Transcript VISIONE OLISTICA DELLA IDROCOLONTERAPIA: AZIONE

Riccardo Annibali, M.D. , M.A.S.C.R.S.
Unity of Coloproctology “MILAN NORTH”
Columbus Hospital- Milan, Italy
TREATMENT OF ANAL FISSURES
ANAL FISSURE - DEFINITION
“A crack or a tear in the
vertical
axis
of
Sentinel Skin Tag
the
Fissure
squamous lining of the anal
canal between the anal
verge and the dentate line “
Anal Polyp
ANAL FISSURE - CLASSIFICATION
• ACUTE FISSURE
Painful cleft in the anoderm exposing
submucosa and possibly the internal
sphincter
• CHRONIC FISSURE
Anodermal cleft with scarred base and
surrounding inflammation. Frequentlly
seen with hypetrophied anal papilla
and “sentinel pile”
ANAL FISSURE - PRESENTATION
CHRONIC FISSURE
• Deep indurated anal ulcer
• Elevated, overhanging edges
• Associated scarring
• “Sentinel pile”+hypertrophied papilla
• Visibile sphincter fibers
• Rarely lateral
• Less pain at defecation with gradually
decreasing intensity (lasts from
minutes to several hours). No nocturnal
• Pruritus
• Blood on occasion
ACUTE FISSURE
• Superficial without fibrosis
• Flat edges
• None (unless prior surgery)
• None
• Not always visible
• May be lateral
• Severe, sudden stinging sharp
pain associated with defecation
(lasts only a few minutes)
• No pruritus
• Blood usual, bright red, stains
paper or drips into the toilet
ANAL FISSURE - ETIOLOGY
• Associated with passage of hard stool
• Associated with sphincteric hypertone
• ? Most common in posterior midline
• ? Some heal spontaneously vs. become
chronic
ANAL FISSURE - PATHOGENESIS
• Abnormality of internal sphincter
 High resting pressures
 NO: Duthie & Bennet, 1964; Braun, Raguse & Dohrenbusch, 1986
 YES: Northmann & Schuster, 1974; Hancock, 1977; Abcarian, 1982
 DIGITAL EXAMINATION IS UNRELIABLE: Jones OM, Ramaligam T,
Lindsey I, et al. Dis Colon Rectum 2005, 48:349-352
 Abnormal reflex relaxation
in response to rectal distention
• Ischemia
 Posterior commissure is less perfused
 Klosterhalfen B, Vogel P, Rixen H, et al. Dis Colon Rectum 1989; 32:43-52
 Schouten WR, Briel JW, Aurweda JJA. Dis Colon Rectum 1994; 37:664-9
ANAL FISSURE - DIFFERENTIAL DIAGNOSIS
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•
•
Intersphincteric abscess
Pruritus ani
Crohn’s disease
Ulcerative Colitis
Tuberculous anal fissures
Syphilitic anal fissures
AIDS
Leukemia
Anal Malignancy
Previous surgery (hemorroidectomy, fistula-in-ano)
Childbirth
Men=Women
Posterior fissure most common
Anterior fissure most common in women (10%)
Both anterior and posterior (10%)
ANAL FISSURE - TREATMENT
ACUTE FISSURE
CHRONIC FISSURE
MEDICAL TREATMENT
SURGICAL TREATMENT
CONSERVATIVE MEDICAL TREATMENT
• Correct precipitating cause (constipation,
diarrhea)
• Increased fluid
• Sitz baths, bran, bulk laxatives
• Topical Steroids
• Local anesthetics
• (solcoderm, sodium tetradecyulfate, anal dilators)
Effective in up to 50% of cases
(placebo in up to 35% of cases)
ANAL FISSURE - CONSERVATIVE TREATMENT
N = 103 patients
1 week
2 week
3 week
healing
Lidocaine
+
+
++
60 %
Hydrocortisone
+
+
++
82,4 %
Sitz baths
Bran
++
++
++
87 %
Jensen SL. BMJ 1986; 292:1167-1169
ANAL FISSURE - NEW MEDICAL TREATMENTS
Reduce MRP - Increase microcirculation
• NO Donors
 Glycerin trinitrate-GTN; Isosorbide dinitrate-ISDN
• Calcium Channel Blockers
 Nifedipine, Diltiazem
• Botulinum Toxin
• Gonyautoxin
MEDICAL TREATMENT - NO DONORS
(Glycerin trinitrate - Isosorbide dinitrate)
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•
•
•
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•
•
Significant decrease in MRP
Effective at concentration from 0, 2% to 0, 5%
Immediate relief of pain that lasts for 2-6 hours
Healing 30% in 4-6 weeks, 86% in 3 months
Need for frequent application
Headache between 20 to 84% (commonly around 25%)
Discontinuation of therapy up to 20%
Recurrence rate up to 30%
MEDICAL TREATMENT
CALCIUM CHANNEL BLOCKERS
• Significant decrease in MRP
• Healing from 65% to 95%
• Side effects: headache (up to 25%), flushing,
hypotension
• Oral administration: lower healing rate, higher
complications
• Recurrence rate: up to 42 %
MEDICAL TREATMENT - BOTULIN TOXIN
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•
•
•
•
•
•
•
Since 1993
Significant decrease in MRP (30%)
Two doses of 0,1 ml diluted toxin
Healing from 43% to 96%
Chemical denervation lasts 2 to 3 months
Transient incontinence: flatus 10-12%, stool 5%
Recurrence rate around 20%
Expensive
MEDICAL TREATMENT - GONYAUTOXIN
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•
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Phytotoxin produced by microscopic planctonic algae
Stored in filter feeders like bivalves
Blocks the voltage-gated sodium channels in a reversible way
Two doses of 100 units (second one after 7 days)
Reduces both and MRP and MVCP
Immediate post injection sphincter relaxation and relief of pain
Healing rate: 98% in 28 days
Recurrence rate: ???
Further studies needed
Garrido R, Lagos N, Lattes K et al. Gonyautoxin: new
treatmentfor healing acute and chronic anal fissures. Dis
Colon Rectum 2005, 48:335-343
ANAL FISSURE - SURGICAL TREATMENT
HISTORY
1838
1835
1892
1930
1934
1939
1951
1969
Recamier - Anal stretch
Brodie
sphincterotomy
Goodsall
Gabriel
Milligan & Morgan
fissurectomy
Miles - “pectenotomy” (division of “pecten band”)
Eisenhammer - open lateral internal sphincterotomy
Notaras - closed lateral subcutaneous internal
sphincterotomy
ANAL FISSURE - SURGICAL TREATMENT
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•
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•
Anal Dilatation
Fissurectomy and Posterior Sphincterotomy
Open Lateral Internal Sphincterotomy
Closed lateral Internal Sphincterotomy
Anoplasty (advancement flap, V-Y flap,
rotational flap, etc.)
ANAL DILATATION
• Still popular in the UK (36% of surgeons)
• Sphincter damage in > 50% of patients
• Incontinence to flatus 12,5 - 28.6%
• Major incontinence 2 - 7,1%
• Soiling up to 39.3%
• 4 fingers x 4 minutes
• Parks retractor at 4.8 cm
• Healing rates from 43/ to 94%
• Recurrence rate:10 to 30%
FISSURECTOMY-POSTERIOR SPHINCTEROTOMY
• Cure rate : 93%
• “Keyhole” deformity: 5%
• Incontinence to flatus: 17-34%
• Incontinence to feces: 3 -15%
• Soiling up to 41%
• Large external wound
• Prolonged time for healing
•Recurrence rate: 1,3 %
Gabriel WB , 1930
LATERAL INTERNAL SPHINCTEROTOMY
OPEN - Eisenhammer S, 1951
CLOSED - Notaras MJ, 1969
LATERAL INTERNAL SPHINCTEROTOMY
No difference for persistence of symptoms,
fissure recurrence or need for reoperation
between open and close. Statistical
significant difference for soiling of
underwear (26,7% vs. 16,1%) and stool
incontinence (11,8% vs. 3,1%). Almost
significant for flatus incontinence (30,3%
vs. 23,6%).
Garcia-Aguilar et al., 1996
No difference between the two methods.
Nelson RL, 1999
Boulous PB et al., 1984
Kortbeek JB et al., 1992
LATERAL INTERNAL SPHINCTEROTOMY
LATERAL INTERNAL SPHINCTEROTOMY
ANAL FISSURE - TREATMENT
“…Fully 45% of patients had some degree of
fecal incontinence at some point after LIS.
However, by one month after surgery, only 6%
were incontinent to flatus. More importantly,
98% of patients were satisfied with the outcome
of surgery, and < 1% of patients had their life
affected by incontinence…”
Nyam DC, Pemberton JH, Dis Colon Rectum1999; 42:1306-10
LATERAL INTERNAL SPHINCTEROTOMY
• Forceful anal dilatation is inferior to LIS owing to a
higher recurrence rate with higher rates of incontinence
Olsen J et al., 1987
Weaver RM et al., 1987
• LIS is superior to fissurectomy and posterior midline
sphincterotomy owing to faster healing rates, less pain
and less postoperative incontinence
Abcarian H, 1980
Saad AM et al., 1992
• LIS is superior to anal dilatation and posterior midline
sphincterotomy
Nelson R, 2004
ANOPLASTY
Advancement
Flap
V-Y Flap
Rotational Flap
ANOPLASTY
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Associated stenosis (mild, moderate, severe)
Usually postoperative (hemorrhoidectomy, fistulotomy)
In patients with normal or low MRP
In recurrences
V-Y flaps: 60-70% of donor sites break down and
median healing time of 4 months (2 - 6)
• Rotational flap: lower break down rate
• No incontinence
• A viable alternative to LIS
Leong AF, Seow-Choen F. Dis Colon Rectum 1995;38:69-71
Kenefick NJ, Gee AS, Durdey P. Colorectal Dis 2002; 4:463
Singh M et al. Int J Colorectal Dis 2005; 20:339-42
ANAL FISSURE PERSONAL SURVEY (1993-2004)
295 Pts Male:151 Female: 144
Mean FU: 96 mths (18-150)
Post.: 255 (87,5%) Ant.: 40 (13%) Both: 31(10%)
274 (93%) operated on under local anesthesia
Open LIS:
Post. IS+Fissurectomy
Advancement flap
V-Y flap
Rotation Anoplasty
239
5
27
23
1
(81%)
(1,6%)
(9%)
(8%)
(0, 4%)
Associated Excision
146
(50%)
Associated pathologies
211
(70%)
(hemorrhoids 62%; mucosal prolapse 19%; hemorrhoids+mucosal prolapse
11%; fistula-in-ano 1%)
ANAL FISSURE PERSONAL SURVEY (1993-2004)
LIS
Incont. Flatus: 21 (8,7%) Soiling: 11 (4,5%) Recurrence: 2 (0,6%)
Hematoma: 8 (3%) ; Perianal abscess: 1 (0,4%) ;
Thrombosed Hemorrhoids: 1 (0,4%) ; Hemorrage: 2 (0,8%)
Post. IS
1/5 not healed at 3 months (DTC); 1/5 Incont. Flatus+Soiling
Advancement Flap
6/27(22%) Ant.+Post. - 3/27 (11%) Breakdown - Healing T: 7,7 wks (2-40)
V-Y Flap
1 deceased - 15/22 (68%) Breakdown - Healing T: 6,5 wks (3-12)
ANAL FISSURE-COMPARISON OF TREATMENT
Nelson R. Dis Colon Rectum 2004, 47 (4):422-431
ANAL FISSURE - TREATMENT
“…first line use of medical therapy cures
most chronic anal fissures cheaply and
conveniently…”
Lindsey I, Jones OM, Cunningham C, Mortensen NJ. Br.
J. Surg 2004;91:279-9
“…medical therapy for chronic anal fissure
may be applied with a chance of cure that is
only marginally better than placebo… [and]
far less effective than surgery…”
Nelson R. Dis Colon Rectum 2004;47:422-31
ASCRS PRACTICE PARAMETERS
1)
2)
3)
4)
Conservative therapy is safe, has few side effects, and
should usually be the first step
Anal fissures may be appropriately treated with topical
nitrates because they can relieve pain; however, nitrates are
only marginally associated with a healing rate superior to
the placebo
Anal fissures may be appropriately treated with topical
calcium channel blockers, which seem to have a lower
incidence of adverse effects than nitrates. There is
insufficient data to conclude whether they are superior to
placebo in healing fissures
Botulinum toxin injections may be used for anal fissures
that fail to respond to conservative measures and have been
associated with a healing rate superior to placebo. There is
inadequate consensus on dosage, precise site of
administration, number of injections or efficacy
ASCRS PRACTICE PARAMETERS
5)
6)
7)
8)
Lateral internal sphincterotomy is the surgical treatment of
choice for refractory anal fissures
Open and closed technique for LIS seem to yield similar
results
Anal advancement flap is an alternative to LIS; further study is
required
Surgery may be appropriately offered without a trial of
pharmacologic treatment after failure of conservative therapy;
patients should be informed about the potential complications
of surgery
“The one who
knows much talks
little. The one who
talks much does
not know”
Lao Tse
THANK YOU FOR
YOUR ATTENTION!