Anal Fissure: the Facts (Are there any?) Tamzin Cuming Colorectal Consultant Homerton University...
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Transcript of Anal Fissure: the Facts (Are there any?) Tamzin Cuming Colorectal Consultant Homerton University...
Anal Fissure: the Facts
(Are there any?)Tamzin Cuming
Colorectal ConsultantHomerton University Hospital
Classic fissure in ano
90% posterior
< 6 weeks: acute
> 6 weeks + sentinel pile + visible sphincter
= chronic
OK some facts
• 90% are the fissures you are thinking of– Young man– High pressure anus– Split is posterior • Because the blood supply is worst at the back• The pain is from anal spasm
Management
Acute Lignocaine, Fybogel and sympathy (90% cure)
Chronic
ALL THE TREATMENTS (except one) TREAT THE SPASM
and let the body heal the fissure
Anal spasm treatment I
• Give it nitrous oxide– GTN 0.4% >0.2% • 25% headache (cling film)
• Cure 60%1 Recurrence 50%2
– Diltiazem 2% • 15% pruritis• Cure: 75%3 RRecurrence 0.664
• Why not block the Ca2+ channels?– nifedipene top/oral
1 2006 Cochrane Review Nelson 2 DCR 2004;47:422-431 3Steele SR 2006 Aliment Pharm 4Sajid MS Colorectal Dis 2013
Anal Spasm treatment II
Paralyse it!
• At least Botox wears off
• Clinical conviction
• Less expensive than 5 years ago
Cochrane review• Healing rate variable: 75%• Recurrence rate 50% at 4 yrs• 10% temporary incontinence• No better than GTN 0.2%• More expensive than NO
(£77/pt)• Works for NO-resistant
Nelson 2012; NICE ESUOM14; Lindsey DCR 2004
Anal spasm treatmentCUT IT!
– Lateral anal (internal) sphincterotomy
– FINALLY! A CURE!
• 95%
– 5% up to 47% ‘mild’ incontinence• forever
No longer
• Posterior sphincterotomy: key-hole deformity
• Lord’s anal stretch
If all else fails
• Histology to exclude odd things plus DOSH• Advancement flap anoplasty– 48% cure with 0% incontinence– Also a treatment for low pressure fissures– recur if pelvic floor dysfunction not addressed
Anoplasty options
• V-Y or rotational island advancement flap• Mucosal advancement flap• Cutaneous advancement flap using sentinel pile
(SCAFA)
• Probably fail due to same high • pressure ischaemia– Botox AND anoplasty if high pressures– LAS and anoplasty