In chronic anal fissure, persistent...

In chronic anal fissure, persistent hypertonia and spasm of the internal anal sphincter cause elevated internal constraining forces that prevent healing. A number of surgical conducts have been developed to eliminate spasm and allow the fissure to heal. Lateral internal sphincterotomy, the mostly popular current procedure, is associated with return rates of less than 10 percent however up to 66 percent of patients experience incontinence. Chemical agents that effect reversible reductions in sphincter constraining force also can enhance healing of anal fissures. Arroyo and colleagues compared the effectiveness and morbidity of surgical (ambulatory make open lateral internal sphincterotomy) and chemical (botulinum toxin pattern A [Botox] sphincterotomy) procedures in patients with chronic anal fissure.

The authors randomly assigned 80 consecutive patients with chronic anal fissure to surgical or chemical sphincterotomy. All patients had fibrous induration or expos internal sphincter fibers despite at least six weeks of conservative medical treatment with high-residue diet, warm sitz baths, and analgesia. The authors performed detailed assessments forward each patient to exclude other pathology (eg sexually transmitted disease, tuberculosis, pregnancy) or contraindication to the contemplation treatments. All treatments were carried without by the same surgeon using standardized techniques. All patients received identical follow-up treatment instructions and were reevaluated at brace six, 12, 24, and 36 month after surgery The follow-up assessment included physical examination, manometric assessment of anal compressing and incontinence scoring.

The brace groups were comparable in all significant areas at assignment to treatment. The mean age was 40 years, and symptoms typically had been not away for 18 to 20 month single in kind patient in each group expanded a hematoma, and one patient in the surgical collection experienced bleeding. Otherwise, no complications were noted at the time of treatment. At united year, 37 (92.5 percent) of the surgical patients had healed compared with 18 (45 percent) patients treated with botulinum toxin. The no other than pretreatment variable significantly associated with non-healing was duration of symptoms. Mean resting hurrys declined significantly in both disposes after treatment, but a significantly greater number of patients treated surgically (327 versus 197 percent) experienced significant reductions in influence At two months, incontinence was reported from three (7.5 percent) of the patients treated with surgical sphincterotomy and from two (5 percent) of the patients treated with botulinum toxin. After single in kind year, two patients in the surgical arrange reported occasional incontinence of flatus, however no incontinence was reported by means of any other patients.

The authors end that patients at high risk of return of anal fissure because of duration of symptoms and squeezing should be treated surgically. For other patients, botulinum toxin could be an initial therapy, especially patients older than 50 years and those at risk of developing incontinence.

ANNE D WALLING, MD

Arroyo A, et al. Surgical versus chemical (botulinum toxin) sphincterotomy for chronic anal fissure: long-term ends of a prospective randomized clinical and manometric consideration Am J Surg April 2005;189:429-34

COPYRIGHT 2005 American Academy of Family Physicians

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