Resolution of chronic anal fissures after treatment of ... · mA. The treatment time varied from 4...

0016-5107/97/4502-015755.00 + 0 GASTROINTESTINAL ENDOSCOPY Copyright © 1997 by the American Society for Gastrointestinal Endoscopy

Resolution of chronic anal fissures after treatment of contiguous internal hemorrhoids with direct current probe Gustavo A. Machicado, MD, Susie Cheng, RN, Dennis M. Jensen, MD Los Angeles and Van Nuys, California

Background: Purposes: (1) to prospectively evaluate efficacy and safety of direct current (DC) probe treatment of chronic anal fissures associated with internal hemorrhoids, and (2) to estimate direct and indirect costs of anoscopic treatment versus surgery. Methods: Ten patients with chronic fissures of 11 mm (mean length) had symptoms for 5 months (mean) in spite of medical management; all had internal hemorrhoidal disease. DC coagulation was applied to two or three contiguous internal hemorrhoids per outpatient session. Eleven mA (mean) of DC current was delivered for 7 minutes (mean) per hemorrhoid segment. Results:All 10 patients had relief of chronic anal pain within two treatments and nine anal fissures healed within 4 weeks. One patient developed a perianal abscess and fistula requiring surgery. There were no recurrences in 20 months (mean) of follow-up with medical management. Mean direct and indirect costs (in terms of lost time from work or usual activity) of DC probe treatments were estimated to be 10% to 30% lower and 2 to 10 times less, respectively, than standard surgery for chronic anal fissures. Conclusion: DC probe treatment for chronic anal fissures associated with internal hemorrhoidal disease is an important advance as an effective, safe, and cost-effective nonsurgical treatment in selected patients. (Gastrointest Endosc 1997;45:157-62.)

Chronic anal fissures are a common problem affect- ing both sexes equally. Another common name given for these fissures is ulcers because of their round, punched-out appearance at anoscopy (Fig. 1). How- ever, without adequate relaxation or dilatation of the anal canal during anoscopy, most look like lacerations. We use the term fissure throughout this paper for the sake of consistency. Since most acute fissures usually heal with medical management, we include only chronic anal fissures in this report.

An anal fissure is a tear (Fig. 2) or ulceration (Fig.

Received April 9, 1996. For revision May 28, 1996. Accepted August 13, 1996.

From the UCLA Center for the Health Sciences and CURE: Diges- tive Disease Research Center, Los Angeles, and Northridge Hospital Medical Center, Van Nuys, California.

Reprint requests: Dennis M. Jensen, MD, 44-133 CHS, Division of Digestive Diseases, UCLA Medical Center, 10833 Le Conte Ave., Los Angeles, CA 90095-1684.

37/1/77275

1) tha t occurs in the anoderm between the dentate line and the external skin. On rare occasions, it may extend proximal to the dentate line onto the rectal mucosa or, less often, onto the anal skin. Fissures occur on the posterior midline aspect of the anus in over 75% of cases. The next most common site is the anterior anus. 1, 2 Anterior anal fissures appear most commonly in women. Although no one knows what causes anal fissures, often the patient will associate the be- ginning of symptoms with the passage of a large, hard stool or explosive diarrhea. For this reason, it is likely that t rauma is the inciting event of most anal fissures. The posterior location of most fissures probably re- lates to the forces applied to the anal canal during the passage of a hard stool and to the anatomic configura- tion and angulation of the anal canal. The health of the anal tissue, particularly the anoderm, and degree of elasticity may also play a role in the development of the fissure and failure to heal.

Chronic anal fissures are extremely incapacitating

VOLUME 45, NO. 2, 1997 GASTROINTESTINAL ENDOSCOPY 157

Figure 1. Chronic anal fissure that appears as an ulcer in the 8 o'clock position of the field, proximal to an internal hemorrhoid. The patient had severe anal pain for 4 months that was unresponsive to medical therapy.

Figure 2. Chronic anal fissure with a laceration appearance. The patient had characteristic fissure pain for 6 months.

to patients and often do not heal without some form of intervention. 3 Patients with chronic anal fissures usually report acute, sharp anal pain with passage of stool, which often leads to rectal spasm and severe constipation. Patients become fearful of having a bowel movement and may develop fecal impaction. This initial pain is followed after defecation with a more indolent but just as aggravating pain that may last minutes to hours. This chronic pain may be mild and annoying or severe and incapacitating. It is probably due to internal sphincter spasm following anal dilation during defecation 4 and/or chemical irritation of the fissure during passage of stool. 3

No ideal t reatment has been found to cure symp- tomatic chronic anal fissures. Most patients are man- aged surgically because medical t reatment is not very effective (less than 45% healed with medical therapy) and, even ff there is relief of pain and healing, these

Figure 3. Direct current (DC) generator, grounding pad, hemorrhoid probe, and slotted anoscope.

take an unacceptable amount of time. 5 Most patients who are incapacitated by their symptoms cannot afford to stay off work for a long period of time nor do they have any desire to continue suffering.

Internal hemorrhoids and chronic hemorrhoidal symptoms often coexist with anal fissures and some surgeons recommend hemorrhoidectomy at the time of surgical fissure surgery. 6 We and others have eval- uated and previously reported direct current (DC) probe (Fig. 3) for the t reatment of chronic internal hemorrhoidal disease in patients without chronic anal fissures.7, s One of our patients with bleeding internal hemorrhoids also had a chronic posterior anal fissure that was very painful. The anal pain due to the fissure resolved within 2 days after DC probe t reatment of the adjacent hemorrhoids. Following subsequent treatments to the contiguous hemorrhoids and marked re- duction in their size, the chronic fissure healed com- pletely. Therefore, we extencled our observations of this device in the treatment of 10 other consecutive patients with chronic anal fissures associated with chronic internal hemorrhoids.

The purposes of this study were as follows: (1) to prospectively evaluate the efficacy and safety of DC probe for t reatment of chronic anal fissures associated with internal hemorrhoids, and (2) to estimate the direct and indirect costs of DC probe compared to surgery for these patients, for our institutions.

METHODS AND EQUIPMENT

All procedures were performed as outpatient treatment in an endoscopy unit. Initial anoscopic evaluations were performed using intravenous sedation, as needed, due to extreme pain and tenderness of the anal canal. A topical an- esthetic (2% viscous lidocaine) was generously applied. Sed- atives included diazepam (Valium) or midazolam (Versed) and meperidine HC1 (Demerol) as needed. Following intravenous sedation, adequate relaxation of the anal sphincter was obtained to allow excellent examination of this area. Often the fissure could be partially visualized externally by

158 GASTROINTESTINAL ENDOSCOPY VOLUME 45, NO. 2, 1997

Figure 4. DC probe in Place at the base of the hemorrhoid 1 to 2 cm above the dentate line, as viewed through a slotted anoscope.

spreading the anus manually. However, better visualization of the entire length of the fissure was achieved with a medium-sized slotted anoscope (Fig. 3 and 4).

For treatment, we used a DC probe (Ultroid, Cabot Med- ical, Langhorne, Pa.) (Figs. 3 and 4), which passes a small amount of direct current between the electrode implanted at the base of the internal hemorrhoid and a grounding plate attached to the thigh or buttocks. 7 The instrument can produce 2 to 16 mA of current. We commonly used 6 to 14 mA depending on patient tolerance, as previously described by Norman et al. 7 The power was increased gradually by 2 mA increments until the desired power level was reached. Once patients advised us that they began to feel the current, the power was maintained at the same level or decreased by 2 mA. The treatment time varied from 4 to 10 minutes depending on the size of the fissure and the size of the adjacent hemorrhoids, s At the completion of treatment, the power was gradually decreased by 2 mA increments. This was done to avoid any large current surges that may be felt by the patient. The treatment was directed at the base of the internal hemorrhoids immediately adjacent to or contiguous with the fissure (Fig. 4). The electrodes were positioned at the base of the hemorrhoid 1 or 2 cm above the dentate line. One to three contiguous hemorrhoid segments were treated per session depending on patient tolerance. 7, s Intravenous sedation was used as needed for rectal pain during the follow-up treatment sessions every 2 to 3 weeks.

Definitions and patient characteristics

We considered an anal fissure to be "chronic" if(l) patients had severe anal pain and/or documented anal fissure for 2 or more months, (2) on anoscopy, the fissure appeared chronic; was deep and large yet had discreet borders, and (3) patients had failed to improve with at least 1 month of medical management (including stool softeners, low-residue diet, ointments, suppositories, analgesia, and sitz baths).

Ten patients, 6 men and 4 women, with chronic anal fissures were studied prospectively. No patient had inflammatory bowel disease. The mean age was 48 years (range 18 to 86). All 10 patients presented with severe pain precipitated by hard bowel movements. The mean duration of symptoms in this group was 5 months (range 4 to 24). The mean length

Figure 5. Grade 1 internal hemorrhoid and healed anal fissure (of patient in Fig. 1) after two treatments with the DC probe, 6 weeks after Fig. 1.

of the chronic fissure was 11 mm. Just above the chronic anal fissure, all patients had chronic internal hemorrhoids with a median grade of 2 and symptoms, as previously described, s The internal hemorrhoids accounted for the fullness, bleeding, and prolapse reported by these patients, whereas the pain and/or spasm with bowel movements was secondary to the anal fissures. A mean of 11 mA of DC current was delivered for a mean period of 7 minutes per hemorrhoid segment per session. A mean of two internal hemorrhoidal segments were treated per session, s All patients continued receiving medical treatment until healing of the fissure. They all underwent long-term follow,up and main- tainenance on high-bulk diet and stool softeners.

Cost estimates

We estimated the indirect costs associated with treatment of this disease related to time lost from work due to the treatment alone. We did not estimate the indirect costs associated with loss of productivity from pain and suffering or from complications of treatments. 9 Anoscopic treatment with DC probe of the two or three contiguous internal hemorrhoids required two or three separate sessions or 2 to 3 days offwork, on average. We did include the direct costs of the one patient with a complication, treated with DC probe, but no complications were calculated into the surgical treatment estimates of direct cost. Postsurgical loss of work time may vary depending on whether a lateral internal sphincterotomy is done alone or in combination with internal hemorrhoidectomy. For indirect cost estimates, the costs of complications of either surgery or DC probe were not included. In our institutions, the number of days off work after surgery for an anal fissure may range from 6 to 30 days.

R E S U L T S

The mean number of t r e a tmen t sessions required to obliterate the contiguous internal hemorrhoids with the DC probe and heal the anal fissures was 2.3. All 10 pat ients experienced marked improvement in anal pa in after the first t rea tment . Complete heal ing of the


Table 1. Direct and indirect cost estimates

Surgery DC probe

Direct cost of treatments $2700-5700* $13504 Indirect cost: loss of time 6-30 days 2-3 days

from work or usual activity$ Costs estimated from charges by community hospitals in Van

Nuys, Calif. *$2700 is the estimated direct cost of internal sphincterotomy

without complications. $5700 is the direct cost of internal sphincterotomy and hemorrhoidectomy combined without complications.

"Hncludes the mean direct costs of three outpatient anoscopies and treatments with the DC probe in Northridge Towers, Van Nuys, Ca- lif. for 10 patients and 1 complication (pefirectal abscess).

SDoes not include loss of time for complications that may occur with either surgery or DC probe.

chronic anal fissures was documented in 9 patients within a mean of 4 weeks (Fig. 5). One patient developed a complication. This was a right-sided perianal abscess and fistula that required surgery following the second treatment with the DC probe. During a mean follow-up of 20 months, there was no recurrence of internal hemorrhoids or anal fissures on serial clinic visits and anoscopies.

The direct cost of anoscopic treatment included gastrointestinal endoscopy unit charges and professional charges for a mean of three separate anoscopic treatments. The total charges approximated $1000. When the direct costs of surgery for the complication in one patient were factored in, the mean cost of the DC probe group increased to $1,350. The total surgical charges, including operating room charges, anesthesia, and professional charges, would be $2,700 for a lateral internal sphincterotomy alone or $5,700 for a combined procedure with hemorrhoidectomy, including 2 days of hospitalization. These cost estimates do not include analyses of complications of surgery such as fecal incontinence or infections, which would increase the direct and indirect cost estimates for the surgical option. These charges were obtained using average charges from our community. The mean direct and indirect costs are summarized on Ta- ble 1.

DISCUSSION

A chronic anal fissure is a common problem that is often incapacitating to the patient. This problem is often unfamiliar to gastroenter01ogists or gastrointestinal endoscopists because such patients are more commonly seen by colorectal or general surgeons. Medical therapy is frequently ineffective in relieving symptoms or healing the chronic fissures. Moreover, patients who eventually heal spontaneously may continue to suffer from severe symptoms for several weeks. 5 Vajrabukka et al. 1° used cryosurgery in 13 patients with chronic anal fissures and reported heal-

Table 2. Proposed mechanisms of action for DC probe on anal fissures 1. Change of blood flow in anorectal area to facilitate heal-

ingT, s, 2~, ~a 2. Stabilization of tissue above dentate line to reduce prolapse. 7, s 3. Retraction of internal hemorrhoid and associated t i s s u e 7, s

4. Initiation of a local inflammatory response which facilitates healing of f i s s u r e 7, 8, 22, 23

5. Interference with reflex mechanisms that cause spasm of the internal sphincter muscle

ing in 10 of 13 patients within 6 to 8 weeks. Pain relief was seen in 7 patients within 2 or 3 days and within a week or more in3 patients. Patients had sig- nificant pain due to the treatment in the first 24 hours. Extreme care was necessary in the application of this t reatment to avoid freezing the perianal skin, since this could produce intense pain. Other serious complications previously reported for cryotherapy could potentially occur, n

Many surgical methods have been utilized to treat chronic anal fissures. Based on anal sphincter studies that showed increased anal pressures in patients with chronic anal fissures, 4, 12, 13 manual sphincter dilations under general anesthesia were performed. The success rate of this procedure was low and the complication rate (fecal incontinence) too high to be generally acceptable. 14, 15 The pathophysiologic sig- nificance of the reported elevated sphincter pressure in patients with chronic anal fissures is unclear since there are no studies to document elevated anal pressures prior to the development of the chronic anal fissure. Posterior anal sphincterotomy was associated with a "key hole" defect of the anus, which caused fecal incontinence in over 20% of patients, in addition to other drawbacks such as wound pain following the operation, slow healing, and prolonged hospitalization.16-1s

Today, lateral internal sphincterotomy is the most commonly used surgical technique for chronic anal fissures. This procedure has many advantages. It re- lieves the pain quickly and the fissure heals in 3 to 4 weeks. The patients do not usually require hospitalization unless a simultaneous hemorrhoidectomy is performed. This is still the risk of wound infection at the incision site. ls-21 The incidence of flatus and fecal incontinence is significantly less (7% to 8%) with lateral internal sphincterotomy than with posterior anal sphincterotomy or manual sphincter dilation.

For the t reatment of internal hemorrhoids, DC probe is a nonsurgical technique tha t does not require general anesthesia, can be administered in the outpatient setting, and is extremely well tolerated by most patients.7, 8 This is the first report of DC probe treatment for chronic anal fissures associated with chronic


in te rna l hemorrhoids . Pa t ien t s do not requi re the incision of t issue. The advan tage of this technique is t ha t one t rea t s the f issure by obl i tera t ing the contiguous in te rna l hemorrhoids . This anoscopic t r e a t m e n t was uni formly effective in the rel ief of pa in and resul ted in hea l ing of the chronic f issures in 9 of 10 pa t ien ts wi thout the need for surgery. The effectiveness appeared to be comparable to la tera l in te rna l sphincterotomy. In addition, the DC probe t r e a t m e n t appeared to be more cost-effective t h a n surgery in pa t ien ts wi th chronic ana l f issures associated wi th in te rna l hemorrhoids when they failed to heal wi th medical management .

The mechan i sms of action of the DC probe to facil- i ta te chronic anal f issure heal ing are unknown. Table 2 lists several possible mechanisms. Dur ing our serial examinat ions , the associated hemorrhoids and sur- rounding t issue re t rac ted significantly. 7, 8 Therefore, re t rac t ion and stabil izat ion are ve ry l ikely to contrib- u te to a change in the local anatomy. Other local ther- mochemical mechanisms have been described t h a t m a y change the local blood flow or ini t ia te an inflam- m a t o ry response t ha t facil i tates f issure healing. 7, 22, 23 Whereas su rgery or m a n u a l dilat ion cut or rup tu re the in te rna l anal sphincter , bo tu l inum toxin, nitroglyc- erin, and DC appear to in ter fere wi th local reflex mechanisms tha t cause spasm of the in te rna l ana l sphincter muscle. Surgical procedures and manu a l di lat ion can cause incontinence of f latus or feces, bu t this has never been repor ted dur ing long-term follow- up of pa t ien ts wi th in te rna l hemorrhoids t r ea t ed wi th DC probes 7, s and has not been seen in any of our pa- t ients wi th anal fissures.

Several quest ions r ema in to be answered, such as the exact mechan i sm of action and t issue react ion of the DC probe. Wha t is the ideal f requency of t reat - ments , the energy level, and length of applicat ion to achieve rapid heal ing? Which anal f issures are ame- nable to this form of t h e r a p y and which should undergo surgical repair? Wha t o ther types of anoscopic probes t ha t are cur ren t ly ut i l ized for t r e a t m e n t of in te rna l hemorrhoids (such as BICAP or hea t e r probe) would allow chronic anal f issures to heal? Fur- t he r invest igat ion will be needed to answer these questions.

A complication ra te of 10% for DC probe t r e a t m e n t wi th chronic anal f issures and chronic in te rna l hemorrhoids is significantly h igher t h a n our group s or N o r m a n et al. 7 have repor ted in DC probe t r e a t m e n t of pa t ien ts wi th chronic hemorrho id disease who lack ana l fissures. The 10% complication ra te (1 pa t i en t out of 10 developed a rectal abscess) m a y be due to the small series size in this initial report . To suppor t the inf requency of this complication, rectal abscesses were not repor ted in large DC probe series to date in DC probe t r e a t m e n t for chronic hemorrhoida l disease. 7, 8

Another possible explanat ion m a y be tha t pa t ien ts wi th chronic anal f issures and in te rna l hemorrhoids m a y be more prone to this complication.

Another nonsurgical a l te rna t ive t r e a t m e n t of symp- tomat ic chronic anal f issures tha t appears p romis ing is bo tu l inum toxin (Botox). Jos t and Schimrigk 24 repor ted t r e a t m e n t of 26 pat ients wi th painful anal f issures wi th Botox. Heal ing was documented in 81% of pat ients . Confi rmat ion is war ran ted .

Gorfine 25 repor ted t r ea t ing 15 pa t ien ts with topi- cally applied ni t roglycer in o in tment with the rel ief of symptoms and heal ing of the fissures in 80% of pat ients . Mild headache occurred in 33% of pat ients .

Our pat ients did r emarkab ly well wi th DC probe t r ea tment . There have been no recurrences of anal f issures or in te rna l hemorrhoids wi th long-term medical management . We conclude t h a t the DC probe shows great promise in selected pa t ien ts wi th in te rna l hemorrho id disease as an effective, safe, cost-effective nonsurgical t r e a t m e n t of chronic anal f issures in as- sociation wi th in te rna l hemorrhoids . This t r e a t m e n t should be considered as an a l te rna t ive to surgery in selected pat ients (without in f l ammatory bowel disease) whose chronic anal f issures do not heal wi th medical t h e r a p y and the f issure is associated with in- t e rna l hemorrhoids .

REFERENCES 1. Mazier WP. An evaluation of the surgical treatment of anal fis-

sures. Dis Colon Rectum 1972;15:222-7. 2. Petros JG, Rimm EB, Robillard RJ. Clinical presentation of

chronic anal fissures. Am Surg 1993;59:666-8. 3. Georgeolis B, Ska]deas G. Pain caused by anal fissure. Proc

Royal Soc Med 1969;62:260. 4. Nothman BS, Schuster MM. Internal anal sphincter derange-

ment with anal fissures. Gastroenterology 1974;67:216-20. 5. Gough MJ, Lewis A. The conservative treatment of fissure-in-

ane. Br J Surg 1983;70:175-6. 6. Ferguson JA. Fissure in ano and anal stenosis part II: radical

surgical management. Clin Gastroenterol 1975;4:629-34. 7. Norman DA, Newton R, Nicholas GV. Direct current electro-

.therapy of internal hemorrhoids: an effective, safe, and painless outpatient approach. Am J Gastroenterol 1989;84:482-7.

8. Randall GM, Jensen DM, Machicado GA, Hirabayashi K, Jensen ME, You S, et al. Prospective randomized comparative study of bipolar versus direct current electrocoagulation for treatment of bleeding inte~mal hemorrhoids. Gastrointest En- dosc 1994;40:403-10.

9. Jensen DM. Economic assessment of peptic ulcer disease. Scand J Gastroenterol 1988;23(suppl 146):214-24.

10. Vajrabukka T, Dhetavat V, Kechanond B, Vajrabukka C. A preliminary report on cryosurgical treatment of chronic anal fissure. Am J Proctology 1977;28:47-50.

11. Alexander-Williams J, Crapp AR. Conservative management of hemorrhoids. Part I: injection, freezing and ligation. Clin Gas- troenterol 1975;4:595-618.

12. Cerdan FJ, Ruiz de Leon A, Azpiroz F, Martin J, Balibrea JL. Anal sphincter pressure in fissure-in-ano before and after lateral sphincterotomy. Dis Colon Rectum 1982;25:198-201.

13. Kuypers HC. Is there really sphincter spasm in anal fissure? Dis Colon Rectum 1983;26:493-4.

14. Goligher JC. An evaluation of internal sphincterotomy and simple sphincter stretching in the treatment of fissure-in-ano. Surg Clin North Am 1965;45:1299-304.


15. Watts J McK, Bennett C, Goligher JC. Stretching of anal sphincters in treatment of fissure in ano. Brt Med 1964;2:342-3.

16. Bennett RC, Goligher JC. Results of internal sphincterotemy for anal fissure. BMJ 1962;2:1500-3.

17. Magee HR, Thompson HR. Internal anal sphincterotomy as an out-patient operation. Gut 1966;7:190-3.

18. Hawley PR. The treatment of chronic fissure-in-ano. A trial of methods. Br J Surg 1969;56:915-8.

19. Notaras MJ. The treatment of anal fissure by lateral subcutaneous sphincterotomy--technique and results. Br J Surg 1971; 58:96-8.

20. Chowcat NL, Aranjo JGC, Boulos PB. Internal sphincterotomy for chronic anal fissures: long-term effects on anal pressure. Br J Surg 1986;73:915-6.

21. Olsen J, Mortensen PE, Krgh-Petersen I, Christiansen J. Anal sphincter function after treatment of fissure-in-ano by lateral subcutaneous sphincterotomy versus anal dilatation. Int J Colorect Dis 1987;2:155-7.

22. Webb JC. The treatment ofhaemorrhoids by electrolysis. BMJ 1921;1:457-8.

23. Keesey WE. Obliteration of hemorrhoids with negative galva- nism. Arch Phys Ther 1934;15:533-40.

24. Jost WH, Schimrigk K. Botulinum toxin in therapy of anal fissure. Lancet 1995;345:188-9.

25. Gorfine SR. Treatment of benign anal disease with topical ni- troglycerin. Dis Colon Rectum 1995;38:453-7.

M o v i n g ?

To ensure continued service please notify us o f a change o f address at least 6 weeks be-

fore your move.

Phone Journal Subscription Services at 1-800-435-4351 (outside the U.S. call 314-453-

4351) or fax your information to 314-432-1158.


Resolution of chronic anal fissures after treatment of ... · mA. The treatment time varied from 4...

Documents

Transcript of Resolution of chronic anal fissures after treatment of ... · mA. The treatment time varied from 4...