce spasms in refractory anal fissures and after anal fistula or hemorrhoid surgery: Pankaj Garg, Vipul D. Yagnik, Kaushik Bhattacharya; Received October 13, 2023 Accepted January 2, 2024 Published online December 2, 2024; DOI: https://doi.org/10.3393/ac.2023.00696.0099 [Epub ahead of print]

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Original Articles

The importance of topical metronidazole in the treatment of acute anal fissure: a double-blind study controlled for prospective randomization: Tuba Mert; Ann Coloproctol. 2023;39(2):131-138. Published online January 18, 2022; DOI: https://doi.org/10.3393/ac.2021.00675.0096

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Graphical Abstract Abstract PDF

Purpose
Acute anal fissure, a disease characterized by severe pain in the anorectal area, reduces quality of life and becomes chronic absent appropriate treatment. More recently, anaerobic infections have been noted as contributive to etiopathogenesis. This study investigates topical metronidazole’s effect in the treatment of acute anal fissure.
Methods
Our prospective randomized controlled double-blind study included 2 groups of 100 patients older than 18 years from our General Surgery Clinic with anal fissure complaints for less than 8 weeks. Topical diltiazem treatment was started in group 1, and topical diltiazem and metronidazole treatment in group 2. Pain levels were evaluated by the visual analogue scale (VAS) score, and recovery status was evaluated by physical examination findings ab initio and at the 1st, 4th, and 6th weeks. VAS score levels, demographic, clinical, and recovery status were then compared.
Results
There was no difference between the groups as to age, sex, pain on defecation, bleeding, constipation, and duration of pain, bleeding and constipation (P>0.05). From week 1, fissure epithelialization and healing rates were higher in group 2 (P<0.001); group 2 VAS score levels were lower than in group 1 (P<0.001) and achieved by group 1 only in week 4 (P=0.073).
Conclusion
Adding topical metronidazole to treatment reduces the duration and severity of pain, shortens healing time, and increases the healing rate.

Citations

Citations to this article as recorded by

Efficacy of local metronidazole with glyceryl trinitrate versus topical glyceryl trinitrate alone in the treatment of acute anal fissure: a randomized clinical trial
Hesham M. Elgendy, Ahmed AbdelMawla, Ahmed F. Hussein
The Egyptian Journal of Surgery.2024; 43(1): 304. CrossRef
Belgian consensus guideline on the management of anal fissures
P Roelandt, G Bislenghi, G Coremans, D De Looze, M.A. Denis, H De Schepper, P Dewint, J Geldof, I Gijsen, N Komen, H Ruymbeke, J Stijns, M Surmont, D Van de Putte, S Van den Broeck, B Van Geluwe, J Wyndaele
Acta Gastro Enterologica Belgica.2024; 87(2): 304. CrossRef
Local plus oral antibiotics and strict avoidance of constipation is effective and helps prevents surgery in most cases of anal fissure
Pankaj Garg, Vipul D. Yagnik, Kaushik Bhattacharya
Annals of Coloproctology.2023; 39(2): 188. CrossRef
COMPARATIVE STUDY ON THE EFFICACY OF TOPICAL METRONIDAZOLE, TOPICAL NITROGLYCERINE, AND TOPICAL DILTIAZEM IN THE MANAGEMENT OF CHRONIC ANAL FISSURE
PURSHOTAM DASS GUPTA, FAHAD TAUHEED, ANURAG SARASWAT, Karthik P
Asian Journal of Pharmaceutical and Clinical Research.2023; : 141. CrossRef
The Italian Unitary Society of Colon-proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of anal fissure
Antonio Brillantino, Adolfo Renzi, Pasquale Talento, Francesca Iacobellis, Luigi Brusciano, Luigi Monaco, Domenico Izzo, Alfredo Giordano, Michele Pinto, Corrado Fantini, Marcello Gasparrini, Michele Schiano Di Visconte, Francesca Milazzo, Giovanni Ferrer
BMC Surgery.2023;[Epub] CrossRef
Comparative Efficacy of Topical Metronidazole and Glyceryl Trinitrate Versus Topical Glyceryl Trinitrate Alone in the Treatment of Acute Anal Fissure: A Randomized Clinical Trial
M Hasaan Shahid, Sidra Javed, Saryia Javed, Anwar Zeb Khan, Adeel Kaiser, Reda H Mithany
Cureus.2022;[Epub] CrossRef

Long-term Outcome of a Fissurectomy: A Prospective Single-Arm Study of 50 Operations out of 349 Initial Patients: Jean-David Zeitoun, Pierre Blanchard, Nadia Fathallah, Paul Benfredj, Nicolas Lemarchand, Vincent de Parades; Ann Coloproctol. 2018;34(2):83-87. Published online April 30, 2018; DOI: https://doi.org/10.3393/ac.2017.06.12

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19 Citations

Abstract PDF

Purpose
The surgical standard of care for patients with chronic anal fissure is still disputed. We aimed to assess the natural course of idiopathic anal fissure and the long-term outcome of a fissurectomy as a surgical treatment.
Methods
All consecutive patients referred to a single expert practitioner in a tertiary centre were primarily included. A fissurectomy was proposed in cases of refractory symptoms after 4 to 6 weeks of standard medical management. Only patients with idiopathic and noninfected anal fissures were included in this second subsample to undergo surgery. Conventional postoperative management was prescribed for all patients who had undergone surgery. The main outcome measures were the success rate (defined as a combination of wound healing and relief of pain) and postoperative anal continence.
Results
Three hundred forty-nine patients were primarily recruited. Fifty patients finally underwent surgery for an idiopathic and noninfected fissure. Among them, 47 (94%) were cured at the end of primary follow-up, and 44 of the 47 (93.6%) could be confirmed as being sustainably cured in the longer-term follow-up. The mean time of complete healing was 10.3 weeks (range, 5.7–36.4 weeks). All patients were free of pain at weeks 42. The continence score after surgery was not statistically different from the preoperative score.
Conclusion
A fissurectomy for the treatment of patients with an idiopathic noninfected fissure is associated with rapid pain relief and a high success rate even though complete healing may often be delayed. Moreover, it appears to have no adverse effect on continence.

Citations

Citations to this article as recorded by

Belgian consensus guideline on the management of anal fissures
P Roelandt, G Bislenghi, G Coremans, D De Looze, M.A. Denis, H De Schepper, P Dewint, J Geldof, I Gijsen, N Komen, H Ruymbeke, J Stijns, M Surmont, D Van de Putte, S Van den Broeck, B Van Geluwe, J Wyndaele
Acta Gastro Enterologica Belgica.2024; 87(2): 304. CrossRef
Use of Botulinum Toxin Injections for the Treatment of Chronic Anal Fissure: Results From an American Society of Colon and Rectal Surgeons Survey
Daniel J. Borsuk, Adam Studniarek, John J. Park, Slawomir J. Marecik, Anders Mellgren, Kunal Kochar
The American Surgeon™.2023; 89(3): 346. CrossRef
New Findings at the Internal Anal Sphincter on Cadaveric Dissection and Review of Sphincter-Related Surgery in a Newer Prospective
Aswini Kumar Pujahari
Indian Journal of Surgery.2023; 85(3): 585. CrossRef
Pelvic floor physical therapy in patients with chronic anal fissure: long-term follow-up of a randomized controlled trial
Daniëlle A. van Reijn-Baggen, Henk W. Elzevier, H. Putter, Rob C. M. Pelger, Ingrid J. M. Han-Geurts
International Journal of Colorectal Disease.2023;[Epub] CrossRef
Fissurectomy with mucosal advancement flap anoplasty: The end of a dogma?
M. Skoufou, J.H. Lefèvre, A. Fels, N. Fathallah, P. Benfredj, V. de Parades
Journal of Visceral Surgery.2023; 160(5): 330. CrossRef
Fissurectomy versus lateral internal sphincterotomy in the treatment of chronic anal fissures: no advantages in terms of post-operative incontinence
Roberta Tutino, Casimiro Nigro, Flavia Paternostro, Rosa Federico, Giacomo Lo Secco, Gaetano Gallo, Mauro Santarelli, Gianfranco Cocorullo, Sebastiano Bonventre
Techniques in Coloproctology.2023; 27(10): 885. CrossRef
The Italian Unitary Society of Colon-proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of anal fissure
Antonio Brillantino, Adolfo Renzi, Pasquale Talento, Francesca Iacobellis, Luigi Brusciano, Luigi Monaco, Domenico Izzo, Alfredo Giordano, Michele Pinto, Corrado Fantini, Marcello Gasparrini, Michele Schiano Di Visconte, Francesca Milazzo, Giovanni Ferrer
BMC Surgery.2023;[Epub] CrossRef
La fissurectomie avec anoplastie muqueuse : la fin d’un dogme ?
Maria Skoufou, Jérémie H. Lefèvre, Audrey Fels, Nadia Fathallah, Paul Benfredj, Vincent de Parades
Journal de Chirurgie Viscérale.2023; 160(5): 363. CrossRef
Modified open posterior internal sphincterotomy with sliding skin graft for chronic anal fissure and anal stenosis: Low recurrence rate and no serious faecal incontinence postoperative complication
Y. Iida, K. Honda, R. Iida, H. Saitou, Y. Munemoto, A. Tanaka, H. Tanaka
Journal of Visceral Surgery.2022; 159(4): 267. CrossRef
Sphinctérotomie interne postérieure modifiée avec un lambeau cutané pour fissure anale et sténose anale : peu de récidives et d’incontinence anale
Y. Iida, K. Honda, R. Iida, H. Saitou, Y. Munemoto, A. Tanaka, H. Tanaka
Journal de Chirurgie Viscérale.2022; 159(4): 283. CrossRef
Injection of botulinum toxin significantly increases efficiency of fissurectomy in the treatment of chronic anal fissures
Philip Roelandt, Georges Coremans, Jan Wyndaele
International Journal of Colorectal Disease.2022; 37(2): 309. CrossRef
Clinical Trial Combining Botulinum Toxin A Injection and Fissurectomy for Chronic Anal Fissure: A Dose-Dependent Study
Nuha Alsaleh, Abdullah I. Aljunaydil, Gaida A. Aljamili
Journal of Coloproctology.2022; 42(02): 167. CrossRef
Fisurectomy and anoplasty with botulinum toxin injection in patients with chronic anal posterior fissure with hypertonia: a long-term evaluation
Beatrice D’Orazio, Girolamo Geraci, Guido Martorana, Carmelo Sciumé, Giovanni Corbo, Gaetano Di Vita
Updates in Surgery.2021; 73(4): 1575. CrossRef
The comparison between the medical and the surgical management of chronic anal fissures
Navneet Mishra, Kamal Kishore Parmar, Tanweerul Huda
Journal of Clinical and Investigative Surgery.2021; 6(1): 11. CrossRef
Anocutaneous advancement flap provides a quicker cure than fissurectomy in surgical treatment for chronic anal fissure—a retrospective, observational study
Edgar Hancke, Katrin Suchan, Knut Voelke
Langenbeck's Archives of Surgery.2021; 406(8): 2861. CrossRef
Fissurectomy Versus Lateral Internal Sphincterotomy in the Treatment of Chronic Anal Fissure: A Randomized Control Trial
Bipin Kishore Bara, Sujit Kumar Mohanty, Satya Narayan Behera, Ashok Kumar Sahoo, Santanu Kumar Swain
Cureus.2021;[Epub] CrossRef
Botulinum toxin associated with fissurectomy and anoplasty for hypertonic chronic anal fissure: A case-control study
Beatrice D'Orazio, Girolamo Geraci, Fausto Famà, Gloria Terranova, Gaetano Di Vita
World Journal of Clinical Cases.2021; 9(32): 9722. CrossRef
Scanner-Assisted CO2 Laser Fissurectomy: A Pilot Study
Iacopo Giani, Tommaso Cioppa, Chiara Linari, Filippo Caminati, Paolo Dreoni, Gianni Rossi, Cinzia Tanda, Giuseppina Talamo, Federico Bettazzi, Alessandra Aprile, Silvia Grassi, Antonella Pede, Luca Giannoni, Claudio Elbetti
Frontiers in Surgery.2021;[Epub] CrossRef
Fissurectomy combined with botulinum toxin A: a review of short- and long-term efficacy of this treatment strategy for chronic anal fissure; a consecutive proposal of a treatment algorithm for chronic anal fissure
M. Trzpis, J. M. Klaase, R. H. Koop, P. M. A. Broens
coloproctology.2020; 42(5): 400. CrossRef

Is There Any Relationship between the Chronicity of Chronic Anal Fissure and Endothelin-1?: Cheong Ho Lim, Hyeon Keun Shin, Wook Ho Kang, Seung Kyu Jeong, Hyung Kyu Yang; J Korean Soc Coloproctol. 2011;27(5):237-240. Published online October 31, 2011; DOI: https://doi.org/10.3393/jksc.2011.27.5.237

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Abstract PDF

Purpose

Many kinds of substances are produced on vascular endothelial activation. The aim of this study is to confirm an increase in Endothelin-1 (ET-1), the most potent vasoconstrictor, which is produced by endothelial activation, in patients with chronic anal fissure and to infer the relationship between ET-1 and anal fissure chronicity.

Methods

The study groups are divided into three different groups with 30 subjects each. Group 1 is comprised of healthy volunteers, group 2 of chronic anal fissure patients, and Group 3 of patients with higher than 3rd degree hemorrhoids. Blood samples were taken to measure the ET-1 levels in subject's serum and to compare the results with those for the control groups.

Results

Among the 90 subjects, 38 were male, and 52 were female. The average age was 36.8. The average ET-1 level marked 1.47 ± 0.78 pg/mL for male subjects and 1.16 ± 0.47 pg/mL for female subjects (P = 0.02). The average ET-1 level in the patient groups is as follow: 1.21 ± 0.44 pg/mL in group 1, 1.46 ± 0.83 pg/mL in group 2, and 1.20 ± 0.56 pg/mL in group 3 (P = 0.14).

Conclusion

Group 2, the chronic anal fissure patient group, showed a higher ET-1 level than groups 1 and 3, the control group and the hemorrhoid patient group, but this difference had no statistical significance.

Citations

Citations to this article as recorded by

Impact of Anal Fissure on Neuroticism, Extraversion, Openness to Experience, Agreeableness, and Conscientiousness: A Case-Control Study
Paloma Luri-Prieto, Asunción Candela-Gomis, Antonio Palazón-Bru, Felipe Navarro-Cremades, Vicente Francisco Gil-Guillén, Antonio Fernando Compañ-Rosique
Visceral Medicine.2021; 37(2): 128. CrossRef
Anatomie und Pathogenese der Analfissur
Martin Mitteregger
coloproctology.2020; 42(6): 441. CrossRef
Cost considerations in the treatment of anal fissures
Giuseppe Brisinda, Giuseppe Bianco, Nicola Silvestrini, Giorgio Maria
Expert Review of Pharmacoeconomics & Outcomes Research.2014; 14(4): 511. CrossRef

Clinical Outcomes of Lateral Internal Sphincterotomy for Patients with Chronic Anal Fissure.: Park, Jung Soo , Lee, Jae Bum , Kim, Tae Sun , Cho, Hang Jun , Kim, Do Sun , Lee, Doo Han; J Korean Soc Coloproctol. 2007;23(5):292-296.; DOI: https://doi.org/10.3393/jksc.2007.23.5.292

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Abstract PDF: PURPOSE
A lateral internal sphincterotomy (LIS) is a safe and effective surgical treatment that is the most commonly used one for patients with chronic anal fissure. However, reports on the recurrence rate and complications after LIS published in Korea are rare. The purpose of our study is to identify the types and rates of recurrence, the complications after LIS, and the differences in clinical outcomes between open and closed LIS.
RESULTS
We used hospital records and telephone interviews to study retrospectively the rates of recurrence and complications of 898 patients who underwent a LIS for chronic anal fissure from July, 2003, to June 30, 2004.
RESULTS
There were 292 male (mean age: 36.8 years, range: 16~84) and 606 female (mean age: 32.4 years, range: 1~68) patients. The preoperative mean maximum resting pressure in anal manommetry was 99.2 cmH2O in male patients and 97.7 cmH2O in female patients. Recurrence of fissure after LIS was present in five cases (0.6%). All underwent a LIS, on the same side of a previous LIS in four cases and on the opposite side in one case. Delayed healing of the fissure was present in six cases (0.7%). All of these patients were improved by conservative management. Complications of the LIS were thrombus formation, perianal abscess, fistula, and incontinence. Thrombus formation was present in eight cases (0.9%). Five patients underwent a thrombectomy and three patients were cured by conservative management. Perianal abscess or fistula was present in three patients (0.3%), who underwent incision and drainage or a simple fistulotomy. Incontinence was present in two cases (0.2%). One patient was lost to follow up, and the other patient was improved by conservative management.
CONCLUSIONS
LIS is a safe and effective treatment for patients with chronic anal fissure, and recurrence and complications of LIS are rare.

Treatment of Chronic Anal Fissure with Topical Nitroglycerin.: Kim, Ji Yeon , Kim, Young Eil , Kim, Taek Kyu , Yoon, Chang Sik , Lee, Ho , Yoon, Wan Hee; J Korean Soc Coloproctol. 2002;18(6):364-368.

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Abstract PDF: PURPOSE
Lateral partial internal sphincterotomy is considered as the best surgical procedure of the idiopathic chronic anal fissure. Because the aim of surgery is to relieve sphincter spasm, and occasional minor incontinence following surgery has been reported, alternative chemical means of spasmolysis could be considered. Nitric oxide (NO) is known to be a major inhibitory neurotransmitter of the internal anal sphincter, so we investigated the effect of topical nitroglycerin for chronic anal fissure.
METHODS
Twenty nine patients (19 women, mean age 36 years) with chronic anal fissure were treated with 0.2% nitroglycerin ointment. Pain score was quantitated with Visual Analog Scale (VAS) in regular time interval. Manometry was performed in five patients and maximum anal resting pressure (MARP) was measured before and 30 minutes after topical application of nitroglycerin ointment. All patients were re-examined and questioned regarding pain relief and side effects 2 years after cessation of treatment.
RESULTS
All had appearances of chronicity and pain. There were 25 posterior and 12 anterior fissures. Pain was significantly abolished within 5 minutes after application of nitroglycerin ointment. Mean pain score (VAS) was 6.03 before, 0.69 30 min after, 0.58 1 week after, and 0.53 3 weeks after application of nitroglycerin ointment (P<0.001). MARP was markedly reduced 30 minutes after application of nitroglycerin from 166.2 15.1 cmH2O to 108.8 20.9 cmH2O (P<0.05). The 57% of patients (13/23) were effective for 2 years and 22% of patients (5/23) had recurred their symptom after cessation of nitroglycerin ointment. Two patients (9%), whose fissures had not healed completely within 3 weeks were requested for surgery and the other 2 patients (9%) had been operate due to the side effect of the ointment. Mild headache (7%) and dizziness (10%) were occured, but well tolerated when the dose was reduced.
CONCLUSIONS
Topical application of nitroglycerin ointment seems to be an effective and safe alternative in the treatment of chronic anal fissure.

Prevalence of Anatomic Anal Stenosis in Patients with Chronic Anal Fissure and Results of Lateral Internal Sphincterotomy.: Cho, Dong Yoon , Kim, Dong Yi , Kim, Young Jin; J Korean Soc Coloproctol. 2002;18(1):7-9.

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Abstract PDF: PURPOSE
The aim of this study was to estimate the prevalence of anatomic anal stenosis in patients with chronic anal fissure (CAF) and ascertain the results of lateral internal sphincterotomy (LIS) using a new calibrator.
METHODS
Ninety-eight adults with CAF and a control group of 40 normal adults underwent anal calibration under spinal anesthesia. The calibrator was a conical design and the diameter was scaled in increments of 1 mm. The calibration was standardized and the reliability of it was assessed by two independent examiners for the same group (n=45). Confounding effects of age, sex, body weight, and height on the anal caliber were studied. The internal sphincter was divided to the level of the dentate line during LIS.
RESULTS
The anal caliber was 34.6 +/- 1.4 mm (mean +/- SD) in the control group and 28.7 +/- 3.0 mm (mean +/- SD) in patients with CAF. Excellent correlation was obtained between the two examiners (r=0.958). The confounding effects of age, sex, body weight, and height were not significant. Therefore, anal stenosis was defined as when the measurement was 31 mm or below (mean-2SD of control value). Stenosis was present in 82 of 98 patients (84%) with CAF. Patients with stenosis had an anal caliber of 27.9 +/- 2.5 mm, with a range of 21 to 31 mm. Following LIS, 91 of 98 patients (93%) with CAF attained the normal range, two patients still had stenosis, and five patients had an anal caliber exceeding the normal value.
CONCLUSIONS
Anatomic anal stenosis was found in 84% of the patients with CAF. Ninety three percent of these patients attained a normal anal caliber, 2 percent of the patients still had stenosis and 5 percent of the patients had an anal caliber exceeding the normal value after LIS.

Randomized Controlled Trial

Topical Glyceryl Trinitrate (GTN) Versus Conservative Treatment (CT) in Chronic Anal Fissure: Prospective and Randomized Study.: Lee, Kwang Real , Cho, Kyung Ah , Hwang, Do Yeon , Kim, Kuhn Uk , Park, Weon Kap , Yoon, Seo Gu , Kim, Hyun Shig , Lee, Jong Kyun; J Korean Soc Coloproctol. 2000;16(6):360-364.

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Abstract PDF: PURPOSE
This study was designed to compare the effect of treatment using glyceryl trinitrate (GTN) ointment with that of conservative treatment (CT) on chronic anal fissure.
METHODS
As a preliminary study, maximal resting pressures of the anal canal were checked in 13 patients having chronic anal fissure before and 10 minutes after application of 0.2% GTN ointment. As the study groups, 59 patients having chronic anal fissure were randomly allocated to the GTN and the placebo groups. All the patients in both groups were given oral analgesics, sedatives, and bulk-forming agents. They had applied 0.2% GTN ointment or a placebo ointment three times a day to their perianal skin. Maximal resting pressures of the anal canal were checked at the beginning and at the endpoint of the treatment period which continued for 6 weeks. If there was complete healing of the fissure in the middle of the treatment, the treatment was stopped. Sixteen patients were lost during the study.
RESULTS
Among the rest, 22 and 21 patients were included in the GTN group and the placebo group, respectively. The maximal resting pressure decreased significantly in all groups (p<0.05). The healing rates, the recurrence rates, and the operation rates were not significantly different between the GTN group and placebo group (p>0.05).
CONCLUSION
The effect of GTN on the symptomatic relief and results of treatment in patients having chronic anal fissure is not superior to that of conservative treatment.

Original Article

Changes in Anal Pressure According to Age and Gender in Hemorrhoids and Anal Fissures.: Kim, Kwang Ho , Shim, Kang Sup , Park, Eung Bum; J Korean Soc Coloproctol. 1998;14(2):283-290.

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Abstract PDF: Hemorrhoid and anal fissure are common diseases in Korea. It has been demonstrated that patients with hemorrhoidal disease have increased activity of the internal anal sphincter. The fissure causes increased contraction in the internal anal sphincter, thereby increasing pressure in the anal canal. Many studies have reported differences in the anal canal pressures between males and females. Moreover, some papers have shown that sphincter pressures decrease with age. But the majority of these studies were not specific for the hemorrhoid and anal fissure. Therefore, we studied the effect of age and gender on anal pressure in hemorrhoid and anal fissure. Two hundred ninety six patients with hemorrhoid and sixty eight patients with anal fissure were retrospectively assessed. Anorectal manometry using a radial eight-port catheter was performed during resting and squeezing maneuvers of the anal sphincter. In hemorrhoid reduction in maximal average resting(MARP) and squeezing pressure(MASP) were found from the sixth decade, however in anal fissure reduction in MARP and MASP were found in the third decade. In hemorrhoid significant decrease of MARP and MASP were noted in entire ages of female, however in anal fissure increase of MARP and MASP were noted in fifth and sixth decade of female. In conclusion, in hemorrhoid both resting and squeezing pressure decrease with age in female. In anal fissure both resting and squeezing pressure decrease in third decade and in male with fifth and sixth decade.

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