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Colorectal Surgical Society of Australia and New Zealand and Section of Colon and Rectal Surgery, Royal Australasian

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 Club Victor Harbor, South Australia.

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Colorectal Surgical Society of Australia and New Zealand and Section of Colon and Rectal Surgery, Royal Australasian

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  1. 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)

  2. FISSURE IN ANOPASTE, BOTOX or CUT but not STRETCH Chronic anal fissure

  3. 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; 3:29-30 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

  4. 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

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

  6. 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%

  7. Ram et al Annals of Surgery August 2005 208-211

  8. 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

  9. 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%

  10. 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

  11. 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% @ 8 weeks • Less side effects (25%) • Compounding chemist

  12. 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 >90% with 2-9% incontinence rate2,3 1.Dis Colon & Rectum 13:67-76,2002 2.Dis Colon & Rectum 35:322-327,1992 3.BJS 86 : 651-655, 1999

  13. 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; 344:1127/8. 4 Minguez M et al. Therapeutic effects of different doses of botulinum toxin in chronic anal fissure. Dis Colon Rectum. 1999; 42:1016-21. 5 Jost WH et al. One hundred cases of anal fissure treated with botulinum toxin: early and long-term results. Dis Colon Rectum. 1997; 40:1029-32.

  14. 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

  15. 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 2:10pm Tuesday, 4 May 2004

  16. 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.

  17. 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

  18. 44 patients 38 patients 5 withdrew consent 1 lost to follow-up 17 Botox® 21 sphincterotomy Randomisation

  19. Healing Rates Chi-squared test * p<0.05 † p<0.01

  20. Incontinence Scores Values are mean (range). Student’s T-test & Paired T-test

  21. Pain Scores Values are mean (range). Student’s T-test * p<0.05 † p<0.01 ‡ p<0.001

  22. Re-Operation Chi-squared test † p<0.01

  23. 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 47:7 1045-1051)

  24. 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.

  25. 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.

  26. 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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