Anal fissure pitfalls in management

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