*Małgorzata Kołodziejczak, Przemysław Ciesielski, Agnieszka Kucharczyk
Standards of anal fissure management in Europe and the United States
Standardy leczenia szczeliny odbytu w Europie i w Stanach Zjednoczonych
Warsaw Proctology Center, St. Elisabeth Hospital, Mokotów Medical Center, Warsaw
Streszczenie
Niniejszy artykuł ma na celu dokonanie przeglądu i porównanie różnic w sposobach leczenia szczeliny w niektórych krajach europejskich i w Stanach Zjednoczonych. Leczenie szczeliny odbytu jest różne w poszczególnych krajach.
W wielu algorytmach zabieg wycięcia szczeliny z plastyką z przesuniętym płatem anodermalnym jest umieszczony na pierwszym miejscu. Często wykonywana w Polsce sfinkterotomia tylna nie została wymieniona w żadnym z zacytowanych algorytmów, preferowana jest sfinkterotomia boczna. Żaden algorytm nie zaleca dywulsji, jest to spójne z naszymi obserwacjami (zabieg jest związany z niekontrolowanym rozerwaniem włókien mięśni zwieraczy i z dużym ryzykiem inkontynencji). W artykule dokonano przeglądu i porównano różnice w sposobach leczenia szczeliny w niektórych krajach europejskich i w Stanach Zjednoczonych.
Summary
Anal fissure is the second most common proctological disorder after haemorrhoids. The majority of researchers agree that conservative treatment should be the first stage of anal fissure management. The procedures used for the treatment of anal fissure are the biggest subject of disagreement.
The aim of this article is to review and compare thedifferences in the methods of anal fissure management in certain European countries and in the United States. Anal fissure treatment varies between different countries.
In many algorithms, fissurectomy combined with anal skin advancement flap reconstruction is listed as the first treatment option. Posterior sphincterotomy, which is frequently performed in Poland, is not included in any of the algorithms quoted in this paper; lateral sphincterotomy is preferred instead. No algorithm recommends manual anal dilation, which is consistent with our observations that this procedure is associated with uncontrolled tearing of sphincter muscle fibres and a high risk of incontinence. This article reviews and compares the differences in the methods of anal fissure treatment in certain European countries and in the United States.
Introduction
Anal fissure is the second most common proctological disorder after haemorrhoids, although there are few epidemiological studies on the subject. The available data indicate a lack of differences in the prevalence of anal fissure in women and men, and its predominance in young patients at the peak of their working lives (1). The cause of anal fissure is not clear; the majority of theories emphasise the role of direct mechanical trauma to the skin of the anus associated with the passing of hard stool. Anal fissure can also be associated with other diseases, including inflammatory bowel disease (Crohn’s disease, ulcerative colitis), HIV infection, and anal and rectal cancer. It may also be due to less common causes described in academic textbooks and single reports such as syphilis and tuberculosis (2). A specific clinical form of anal fissure is postpartum fissure, which usually does not involve increased sphincter tone and should be treated as a separate condition.
The majority of researchers agree that conservative treatment should be the first stage of anal fissure management. However, there is some disagreement about treatment procedures at further stages. The aim of this article is to review and compare the differences in anal fissure treatment methods in certain European countries and in the United States.
American standards
Recommendations presented by the American Gastroenterological Association distinguish between the treatment of acute and chronic fissures. An American algorithm with grades of recommendation is presented below (3).
Algorithm of the American College of Gastroenterology:
Acute anal fissure:
• 1B,
• conservative treatment as the first-line treatment option, safe, with a low risk of complications:
– warm sitz baths,
– high-fibre diet:
– it is possible to add topical analgesics and steroid drugs.
Chronic anal fissure:
• 1A:
– topical application,
– nitric oxide donors,
– calcium channel blockers,
• 1C:
– botulinum toxin.
Anal fissure of atypical origin:
• 2C:
– Crohn’s disease (IBD):
– conservative management + treatment of the underlying disease,
– surgical treatment in patients with no inflammatory lesions in the anal canal,
– sexually transmitted diseases:
– biopsy to identify the pathogen,
– HIV-related anal ulceration: diagnostic biopsy and anal canal culture testing; treatment: steroid therapy + antiretroviral drugs.
Anal fissure of atypical origin with decreased sphincter tone:
• 2C
• postpartum anal fissure:
– conservative management as first-line treatment,
– surgery in selected patients: fissurectomy combined with anal skin advancement flap reconstruction.
Comment
American authors, similar to the majority of researchers, recommend conservative treatment of a fissure at first. The recommendation to treat postpartum fissures with fissurectomy combined with anal skin advancement flap procedure is a controversial one. This method is rarely applied in Poland and is usually used to treat recurrent fissures. The American guidelines also include fissures of atypical origin, which increases the utility of these recommendations. Interestingly enough, calcium channel blockers are recommended only for chronic fissures, while in Poland they are used at the first stage of treatment of an acute fissure.
French standards
The French standards presented here are based on the recommendations of Sociètè Nationale Française de Colo-Proctologie (4):
• first-line conservative treatment:
– pain alleviation: analgesics and anti-inflammatory drugs,
– drugs improving intestinal transit: laxatives,
– medicines that protect and stimulate the healing of the anal canal in the form of suppositories and ointments,
• second-line conservative treatment:
• sphincter relaxants:
– calcium channel blockers and nitroglycerin derivatives in the form of ointments to be applied multiple times during treatment,
– injections acting for a few months,
• surgery:
– chronic anal fissures without increased sphincter muscle tone:
– fissurectomy combined with the reconstruction of the proximal part of the wound with a mucosal flap: the flap is sutured to the edge of the internal anal sphincter muscle at the level of the dentate line,
– chronic anal fissure with increased sphincter muscle tone:
– closed lateral sphincterotomy,
• manual anal dilation is not recommended.
Comment
Manual anal dilation is not recommended in Poland either. The French researchers do not mention posterior sphincterotomy; they recommend lateral sphincterotomy in patients with increased sphincter tone. Surgical treatment of chronic fissures with mucosal advancement flap is a recommendation not found elsewhere. The present authors have never performed such an operation for anal fissure in their professional practice. In the French recommendations, calcium channel blockers are also not used as first-line treatment.
British standards
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Piśmiennictwo
1. Mapel DW, Schum M, Von Worley A: The epidemiology and treatment of anal fissures in a population-based cohort. Incidence of anal fissure (cases per 1000 persons per year) by sex and age group. BMC Gastroenterol 2014; 14: 129.
2. Dutkiewicz P, Gorajska M, Siekierski P, Ciesielski P: Gruźlica odbytu – opis przypadku. Nowa Med 2015; 23(3): 81-84.
3. Stewart DB, Gaertner W, Glasgow S et al.: Clinical Practice Guideline for the Management of Anal Fissures. Dis Colon Rectum 2017; 60: 7-14.
4. https://www.snfcp.org/informations-maladies/fissure-anale/la-fissure-anale/.
5. Farkas N, Solanki K, Frampton AE et al.: Are we following an algorithm for managing chronic anal fissure? A completed audit cycle. Ann Med Surg (Lond) 2015; 5: 38-44.
6. Arroyo A, Montes E, Caldero T et al.: Treatment Algorithm for Anal Fissure. Consensus Document of the Spanish Association of Coloproctology and the Coloproctology Division of the Spanish Association of Surgeons. Chirugia Espanola 2018; 96(5): 260-267.
7. Marti L, Post S, Herold A et al.: Analfissur AWMF-Registriernummer: 081-010 Coloproctology 2020; 42: 90-196.
8. Kucharczyk A: Kliniczna i obrazowa ocena powierzchownej otwartej sfinkterotomii w leczeniu przewlekłej szczeliny odbytu. Rozprawa na stopień naukowy doktora nauk medycznych w zakresie medycyny. Warszawa 2013.
