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

Abstract

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.

Komplikationsmanagement in der Fissur- und Fistelchirurgie

“…3 [24]. Operative Therapieoptionen zielen in der Regel auf eine Wiederherstellung der Integrität der Sphinkteren.…”

“…In amerikanischen und italienischen Leitlinien wird letztere als Therapie der Wahl beschrieben [3,20].…”

Mise au point sur la prise en charge des fissures anales

“…L'effet secondaire le plus fré-quent est la céphalée survenant dans 20 à 30 % et faisant interrompre le traitement 1 fois sur 5. La céphalée est dose dépendante et peut être prévenue par les antalgiques et l'augmentation progressive des doses sur quatre à cinq jours [19,20].…”

“…La toxine botulique n'est pas recommandée [20]. L'Association of Coloproctology of Great Britain and Ireland (ACPGBI) recommande en cas de fissure anale (aiguë et chronique) un traitement médical non spécifique associé aux inhibiteurs calciques à 2 % pour 6 à 8 semaines et en cas d'échec, l'injection de 20 à 25 unités de botox [33].…”

Clinical and manometric evaluation of women with chronic anal fissure before and after internal subcutaneous lateral sphincterotomy

“…The majority of the anal fissure patients will report hard bowel movements and consequent local trauma, and, although there is no consensus regarding the anal fissure etiology, according to the most believed theory, this local trauma would result in internal sphincter spasm and consequent increased anal resting pressure which in turn would cause a posterior anal skin ischemia resulting in an unhealed wound 5,6,7 . Currently, lateral internal sphincterotomy (LIS) is the "gold standard" for the surgical treatment of anal fissure patients 8 . Described in 1835, this procedure results in a 95% healing rate with up to 10% patients developing some degree of anal incontinece 9 .…”