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Current Management of Chronic Anal Fissure Joint Hospital Grand Round Department of Surgery,North District Hospital and Alice Ho Mui Ling Nethersole Hospital,

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Presentation on theme: "Current Management of Chronic Anal Fissure Joint Hospital Grand Round Department of Surgery,North District Hospital and Alice Ho Mui Ling Nethersole Hospital,"— Presentation transcript:

1 Current Management of Chronic Anal Fissure Joint Hospital Grand Round Department of Surgery,North District Hospital and Alice Ho Mui Ling Nethersole Hospital, NTEC

2 Anal Fissure  Definition: An elongated ulcer in the long axis of lower anal canal

3 Pathology  A split of anoderm  Associated with anal skin tag and hypertrophied anal papilla  Occur at midline just distal to dentate line  90% posterior, 10% anterior with less than 1% simultaneous

4 Presenting Sym.  Pain  Bleeding  Discharge  Constipation

5 Examination  Gentle eversion of anus with limited digital examination  Anoscopy and rigid sigmoidoscopy under anaesthesia or deferred till healing occur  Anomanometry is not useful

6 Differential Dx.  Fissure occurs out of midline 1. Carcinoma of anus 2. Inflammatory bowels 3. Tuberculous ulcer 4. HIV/Herpes – Biopsy should be taken for ulcer out of mid line or those fail to heal

7 Anorectal Physiology  Continence is maintained when intrarectal pressure are lower then the pressure generated by the resting internal and external sphincters.

8 Anorectal Physiology  Internal Sphincter: Smooth muscle Innervated by sympathetic (excitatory) and parasympathetic fibre; (inhibitory) Constant contraction 85% of resting tone

9 Pathophysiology Split of anoderm Sphincter spasm ischemia Fail to heal Fail to relax when BO Forceful dilatation

10 Pathophysiology  Great pain associated with initial bowel motion  Patient ignores the urge to defecate  Allows harder stool to form  Self-perpetuating cycle

11 Management  good bowel habit  Relieve internal anal sphincter spasm

12 Management  Conservative: to regulate bowel habit, break the self-perpetuating cycle Stool softener Bulk forming agent Sitz-bath  90% healing rate (1 st epsiode)  60% healing rate for recurrent

13 Management  Sphincterotomy to break the vicious cycle induced sphincter spasm to reduce anoderm ischemia and to promote healing

14 Management  Conventional surgical sphincterotomy versus chemical sphincterotomy

15 Surgical sphincterotomy 1. Lateral internal anal sphincterotomy Open v.s. Close 2. Fissurectomy with anoplasty: reserved for cases with prominent skin tag/recurrent anal fissure Longer healing time

16 Results and complication OpenCloseP value Persistence3.4%5.3%0.27 Recurrence10.9%11.7%0.77 reoperation3.4%4%0.70 Lack of control of gas 30.3%23.6%0.06 Soiling26.7%16.1%<0.001 Accidental BM11.8%3.1%<0.001

17  Surgery good healing rate…… but rather high complication  Alternatives?

18 Sphincterotomy-chemical  Chemical sphincterotomy Nitrogylcerin ointment Botulinum toxin injection Ca channel blocker/steriod……

19 Nitrogylcerin ointment  As a source of nitric oxide  Inhibitory neurotransmitter cause internal anal sphincter relaxation  Commonly used 0.2-0.3% nitroglycerin  Local application by patient twice daily for 6/52

20 Result  Healing rate :60-75%  Side effect: 15-40% headache

21 Result Parellada C et al. Randomized, prospective trial comparing 0.2 percent isosorbide dinitrate ointment with sphincterotomy in treatment of chronic anal fissure; a two years follow-up. Dis Colon rectum. 2004 ;47(4) 437-43 N=440.2% isosorbide dinitrate surgery 5 weeks healing rate 67%96% 10 weeks healing rate 89%100% 30% decrease of maximal anal pressure in both arms side effect30% headache15% incontinence

22 Botulinum Toxin  Mechanism of action: Action on internal anal sphincter as shown in manometric studies( reducing both the resting and squeezing pressure) Exact mechanism uncertain; inhibit acetylcholine release into synaptic gap causing neuormuscular blockade More sustained action then Nitroglycerin ointment

23 How to inject?  Botulinum toxin A  Target: internal anal sphincter as palpated  No local anesthetic nor sedation required

24 How to inject?  at least 15 unit  ? Probably better in multiple punture Minguez M et al. Theraputic effects of different doses of botulinum toxin in chronic anal fissue Dis Colon Rectum. 1999 Aug;42(8):1016-21

25 Where to inject?  anterior injection of the internal anal sphincter resulted in improved lowering of resting anal pressure and produced an earlier healing Maria G et al. Influence of botulinum toxin site on healing rate in patients with chronic anal fissure. Am J Surg. 2000; 179(1):46-50.

26 Result:  Fissure healing rate: 70-90% at 2 months  Recurrence/non healing: 20%  No major side effect;

27 Giuseppe Brisinda and Maria G et al. A comparison of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure N Engl J Med1999;341(2): 65-68

28 Result  RCT comparing comparing Botulinum vs Nitroglycerin ointment  N=50  Higher fissure healing rate at 8 weeks in Botox group 96% vs 60%  Significant lower resting anal pressure in Botox group

29 B.Bulent Mentes et al. Comparison of Botulinum toxin injection and lateral internal sphincterotomy for the treatment of chronic anal fissure Dis Colon Rectum 2002. 46(2) 232-37

30 N=111SurgeryBotox Fissure healing rate at 2 months 82%73.8% At 6 months98%86.9% recurrent011.4% Return of daily activities 14.8 days1 day complication16%0

31 Conclusion:  Internal anal sphincter spasm is the key to tackle chronic anal fissure  Traditional lateral sphincterotomy give excellent result in terms of fissure healing but bearing significant risk of incontinence

32 Conclusion  Result of chemical sphincterotomy is satisfactory, without the complication of lateral sphincterotomy and should be consider the first line treatment.  Botox injection give the most reliable result among different methods of chemical sphincterotomy

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