Nitroglycerin, Botox or Sphincterotomy for Anal Fissure


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Associate Professor Nick Rieger
Adelaide University
Department of Surgery

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Nitroglycerin, Botox or Sphincterotomy for Anal Fissure

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