Fissurectomy combined with anoplasty and injection of botulinum toxin in treatment of anterior chronic anal fissure with hypertonia of internal anal sphincter: a pilot study

Introduction: Anal fissure is a linear tear in the anal mucosa seen distal to the dentate line. The diagnosis of chronic anal fissure depends on clinical history, physical exam, anoscopy and other imaging modalities are uncommonly recommended unless an associated condition was suspected. Management is either by chemical sphincterotomy or surgery through lateral internal sphincterotomy when chronic anal fissure was resistant to treatment. Purpose of the Study: The current study aimed to evaluate the sonographic findings that can be observed in cases with chronic anal fissure and their significance. Methodology: 15 asymptomatic patients and 30 patients with chronic anal fissure were examined with 3 dimensional transperineal ultrasound and if females an additional transvaginal ultrasound was performed. Results: 26 patients (86.5%) showed diffusely thickened internal anal sphincter of mean thickness >3.5mm, ranging from 3.7 mm to 6.4mm and the mean value was 5mm. 3 patients (10%) with posterior fissure showed a lucent narrow defect in the internal anal sphincter at the midline of the distal aspect of the anal canal wall. One of them showed associated localized intersphincteric plane sepsis. Conclusion: Use of ultrasound in cases with chronic anal fissure may show gapping of the internal anal sphincter and an associated intersphincteric plane sepsis corresponding to the high morphological grade of anal fissure which predict poor healing response to chemical sphincterotomy and further studies that correlate between the thickness and texture of IAS and the healing response to chemical sphincterotomy recommended.

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Manometric Evaluation of Internal Anal Sphincter after Fissurectomy and Anoplasty for Chronic Anal Fissure: A Prospective Study

The American Surgeon ◽

10.1177/000313481207800531 ◽

2012 ◽

Vol 78 (5) ◽

pp. 523-527 ◽

Cited By ~ 1

Author(s):

Rosalia Patti ◽

Valentina Territo ◽

Paolo Aiello ◽

Giuseppe Livio Angelo ◽

Gaetano Di Vita

Keyword(s):

Postoperative Complications ◽

Anal Fissure ◽

Anal Sphincter ◽

Anal Incontinence ◽

Internal Anal Sphincter ◽

Healthy Subjects ◽

Chronic Anal Fissure ◽

Skin Flap ◽

Anal Continence ◽

Squeeze Pressure

Chronic anal fissure (CAF) is a common painful clinical disease and its pathogenesis remains poorly understood. After failure of pharmacological therapy, that is the first-line treatment, surgical sphincterotomy remains the treatment of choice although it is followed by a high rate of anal incontinence resulting from the sphincter damage; therefore, the research of a sphincter-saving surgical option has become an important goal. The aim of this study was to evaluate the manometric modifications and the incidence of anal incontinence after fissurectomy and anoplasty with advancement skin flap in patients affected by CAF with hypertonia of the internal anal sphincter (IAS). Fifteen patients affected by CAF with hypertonia of IAS, unresponsive to medical therapy, were enrolled. All subjects underwent fissurectomy and anoplasty with advancement skin flap. Anorectal manometry was performed preoperatively and after 6 and 12 months from surgery. Maximum resting pressure (MRP), maximum squeeze pressure (MSP), ultraslow wave activity (USWA), fissure healing, anal continence, and postoperative complications were recorded. All patients healed within 30 days from surgery. No intra- or postoperative complications were recorded except for a case of partial donor site break. No significant modifications of MSP were detected. Six months after surgery, MRP was higher with respect to healthy subjects but significantly reduced in comparison to baseline levels. At 12 months, it was higher have versus 6-month values but significantly lower versus preoperative values. USWA was significantly represented in patients with CAF versus healthy subject. Both at 6 and 12 months, they decreased significantly with respect to preoperative values without significant differences versus healthy subjects. Both at 6 and 12 months, anal continence did not differ with respect to preoperative time. The fissurectomy with anoplasty resulted in a high healing rate without surgical sequelae or anal incontinence. Also, it was able to reduce IAS pressure in the same manner as surgical sphincterotomy or forceful dilatation.

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Su1609 High-Dose Circumferential Chemodenervation (HDCC) of the Internal Anal Sphincter: A New Treatment Modality for Uncomplicated Chronic Anal Fissure

Gastroenterology ◽

10.1016/s0016-5085(13)63997-9 ◽

2013 ◽

Vol 144 (5) ◽

pp. S-1072

Author(s):

Porter H. Glover ◽

James Z. Whatley ◽

Shou Jiang Tang ◽

Eric D. Davis ◽

Kellen T. Jex ◽

...

Keyword(s):

Anal Fissure ◽

Anal Sphincter ◽

Treatment Modality ◽

Internal Anal Sphincter ◽

Chronic Anal Fissure ◽

High Dose ◽

New Treatment

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THE TREATMENT OF CHRONIC ANAL FISSURES WITH FISSURE EXCISION AND BOTULINUM TOXIN TYPE A INJECTION (ISRCTN97413456)

Koloproktologia ◽

10.33878/2073-7556-2020-19-1-80-99 ◽

2020 ◽

Vol 19 (1) ◽

pp. 80-99 ◽

Cited By ~ 2

Author(s):

O. V. Tkalich ◽

A. A. Ponomarenko ◽

O. Yu. Fomenko ◽

K. I. Arslanbekova ◽

R. Yu. Khryukin ◽

...

Keyword(s):

Botulinum Toxin ◽

Anal Fissure ◽

Anal Sphincter ◽

Chronic Anal Fissure ◽

Botulinum Toxin Type A ◽

Type A ◽

Botulinum Toxin Type ◽

Main Group ◽

Control Group ◽

Pneumatic Balloon Dilatation

AIM: to assess the efficacy of botulinum toxin type A for chronic anal fissure.PATIENTS AND METHODS: the study included 80 patients randomized by random number generation in 2 groups. Forty patients underwent fissure excision in combination with injections of botulinum toxin type A into the internal sphincter (main group) and 40 – in combination with pneumatic balloon dilatation of the anal sphincter (control group).RESULTS: there were no statistically significant differences in the intensity of postoperative pain after defecation and during the day between the groups, p=0.45 and p=0.39, respectively. The groups were comparable in the complications such as perianal skin hematomas (p=0.84), external hemorrhoid thrombosis (p=0.1), urinary retention (p=0.46), long-term non-healing wounds (p=0.76). Transitory weakening of the anal sphincter was significantly more often in the control group. On day 30, the transitory anal incontinence in the main group was detected in 6 (21%), in the control group – in 18 (75%) patients, p=0.0002. On day 60, the weakness of the anal sphincter remained in the main group in 3 (10.7%), in the control group – in 10 (41%) patients, p=0.02.CONCLUSION: botulinum toxin type A and pneumatic balloon dilatation have equal effectiveness in the treatment of chronic anal fissure. The use of botulinum toxin type A can reduce the incidence of transitory weakening of the anal sphincter function in patients with chronic anal fissure.

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