PITFALLS IN THE MANAGEMENT OF ANAL FISSURE
Dukes’ Club 2013
Mr Graham Williams
Consultant Colorectal Surgeon
Royal Wolverhampton Hospitals
What I’ve Learned the Hard Way
Anal Fissure- Pitfalls
Dear Mr Williams,I would be grateful if you would see this 43 year old man who has a very painful bottom and some bleeding. This has gone on for a few weeks and has not responded to laxatives and soothing ointments. He is otherwise fit and well. He is too sore to examine.
Anal Fissure- Pitfall 1A fissure is not visible – too sore to examine
Anal Fissure- Pitfall 1
• Length of history
• Age
• Associated features
A fissure is not visible – too sore to examine
Low Threshold for EUA-Consent issues
Anal Fissure- Pitfall 1
• Anal / low rectal tumour
• Intersphincteric abscess
• Anal fissure
• Crohn’s ulcer
A fissure is not visible – too sore to examine
If you don’t think of these things, you will miss them
Anal Fissure- Pitfall 1Intersphincteric abscess
Anal Fissure- Pitfall 1
• Midline (posterior)
• Sentinel tag
• Internal sphincter fibres visible
Common Garden Variety
Anal Fissure- Pitfall 2
What else could it be?
• Hepetic ulcer
• Chancre
• Drugs–Nicorandil
• Crohn’s ulcer
• Severe pruritis ani
• TB
• Anal cancer
• HIV
Anal Fissure- Pitfall 3Looking for the Best Treatment
Anal Fissure- Pitfall 3
• Resolve the pain
• Heal the fissure
• Maintain continence
• Keep the fissure healed
What are the treatment goals?
Treatment Algorithm
Chronic Anal Fissure
Healed
Unhealed
GTN
Diltiazem
Botox
Surgery
Healed
Unhealed
ARP studies
Male Female
Surgery
Healed
Healed
Surgery
Anal Fissue - GTN vs Placebo
RL Nelson: Cochrane review 200847% 33%
Healing
GTN vs Topical Diltiazem
Healing
RL Nelson: Cochrane review 200853%64% 53%
Anal FissureBotulinum toxin vs GTN
RL Nelson: Cochrane review 2008
Healing
67% 53%
Lateral Sphincterotomy
• Anal retractor to put IAS on stretch
• Closed technique – small blade
• Open technique – direct vision
• Divide IAS to upper margin of fissure
RL Nelson: Cochrane review 2008
Anal FissureSurgery vs Medical treatment
Healing
90% 51%
Anal SphincterotomyPost Operative Anal Incontinence
Sphincterotomy for Anal FissureWolverhampton Data
Follow up after 6 weeks [86/101] attended -85%..
8
1
4
83
78
85
82
3
NoYes
Fissure Healed97%
Altered Control5%
Bleeding1%
Anal Pain10%
Patient Satisfaction
Sphincterotomy for Anal FissureWolverhampton Data
0 1 1 1 1 24 11
911
31
0 1 2 3 4 5 6 7 8 9 10
Not Happy Very Happy
Visual Analog Point Scale 0-10
86%
Surgery for Anal FissurePitfalls - 4
• Be sure of the diagnosis
• Be aware of potential for previous sphincter damage
–Anal surgery, Vaginal deliveries
• Be aware of the “low pressure” fissure
• Consider investigation with anal ultrasound (AUS) and anorectal physiology (ARP)
Open vs closed sphincterotomy
Questionnaire follow-up (1-6 years)
Open Closed
Number 324 225
Persistent symptoms 3.4% 5.3%
Further surgery 3.4% 4.0%
Poor flatus control 30.3% 23.6%
Soiling 26.7% 16.1%Garcia-Aguilar et al DCR 1996
Manual Dilatation of the Anus
• Four fingers
• Significant incontinence and recurrence in some series
• Fragmentation of IAS seen on anal ultrasound
Anal Dilatation
Uncontrolled sphincter disruption
Manual Dilatation of the Anus
• 302 patients
• Neuromuscular blockade
• 89% healed
• 3.8% impaired continence
• No sphincter defectStrugnell et al BJS 1999
Anal Fissure- Pitfall 5
Dear Mr Williams,I would be grateful if you would see this unfortunate 26 year old man. He had an anal fissure and had an operation under you colleague Miss Soulsby, which has been a complete disaster and he is still in a lot of pain. Understandably he does not want to see her ever again ......... (goes on for 2 more pages)
Anal Fissure- Pitfall 5The fissure does not heal
Anal Fissure- Pitfall 5The fissure does not heal
• Have you got the diagnosis right?
Anal Fissure- Pitfall 5The fissure does not heal
• Have you got the diagnosis right?
• Has the operation been done effectively?
Anal Fissure- Pitfall 5The fissure does not heal
• Have you got the diagnosis right?
• Has the operation been done effectively?
• Is the anal pressure reduced?
The Unhealed Fissure
100 cms Water
50 cms Water
EMG
10 cms water
10 secs
RESTING PRESSURE
SQUEEZEPRESSURE
The Unhealed FissureAno-rectal Manometery
Options for treatment
• Tincture of time
• Pastes or Botox
• Further sphincterotomy (open)
• Anal advancement flap
The Unhealed Fissure
Anal advancement flaps
• 51 patients
• Cutaneous advancement flap
• 3 (6%) early flap dehiscence
• All eventually healed
• 3 (6%) late fissure recurrence
• No change in control
Giordano et al World J Surg 2009
Whipps Cross Hospital
Anal advancement flaps
• 54 patients, V-Y advancement flap
• 3 (6%) wound dehiscence
• 1 (2%) failed to heal
• No change in anal control
Chambers et al, Int J Colorectal Dis, 2010
Frenchay, Bristol
PITFALLS IN THE MANAGEMENT OF ANAL FISSURES
• High index of suspicion
• Post partum
• Predominantly anterior
• Aetiology uncertain
• Avoid sphincter weakening surgery
The “low pressure” fissure
PITFALLS IN THE MANAGEMENT OF ANAL FISSURES
• Not as easy as you would like to think
• Non surgical treatments of some help, at most
• Surgery still the “gold standard”
• Case selection and technique paramount
• Informed consent needs time
Conclusions
Picture millstone
A Big Scouse WelcomeACPGBI – Liverpool July 1st -3rd 2013