Daria Marcinkowska1, *Sławomir Glinkowski1, 2
Pitfalls of conservative and surgical treatment for anal fissure
Pitfalls of conservative and surgical treatment for anal fissure
1Department of General and Oncological Surgery, Tomaszów Health Centre, Tomaszów Mazowiecki
2MEDICALL – Health Institute in Piotrków Trybunalski
Streszczenie
Szczelina odbytu jest jedną z najczęściej rozpoznawanych chorób proktologicznych. Ze względu na częstość występowania nawrotów wciąż poszukiwane są skuteczne metody leczenia. Pomimo istniejących wytycznych, w każdym przypadku leczenie powinno być indywidualnie dobrane do pacjenta na podstawie przeprowadzonej diagnostyki. Zwykle jako pierwszy etap leczenia wskazane jest leczenie zachowawcze, jednak nie powinno być ono zbyt długo kontynuowane w przypadku nieskuteczności. Istnieją również sytuacje, kiedy nie powinno być wdrażane. Spośród leczenia operacyjnego najczęściej wykonywana jest boczna wewnętrzna sfinkterotomia, często łączona z innymi metodami. Dość popularną w Polsce metodą jest podanie toksyny botulinowej do mięśnia zwieracza wewnętrznego, co obecnie bywa dyskutowane w piśmiennictwie. Pomimo stanowczego zakazu wykonywania dywulsji, jest to metoda obecnie dość powszechna w naszym kraju.
W artykule przedstawiono najnowsze wyniki leczenia szczeliny odbytu, zarówno metodami zachowawczymi, jak i zabiegowymi, jak również najczęstsze niepowodzenia. Omówiono także wstępne obserwacje na temat stosowania fizykoterapii dna miednicy, biofeedbacku oraz metod neuromodulujących, które mogą stanowić doskonałe uzupełnienie leczenia. Obecnie sfinkterotomia wewnętrzna lewoboczna wciąż pozostaje najskuteczniejszą metodą prowadzącą do długotrwałego wyleczenia.
Summary
Anal fissure is one of the most commonly diagnosed anorectal disorders. Due to the frequency of relapses, effective therapeutic approaches are still being sought. Despite the existing guidelines, the treatment should be always individually selected for a given patient based on the diagnosis. Conservative methods are usually indicated as first-line treatment, but should not be continued for too long in the event of failure. There are also situations when conservative treatment should not be implemented at all. As for surgical approaches, lateral internal anal sphincterotomy (LIAS) is the most common technique, often combined with other methods. Botulinum toxin injections in the internal anal sphincter, which are currently discussed in the literature, are relatively popular in Poland. Despite the strict ban on performing anal divulsion, this method is now relatively common in our country.
The paper presents the latest findings on anal fissure treatment using both conservative and surgical approaches, as well as the most common therapeutic failures. Preliminary observations on the use of pelvic floor physical therapy, biofeedback and neuromodulatory methods, which can be an excellent complement to treatment, are also discussed. Currently, left lateral internal anal sphincterotomy is still the most effective method ensuring long-term recovery.
Introduction
Anal fissure is one of the most common anorectal disorders. It mostly affects young people. According to the literature, 80% of patients develop anal fissure before the age of 35 years (1). The prevalence rate in men and women is similar, and the postpartum fissure is currently considered a separate clinical entity.
Post-treatment recurrence rates are estimated at 7-42% (2), which is still unsatisfactory and prompts intensive search for effective treatment strategies and modifications of the existing ones.
All available guidelines and literature point to conservative treatment as first-line treatment of anal fissure. It is recommended primarily for patients with acute anal fissures, reduced sphincter tone, as well as for pregnant and postnatal patients.
The most common conservative treatment methods include:
– sitz baths (warm water, chamomile, oak bark),
– high-fibre diet, adequate hydration,
– stool softeners,
– topical agents:
• analgesics, anaesthetics,
• anti-inflammatory,
• steroids,
• NO2,
• calcium channel blockers,
• botulinum toxin.
Botulinum toxin is a method on the borderline of conservative and surgical treatment. It can be either a separate procedure or part of surgical treatment, usually sphincterotomy or excision of chronic anal fissure.
Biofeedback and pelvic floor physical therapy (PFPT), as well as neuromodulatory methods are separate conservative treatment approaches.
Before attempting conservative treatment of chronic anal fissure, the patient should undergo careful examination and extended diagnosis should be performed to exclude other pathologies.
Even if colonoscopy had been done, the diagnosis should be extended to include rectoscopy to accurately assess the anal canal. Literature also recommends manometry to assess sphincter tone, but this test is rarely performed due to its poor availability.
Different treatment methods should be used in the case of a fissure with increased or normal sphincter tone than in the case of reduced tone. It is also advisable to perform transrectal ultrasound (TRUS), especially in patients with recurrent fissures and a history of surgical treatment, to exclude previous sphincter damage. Unfortunately, this diagnostic tool is not widely available in Poland.
The most common surgical treatment methods include:
• lateral internal anal sphincterotomy (LIAS),
• fissure excision + posterior sphincterotomy,
• sphincterotomy + intersphincteric Botox injections,
• advancement flap repair.
Depending on the local condition, these methods are modified and combined.
Divulsion remains a non-recommended and even forbidden method. It is considered to cause an uncontrolled and irreversible tearing of the sphincter muscle. However, our observations show that this technique is still relatively commonly used by doctors.
According to a 2022 study (3), up to 96% of patients presenting with chronic anal fissure are initially treated with increased intake of fibre, agents to facilitate bowel movements and topical ointments. Here, topical diltiazem ointment is firsts-choice treatment in up to 90% of cases. Pelvic floor physical therapy is added to treatment in only about 22% of patients. Botulinum toxin, which is used in general and spinal anaesthesia or intravenous sedation, is very popular (54%). Fissurectomy combined with LIAS is the most commonly chosen surgical method. Fissurectomy was combined with botulinum toxin injections in up to 51% of the analysed cases.
Pitfalls of conservative treatment
Although conservative management should be the first choice in most cases, there are situations where such treatment should not be continued or even undertaken. These situations primarily include:
• suspicion of malignancy within the chronic anal fissure,
• abscess or submucosal fistula,
• a large component of the anodermal fold, hypertrophied sentinel papilla.
Obviously, in the case of suspected malignancy, extensive excision of the pathology for histopathological examination is necessary, followed by further treatment depending on the findings. The presence of a hypertrophied anodermal fold and a large sentinel papilla as a chronic anal fissure can significantly affect the patient’s quality of life and cause great discomfort. The entire pathological lesion should be removed in such cases.
Intersphincteric Botox injections are a conservative treatment option enjoying great trust and interest among doctors and patients in Poland. The procedure causes temporary paralysis of the internal sphincter muscle, which creates conditions for anal canal wound healing. However, according to the latest reports (4), the use of botulinum toxin does not show statistically significant differences in terms of outcomes compared to topical glycerine (glycerol). Glycerine is usually considered for its moisturising/greasing properties. Although botulinum toxin is used for chronic anal fissure due to its muscle paralyzing effect, no significant differences in treatment outcomes have been demonstrated between both agents. Additionally, the cited paper assessed 17 randomised trials comparing the efficacy of topical treatments. Diltiazem was shown to be superior to glycerine and nifedipine to be superior to lidocaine. No statistically significant differences were shown between botulinum toxin and glycerine or isosorbide dinitrate (ISDN). Given the possible adverse effects of topical botulinum toxin and the lack of solid evidence showing its superiority over other topical agents, the authors recommend further studies to assess the indications for its use.
Another paper (5) reviewed 37 studies to compare the efficacy of other topical agents. A significant superiority of glyceryl trinitrate vs placebo was demonstrated in 17 studies. In turn, 11 studies showed only a slight difference in the outcomes of glyceryl trinitrate vs. diltiazem. Surprisingly, no significant differences were found between diltiazem and placebo. However, glyceryl trinitrate was shown to be significantly more likely to cause headaches than placebo or diltiazem. In their conclusions, the authors raise doubts as to the legitimacy of topical calcium channel blockers, despite their wide therapeutic use.
Some of the authors still point to insufficient evidence on the use of botulinum toxin in the treatment of chronic anal fissure (6). They assessed treatment outcomes in 57 patients who were followed-up for 42 months for botulinum toxin treatment outcomes and potential relapses. Lesions within the anal canal healed within 6 months after botulinum toxin injection in all cases. Four patients were excluded from the study due to lack of full follow-up. Recurrence was observed in 22 patients (41.5%). It was shown, based on the conducted observation, that symptom recurrence was associated with the presence of fissure on the anterior circumference of the anal canal, longer duration of the disease, the need for repeated injections and a higher dose of the drug needed to achieve the effect.
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Piśmiennictwo
1. Al-Ubaide AF, A-Rubaye SM, Al-Ani RM: Lateral Internal Anal Sphincterotomy of Chronic Anal Fissure: An Experience of 165 Cases. Cureus 2022; 14(10): e30530.
2. Reijn-Baggen D, Elzevier HW, Pelger RCM, Geurts IJM: Pelvic floor physical therapy in the treatment of chronic anal fissure (PAF-study): Study protocol for a randomized controlled trial. Contemp Clin Trials Commun 2021; 16(24): 100874.
3. Reijn-Baggen DAV, Dekker L, Elzevier HW et al.: Management of chronic anal fissure: results of a national survey among gastrointestinal surgeons in Netherlands. Int J Colorectal Dis 2022; 37(4): 973-978.
4. Sierra-Arango F, Hoz-Valle J, Espinosa JP et al.: Clinical outcomes of Medical management options for chronic anal fissures in a long term follow up: systematic review and meta-analysis. Dig Dis 2023.
5. Zin J, Hardy M-O, Unasa H et al.: A systematic review and meta-analysis of the efficacy of topical sphincterotomy treatments for anal fissure. Int J Colorectal Dis 2022; 37(1): 1-15.
6. Minguez M, Herreros B, Espi A et al.: Long-term follow-up (42 months) of chronic anal fissure after healing with botulinum toxin. Gastroenterology 2002; 123(1): 112-117.
7. Herreros B, Espi A, Rodriquez CM et al.: Botulinum Toxin Injection Plus Topical Diltiazem for Chronic Anal Fissure: A Randomized Double-Blind Clinical Trial and Long-term Outcome. Dis Colon Rectum 2021; 64(12): 1521-1530.
8. Garg P: High Recurrence Rate After Nonsurgical Treatment of Chronic Anal Fissure: Can It Be Prevented? Dis Colon Rectum 2022; 65(5): e339.
9. Espi A, Herreros B, Minquez M: Authors reply to comments high recurrence rate after non-surgical treatment of chronic anal fissure: can it be prevented? Dis Colon Rectum 2022; 65(5): e340.
10. Reijn-Baggen D, Elzevier HW, Putter H et al.: Pelvic floor physical therapy in patients with chronic anal fissure: a randomized controlled trial. Techniques in Coloproctology 2022; 26: 571-582.
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12. Falt UA, Lindsten M, Strandberg S et al.: Percutaneous tibial nerve stimulation (PTNS): an alternative treatment option for chronic therapy resistant anal fissure. Tech Coloproctol 2019; 23(4): 361-365.
13. Nelson RL, Manuel D, Gumienny C et al.: A systematic review and meta-analysis of the treatment of anal fissure. Tech Coloproctol 2017; 21(8): 602-625.
14. Mustafa G, Hossain MS, Sheikh SH et al.: Clinical Outcome of 0,2% Glyceryl Trinitrate Topical Ointment Compared to Lateral Internal Sphincterotomy in the Treatment of Patient with Chronic Anal Fissure: A Randomized Control Trial. Mymensingh Med J 2022; 31(4): 1034-1039.
15. Muhteseb MSE, Alfaraa N, Rabbaaa Y et al.: Long-term fecal incontinence after lateral internal sphincterotomy for anal fissure. Pol Przegl Chir 2022; 94(4): 32-36.
16. Lida Y, Honda K, Lida R et al.: 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. J Visc Surg 2022; 159(4): 267-272.
