Nitroglycerin, Botox or Sphincterotomy for Anal Fissure Associate Professor Nick Rieger Adelaide University Department of Surgery
Jan 15, 2015
Nitroglycerin, Botox or Sphincterotomy for Anal Fissure
Associate Professor Nick Rieger
Adelaide University
Department of Surgery
Aetiology ?
Trauma Sphincter spasm Ischaemia
Typical Anal Fissure
Treatment
Relieve Sphincter spasm
Alleviate ischaemia
Healing
How to relieve spasm?
• Mechanical - Sphincterotomy, Stretch
• Chemical - GTN, Diltiazem, Nifedipine
• Neurotoxic - Botox
Botox
• Botulinum Toxin A• Prevents release of acetylcholine by
presynaptic nerve terminals.• Lasts up to 3 months• Regrowth new axon terminals• Few side effects• Cost $400.00
GTN
• Glyceryl trinitrate
• NO2 donor (inhibitory neurotransmitter in the Internal Anal Sphincter)
• 3 applications per day for 6 weeks
• Headache (dose related)
• Efficacy 47 to 86%
Sphincterotomy
• Requires anaesthesia
• Day case admission
• Very effective (90-95%)
• Incontinence; may be minor (flatus, smearing) but can be permanent
• Up to 5% of patients (some studies quote more)
SphincterotomyDefine the IASOpen or Closed?Tailored?Debride the fissure?
Adelaide study 1
• GTN vs Sphincterotomy (RCT)Evans J, Luck A, Hewett P. DCR 2001
GTN (33 pt) vs LAS (27 pt)
Healed 8 Weeks 20/33 (61%) 26/27 (97%)
Recurrence 9 patients
Sphincterotomy 12 patients
Time to healing significantly faster for sphincterotomy
No incontinence reported
Adelaide study 2
• Open vs Closed Sphincterotomy (RCT)• Wiley M, Day P, Rieger N, Stephens J, Moore J. DCR 2004
• RCT 76 patients; 36 closed:40 open• 6 weeks 96% healed• Incontinence of any grade was seen in 6.8 percent
of patients at 52-week follow-up. Three patients (4.1 percent, 1 closed, 2 open) suffered major incontinence at 52 weeks.
Adelaide study 3• Botox vs Sphincterotomy (RCT)• 38 patients; 17 Botox® ; 21 sphincterotomy• Healing at 6 weeks 7/17 (41%); 18/21 (86%) P = 0.004*• Healing at 26 Weeks 7/17 (41%); 19/21 (91%) P < 0.001†• Of the 17 patients who were treated with Botox®, 9 required
reoperation (53%) within six months, as compared to 2 of 21 cases treated with sphincterotomy (9.5%).
• Eight of the nine Botox® “failures” were cured by sphincterotomy, while 1 continued to have symptoms. One patient who had healing of the fissure by Botox® treatment, had recurrence following a vaginal delivery, some 18 months following the procedure. This was treated by sphincterotomy.
• Botox group were found to have significantly higher two-week pain scores and re-operation rates,
• Continence scores were not significantly different in the two groups.
Literature
Meta-analysis: Nelson; DCR 2004 (Cochrane)• 31 trials• Medial therapy for chronic anal fissure, acute fissure
and fissure in children may be applied with a chance of cure that is only marginally better than placebo.
• For chronic anal fissure surgery more effective than medical therapy (OR=0.12, 95% CI, 0.07-0.22)
Management Considerations
• Crohn’s disease• Patient sex• Obstetric history• Patient age• Duration of symptoms• Prior treatment
Primary FissureWhat I do
• Explanation of treatment options
• Explanation of side effects
• Analgesia (local and systemic)
• Stool softeners
• GTN
• Failure or recurrence go to sphincterotomy
Recurrent Fissure after sphincterotomy
• GTN first line• Consider Botox• Anal ultrasound• Redo sphincterotomy
Other Alternatives?
• Fissure excision and primary closure
• Flap repair - V/Y flap
- Island flap
Incontinence Post Sphincterotomy
• Diet modification
• Physiotherapy
• Imodium
• Sphincter injection - PTP
- EVOH
Summary
• Sphincterotomy remains the best “curative” procedure for anal fissure (incontinence)
• GTN has a role in the initial management (failure and headache)
• Botox may be useful in selected patients (failure)
Conclusions
No perfect management for anal fissure
Informed consent paramount
Tailor the treatment to the individual