Colorectal Surgical Society

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Colorectal Surgical Society of Australia and New
Zealand and Section of Colon and Rectal
Surgery, Royal Australasian College of Surgeons
Spring Continuing Medical Education Meeting
October 2nd-5th 2007, McCracken Country
ClubVictor Harbor, South Australia
International Visiting Speaker Ronan O'Connell
(Dublin)
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FISSURE IN ANOPASTE, BOTOX or CUT but not STRETCH

• Chronic anal fissure

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Introduction

• Chronic anal fissure
• significant cause of morbidity
• seen in up to 10 of patients presenting to
  colorectal clinics 1
• 90 are located in the midline posteriorly 2

1 Pescatori MIA. Annual report of the Italian
Coloproctolopgy units. Tech Colproctol. 1995
329-30 2 Maria G, et al. A comparison of
botulinum toxin and saline for the treatment of
chronic anal fissure. N Engl J Med. 1998 338
217-20
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PATHOGENESIS

• Tears to the anal canal that fail to heal.
• Elevated resting anal pressures.
• Local ischaemia of the posterior anoderm
• Fewer arterioles in the posterior midline
• Increased anal canal pressure exceeds the
  intraluminal pressure of arterioles

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PATHOGENESIS

• Fissure patients lt blood flow in the posterior
  and anterior midline compared with controls
• Following sphincterotomy lt anal pressure with
  corresponding increase in blood flow to the
  fissure site.

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LATERAL INTERNAL SPHINCTEROTOMY

• Improves blood flow to the posterior anoderm.
• Fewer wound complications than posterior
  sphincterotomy.
• Open or closed technique have healing rates of
  90-100

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Ram et al Annals of Surgery August 2005 208-211
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LATERAL INTERNAL SPHINCTEROTOMY

• Incontinence rates Variable
• Lewis et al 17 1988
• Khubchandani Reed 22 1989
• Hsu 0 (1750 pts) 1984
• Ram et al 2 2005
• Mentes et al 1.2 2006

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GLYCERYL TRINITRATE (GTN)

• Gel
• Nitric Oxide donor
• Smooth muscle relaxation of the IAS
• Decrease in anal canal pressure 25-30
• Fissure healing rate of 50-70
• Recurrent fissure rates 50
• Adverse reaction rate 75

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GLYCERYL TRINITRATE (GTN)

• 65 patients 31 (S) 34 (GTN)
• 8 weeks 60 97 healing rate.
• Poor tolerance and poor compliance
• Faster healing with sphincterotomy
• GTN 45 recurrence in 6 month followup
• Conclusion GTN is labour intensive for patient
  and physician has significant side effects and
  has been shown to be inferior to sphincterotomy
  in rate and efficacy of healing.
• Evans J. Luck A. Hewett P. DCR 44 93-97 Jan 2001
  

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CALCIUM CHANNEL BLOCKERS

• Nifedipine or Diltiazem
• Calcium channel blockers work by blocking L-type
  voltage gated calcium channels (VGCC). This
  prevents calcium levels from increasing as much
  in the cells when stimulated, leading to less
  contraction.
• Relax IAS (RAP 36)
• Oral or gel (gel has better healing rates)
• Healing rates of 60 _at_ 8 weeks
• Less side effects (25)
• Compounding chemist

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BOB THE ANAL FISSURE www.zug.com/scrawl/analbob/
Uncontrolled anal dilatation has unacceptable
levels of faecal incontinence and is less
effective than sphincterotomy.1
Controlled dilatation has success Rates of gt90
with 2-9 incontinence rate2,3
1.Dis Colon Rectum 1367-76,2002 2.Dis Colon
Rectum 35322-327,1992 3.BJS 86 651-655, 1999
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BOTOX

• Botulinum toxin A
• studies have suggested encouraging results 3-5
• healing rates vary from 60-90 3-5

3 Gui DC et al. Botulinum toxin for chronic anal
fissure. Lancet. 1994 3441127/8. 4 Minguez M et
al. Therapeutic effects of different doses of
botulinum toxin in chronic anal fissure. Dis
Colon Rectum. 1999 421016-21. 5 Jost WH et al.
One hundred cases of anal fissure treated with
botulinum toxin early and long-term results. Dis
Colon Rectum. 1997 401029-32.
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Mode of Action1

• Blockade of sympathetic (noradrenaline mediated)
  neural output.
• Postganglionic action involving a reduction in
  noradrenaline release at the neuromuscular
  junction.
• No effect on nitregeric transmission.
• 1. BJS 2004 Feb 91 (2) 224-8

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A randomised prospective controlled trial of
lateral internal sphincterotomy versus injections
of botulinum toxin for the treatment of
idiopathic fissure in ano.
H Iswariah, JH Stephens, NA Rieger, D Rodda, PJ
Hewett The Queen Elizabeth Hospital, South
Australia 210pm Tuesday, 4 May 2004
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Aims

• To compare the short and long term outcomes of
  treatment of idiopathic fissure in ano via
  lateral internal sphincterotomy compared to
  injection with botulinum toxin.

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Procedure

• Lithotomy position
• General anaesthesia
• Sphincterotomy
• open or closed
• left lateral position
• Botulinum injection
• Botulinum toxin Type A (Botox Allergan Australia
  Pty Ltd)
• 20 units
• either side of the fissure
• into internal anal sphincter

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Randomisation
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Healing Rates
Chi-squared test plt0.05 plt0.01
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Incontinence Scores
Values are mean (range). Students T-test
Paired T-test
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Pain Scores
Values are mean (range). Students T-test
plt0.05 plt0.01 plt0.001
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Re-Operation
Chi-squared test plt0.01
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Algorithm1

• Topical treatment. if fails
• Botulinum toxin A (combine with topical
  agents)..if fails
• Lateral internal anal sphincterotomy
• Avoid surgery in 88 of patients
• Cost saving 10 528 1119 (125 reduction)
• Continuing symptoms in 54 of patients ?social
  cost
• QOL poor with ongoing or recurrent symptoms.
• ( DCR 477 1045-1051)

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CONCLUSION

• Lateral anal sphincterotomy remains the most
  efficient and effective treatment.
• Delay in symptom relief worsens QOL and has an
  undisclosed cost
• GTN topical heals 60 with significant side
  effects and at least 40 recurrence rate
• Calcium channel blockers are as good with less
  side effects.
• Botox is not effective but combination with a
  topical agent may improve its efficacy.

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CONCLUSION

• Realistic explanation of risks of sphincterotomy
  compared to efficacy of non surgical measures
  needs to occur for an adequate consent process
• Timely intervention with failure of non medical
  treatments.

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Colorectal Surgical Society of Australia and New
Zealand and Section of Colon and Rectal
Surgery, Royal Australasian College of Surgeons
Spring Continuing Medical Education Meeting
October 2nd-5th 2007, McCracken Country
ClubVictor Harbor, South Australia
International Visiting Speaker Ronan O'Connell
(Dublin)