hemorrhoids & fissure in ano

2/10/2015 Hemorrhoids&FissureinAno

http://www.fascrs.org/physicians/education/core_subjects/2008/hemorrhoids_fissure_in_ano/ 1/17

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Hemorrhoids&FissureinAno

Hemorrhoids

TheprevalenceofsymptomatichemorrhoidsintheUnitedStatesisreportedtobe4.4%withapeakprevalenceoccurringbetween45and65yearsofage,equallyinmenandwomen.Approximatelyonethirdoftheseindividualsseekmedicalattention.Treatmentdependsonthedegreeofprolapseandseverityofsymptoms.However,whenundertakinganytreatmentforhemorrhoidaldiseaseitisessentialtoconsiderhemorrhoidsapartofnormalanorectalanatomyimportantinthecontinencemechanism,thesignificancebeingthatsurgicalremovalmayresultinvaryingdegreesofincontinence(particularlyinindividualswithmarginalpreoperativecontrol).

AnatomyHemorrhoidsareanormalfeatureofthehumananorectalanatomy.Thesearefibrovascularcushionslocatedinthesubepithelialspaceoftheanalcanal,containingarteriovenouscommunications1.Theyaresupportedwithintheanalcanalbysmoothmuscle(Treitzsmuscle)thatoriginatesfromtheconjoinedlongitudinalmuscleandpassesthroughtheinternalanalsphinctertoinsertintothesubepithelialvascularspace1.Asanindividualstrains,coughsorsneezes,thesefibrovascularcushionsengorgeandmaintainclosureoftheanalcanaltopreventleakageofstool.Thesecushionsaccountforapproximately1520%oftheanalrestingpressure2.Theliningofthesecushionsintheanalcanalalsosuppliesvisceralsensoryinformationthatenablesindividualstodiscriminatebetweenliquid,solidandgas,furtheraidingincontinence.Inaddition,duringtheactofdefecationthefibrovascularcushionsengorgewithblood,cushiontheanalcanalliningandallowtheanalcanaltodilatewithouttearing.

Therearethreemainfibrovascularcushionslocatedintheleftlateral,rightanteriorandrightposteriorpositionsoftheanus,withinterveningsecondarycomplexesinsomeindividuals.Theconfigurationisconstantandbearsnorelationshiptotheterminalbranchingofthesuperiorrectalartery,contrarytowhatwaspreviouslythought.Internalhemorrhoidsarisefromthesuperiorhemorrhoidalplexusproximaltothedentatelineandarecoveredbyinsensatecolumnarandtransitionalepithelium.Bloodinthesuperiorhemorrhoidalplexusisdrainedthroughthesuperiorrectalveinsintotheinferiormesentericveinandsubsequentlyintotheportalsystem.Externalhemorrhoidsarisefromtheinferiorhemorrhoidalplexusdistaltothedentatelineandarecoveredbysquamousepitheliumcontainingnerveendings.Bloodfromtheinferiorhemorrhoidalplexusisdrainedinpartthroughthemiddlerectalveinsintotheinternaliliacveins,butmainlythroughtheinferiorrectalveins,intothepudendalveins(tributariesoftheinternaliliacveins).

Etiology,pathophysiologyandsymptomologyHemorrhoidsdonotconstituteadiseaseunlesstheybecomesymptomatic.Hemorrhoidaldiseaserequiresthepresenceofpathologicchangesthatleadtobleeding,prolapse,pruritus,soiling,thrombosis,oracombinationthereof.Withrepeatedstraining,eithersecondarytoconstipation,diarrheaandtenesmusorprolongedattemptsatdefecation,especiallywhilereadingonthecommode,thefibrovascularcushionsslideintheanalcanal,engorgeandtheoverlyingmucosabecomesthinandfriablewithtraumatotheunderlyingvesselsleadingtopainlessbrightred(duetothearterialoxygentensioncausedbythearteriovenouscommunications3)bleedingonthetissuepaper,onthestoolordrippingintothetoiletbowl.FurtherstrainingdisruptsthesuspensoryTreitzsmuscleeventuallyleadingtoprolapseandengorgementoftheinternalhemorrhoidalcushionsassociatedwithperianalfullnesssanddiscomfort.Prolapsemayalsooccurduringwalking,heavyliftingandpregnancyasaresultofincreasedintraabdominalpressure.Althoughthismayinitiallyreducespontaneously,overtimethisprolapsewillresultinpersistentmucoiddischargeassociatedwithpruritusandperianalexcoriation,bloodstainingofundergarments,aswellasfecalsoiling(particularlyintheelderly).Iftheprolapsebecomesirreduciblebecauseofswellingandspasmofthesphincter,theinternalhemorrhoidscanbecomestrangulated,necroticandpainfulandmayleadtosystemicillness.Becauseoftheconnectionwiththeportalsystem,gangrenoushemorrhoidswithsuperimposedinfectioncanleadtopyelephlebitisinrarecases.Anemiaduetohemorrhoidaldiseaseisuncommon(0.5patients/1000000population)4andiseasilycorrectedwithhemorrhoidectomy.



Becausecommunicationexistsbetweentheinternalandexternalhemorrhoidalplexusesatthedentateline,theexternalhemorrhoidalveinsalsobecomeengorgedwithstrainingandovertimechronicstrainingcanleadtothedevelopmentofcombinedinternalandexternalhemorrhoids.Forthemostpartexternalhemorrhoidsareasymptomaticunlesstheybecomethrombosed,inwhichcasetheypresentasanacutelypainfulperianallump,ortheskintagsaresolargethathygieneisimpossible

EvaluationandclassificationNotallcomplaintsaretrulyhemorrhoids.Hemorrhoidalsymptomsmaybeamanifestationofseveraldifferentmedicalconditions,andthereforeacarefulevaluationofthepatientshouldbeconductedtodeterminetheunderlyingcausesofthepatientscomplaints.Ahistoryshouldincludenotonlycharacterizationofbleeding,protrusion,painandbowelhabits,butalsoanassessmentofthepatientscoagulationhistory,andthepossibilityofliverdisease,inflammatoryboweldiseaseorimmunosuppression.Acompleteexaminationincludinginspectionwitheversionoftheanalcanalbyopposingtractionwiththethumbs,digitalrectalexamination,anoscopy(withoutandwithstraining)andrigid/flexiblesigmoidoscopyshouldbeperformedbeforetreatment.Onemustentertaintheappropriatespectrumofdifferentialdiagnosesincludingcolorectaltumors,abcess/fistuladisease,analfissures,inflammatoryboweldisease(particularlyCrohnsdisease),rectalprolapse,hypertrophiedanalpapillae,perianalcondylomas,otherSTDsandhidraadenitissupppurativa.Inaddition,anyindividualwithrectalbleedingshouldundergoappropriateworkuptoexcludethepossibilityofproximalcolorectalneoplasia.Inayoungindividualwithrectalbleedingandhemorrhoidaldiseaseonexaminationwithnoothersystemicsystemsandnofamilyhistory,anoscopyandsigmoidoscopyareallthatiswarranted.However,rectalbleedinginanindividualolderthan50,orolderthan40witheitherafamilyhistoryofcolorectalcancerorachangeinbowelhabits,demandsacompletecolonoscopy,virtualcolonoscopyorbariumenemawithflexiblesigmoidoscopy.Apositivefecaloccultbloodtest,orirondeficiencyanemiaalsonecessitateacompletecolonevaluation5.Hemorrhoidaldiseaseassociatedwithsymptomsofsoilingorincontinencemayrequireanorectalphysiologytestingandendoanalultrasoundifthepatientisbeingconsideredforsurgery.

Internalhemorrhoidsareclassifiedintofourgradesbasedonprolapseandclinicalsymptoms6.GradeIinternalhemorrhoidsbulgeintothelumenoftheanalcanalandmayproducepainlessbleeding.GradeIIinternalhemorrhoidsprolapsewithstrainingbutreducespontaneously.GradeIIIinternalhemorrhoidsprolapsespontaneouslyorwithstrainingandrequiremanualreplacement.Finally,GradeIVinternalhemorrhoidsarepermanentlyprolapsedandirreducible.Accurateclassificationisimportantforbothselectingtheappropriatetreatmentandassessingthereportedefficacyofvarioustreatments.Ingenerallesssymptomatichemorrhoids,suchasthosethatcauseonlyminorbleedingcanbetreatedwithsimplemeasuressuchasdietarymodificationsandchangeindefecatoryhabits,orofficeprocedures.MoresymptomatichemorrhoidssuchasgradeIIIandIVhemorrhoidsaremorelikelytorequireoperativeintervention,asnononoperativemanagementisineffective7.

Treatment

I.Conservativemanagement(dietaryandlifestylemodification)

Dietarymanagementconsistingofadequatefluidandfiberintaketorelieveconstipationandeliminatestrainingatdefectaionistheprimarynoninvasivetreatmentforallsymptomatichemorrhoids5.Fibersupplementssuchaspsylliumworkinconcertwithwatertoaddmoisturetothestoolandsubsequentlydecreasesconstipation.Diarrheamayalsobecontrolledwithpsylliumtoaddbulktotheliquidstooltherebyincreasingtheconsistencyanddecreasingthefrequencyofbowelmovements.ArecentmetaanalysisconfirmedthatfibreiseffectiveIntreatingsymptomatichemorrhoidsassociatedwithlesserprolapseandbleeding(GradesIandII)8,however,conservativemanagementaloneisineffectiveforhemorrhoidswithsignificantprolapse(GradesIIIandIV)7whicharemorelikelytorequiresurgicalintervention.Stoolsoftenersmaybeaddedifnecessary.Sitzbathsareusefulforrelievinganalpainandmaintaininganalhygiene9,10.Exerciseshouldberecommended.Simplyinstructingpatientstoavoidreadingonthecommodewillfrequentlyresolvesymptoms.

Overthecountertopicalagentsandsuppositoriescontaininglocalanesthetics,corticosteroids,astringent,antisepticsandprotectantsareavailableandmayalleviatesymptomsofpruritusanddiscomfort.However,longtermuseoftheseagentsshouldbediscouraged,particularlycorticosteroidpreparationswhichcanpermanentlydamageorcauseulcerationoftheperianalskin.Norandomizedcontrolledtrialsareavailabletosupporttheirwidespreaduse.Inoneprospectiveseries,nitroglycerinointmentrelievedpainduetothrombosedhemorrhoids,presumablybydecreasinganaltone11.

Oralvenotonics,suchasflavanoids,havebeenusedasdietarysupplementsinthetreatmentofsymptomatichemorrhoidsinEuropeandtheFarEast.Themechanismofactionofthesedrugsremainsunclear,buttheymayimprovevenoustone,reducehyperpermeability,andhaveantiinflammatoryeffects.However,arecentmetaanalysisconcludedthatlimitationsinmethodologicalqualityandpotentialpublicationbiasraisedoubtsaboutthebenefitsoftheseagentsintreatinghemorrhoids12.FlavanoidshavenotbeenapprovedforuseinAmericabytheFoodandDrugAdministartion.



II.Nonoperativemanagement(officeprocedures)+Minoroperativeprocedures

Excisionalhemorrhoidectomy(EH)providesexcellentlongtermcureofsymptoms,butattheexpenseofpain,complicationsandtimeoffwork.Fordecadesalternativeshavebeensoughttoachieveminimallyinvasivetreatmentoptions.Becauseanodermisviscerallyinnervated,itisnotsensitivetotouch,painandtemperature,makingiteasilyamenabletoofficeprocedures.Thegoalofofficeprocedures,justlikeEH,istoablatethevesselsinvolvedandfixtheslidinghemorrhoidaltissuebackontothemusclewalloftheanalcanalinordertoimprovesymptomsofbleedingandprolapse.OfficeproceduresarerecommendedformostpatientswithrefractoryGradesI,IIorIIIhemorrhoids.Optionsincludesclerotherapy,infraredcoagulation,bipolarcoagulation,directcurrentelectrotherapy,monopolarcoagulation,cryotherapyandDopplerguidedarteryligation.Only510%ofpatientsrequiresurgery.

a.RubberBandLigationThemostcommonofficeprocedureusedforthetreatmentofsymptomaticinternalhemorrhoidsisrubberbandligation.Throughasideviewinganoscope,anatraumaticclamp(modifiedAllisforcep)isusedtoretractthetissueattheapexofthehemorrhoidalcomplex(2cmproximaltothedentateline)intoaligator(BarronorMcGivney),andasingleordoubleelasticbandisfiredfromthedrum.Theintroductionofsuctionbandshaveallowedthisproceduretobeperformedbyasingleoperator13.Thisisarelativelypainlessprocedure,aslongastheringsareproperlypositionedabovethedentateline.Thebandedtissueinfarctsandsloughsoverthenext710days,formingasmallulcer,resultinginreductionoftheprolapsedhemorrhoidaltissueaswellasfixationoftheresidualhemorrhoidintheupperanalcanal.Inourpracticeweprefersingleligationsatintervalsof46weekstoreducediscomfortandvasovagalsymptomsandallowtheulcertoheal.However,prospectivestudieshaveshownnoincreaseinpostligationpainorcomplicationswithmultiplebanding14,15,somanysurgeonsapplyupto3bandsateachvisit.Inattempttoreducethediscomfortofmultiplebanding,injectionoflocalanestheticintothebandedhemorrhoidshasbeentried,butwithoutsuccess16.Morerecently,localanesthesiaoftheupperanalcanalhasbeendescribedtoproducefullrelaxationandmaximalmucosalredundancyoftheanalcanal,thusprovidinganexcellentexposureandallowingaccurate,multiplerubberbandligationwithoutcausingsignificantpainduringoraftertheprocedure17.However,theseareonlypreliminaryresults.

Rubberbandligation(RBL)iscommonlyusedforGradesI,II,andIIIhemorrhoidsinternalhemorrhoids.SomeauthorsrecommenditforGradeIVhemorrhoidsafterreductionoftheincarceratedprolapse18,butnolongtermdataisavailable.RBLwasfoundtobethemosteffectiveoftheofficeproceduresinametaanalysisof18prospective,randomizedtrials.RBLwasassociatedwithalowerrecurrenceratebutmoreoverallpainthansclerotherapyorinfraredcoagulation19.Arecentmetaanalysis20comparingRBLtoEHconfirmedlongtermcurewasbetterwithEH,particularlyforGradeIIIhemorrhoids,althoughpain,complicationsandtimeoffworkweresignificantlygreaterthanwithRBL.TheauthorsrecommendedthatRBLbeadoptedasthetreatmentofchoiceforGradeIIhemorrhoidswithsimilarresultsbutwithoutthesideeffectsofEH,whileEHcouldbereservedforGradeIIIhemorrhoidsorrecurrenthemorrhoidsafterRBL.

Bandingtechniquesappeartoachievecompletereliefofsymptomsin6585%ofpatients.Therecurrenceratemaybeashighas68%atfourorfiveyearsoffollowup,butsymptomsusuallyrespondtorepeatligationonly510%ofsuchpatientsrequireEH21.Complicationsincludepain,bleeding,thrombosisandperinealsepsis.Adullpersistentacheiscommonforthefirst2448hoursfollowingbanding.Ifsignificantpainisexperiencedimmediatelyfollowingthebanding,thentherubberbandcanberemovedwithabeaverblade,althoughthisisdifficultendeavor.Ifthepatientdevelopspainlateron,itisgenerallytreatedwithsitzbaths,analgesicsandavoidanceofconstipation.Bleedinggenerallyoccursimmediatelyafterbandingor710dayslaterwhenthebandfallsoff.Thoughrare,thismayrequireoperativeinterventionwithsutureligationtocontrolpersistenthemorrhage.Bandingiscontraindicatedinpatientswhoareanticoagulated.Occasionally,bandingcanresultinthrombosisofinternalandexternalhemorrhoidsresultinginsignificantpain.Rarelybandingcanleadtolifethreatningperianalsepsis.Therefore,patientscomplainingofsignificantpain,feveranddysuriashouldbeadministeredbroadspectrumantibioticsandshouldundergopromptexaminationunderanesthesia.Becauseofthepotentialriskofperianalsepsis,someauthorsrecommendavoidinghemorrhoidalbandinginimmunocompromisedindividuals.

b.SclerotherapySclerotherapyisreservedforGradeIandIIhemorrhoids.Itinvolvesasubmucosalinjectionofasclerosant(12mlof5%phenolinalmondoil,5%quinineurea,or5%sodiummorrhuate)attheapexofthehemorrhoidalcomplexthroughananoscopeusinga25or30gaugeneedle.Thiscausesthrombosisofthevessels,sclerosisoftheconnectivetissue,withshrinkageandfixationoftheoverlyingmucosatherebydecreasingbleedingandprolapse.Sclerotherapycanbeusedinpatientsonanticoagulation.Sclerotherapycanresultinadullachelasting2448hoursbutcomplicationsareinfrequentandusuallyrelatedtoincorrectplacementofthesclerosant.Rarely,apatientmaydevelopmucosalulcerationandnecrosis,localinfectionandabcessformation,prostatitis,erectiledysfunctionorportalpyaemia.Thoughitischeap,easytoperformandslightlylesspainfulthanhemorrhoidalbanding19itislesswidelyusedthanbandingbecauseofahigherfailurerate.However,ithasbeen



usedincombinationwithRBLwithgoodresults22,23.Repetitivesclerotherapyshouldbeusedwithcautionbecauseofthepotentialofscarringandstrictureformation.

Takanoetal.24describedtheuseofanewsclerosingagentOC18(containingaluminumpotassiumsulfate)forthetreatmentofGradeIIIandIVinternalhemorrhoidsandfoundittobeaseffectiveasEHat28days.HoweverrecurrencewasstillsignificantlyhighercomparedtoEH.Furthermorethistechniquerequiredeitherlocalorspinalanesthesiainordertoinjectthesolutioninfourareasofeachhemorrhoidalcomplex.Recently,acasestudy25evaluatedtheuseoffoamsclrotherapybyflexibleendoscopyforGradeIIIVhemorrhoids.Bleedingandprolapsedwereresolvedwithatmost2sessions,whilepainresolvedafter1session,withnocomplications.However,nocomparativestudiesandlongtermdataareavailable.

a.InfraredphotocoagulationTheinfraredphotocoagulator(IRC)producesinfraredlightwhichpenetratesthetissueandconvertstoheat,promotingcoagulationofvesselsandfixationofhemorrhoidaltissue.Theamountoftissuedestructiondependsontheintensityanddurationoftheapplication.Itisrecommendedthattheinfraredprobebeappliedfor1.5secondstotheapexofeachinternalhemorrhoid,andberepeatedthreetimesoneachhemorrhoid.Infraredcoagulationdoesnotcausetissuenecrosisbecauseofthesmallamountofheatdelivered,andisthereforeonlyusefulinthetreatmentofGradeIandpossiblysmallGradeIIhemorrhoids,withoutsignificantprolapse.Infraredcoagulationseldomcausespainorothercomplications.Inametaanalysisofrandomizedcontrolledtrials,infraredcoagulationwasfoundtobesignificantlylesspainfulthanRBL,butrequiredmoresessionstorelievesymptoms,hadahigherrecurrencerateandismoreexpensivethanRBL19.

b.ElectrocoagulationLikeIRC,electrocoagulationtechniquesallrelyoncoagulationandfixationofhemorrhoidaltissueattheleveloftheanorectalring.ElectrocoagulationhasprovenusefulinthetreatmentofGradesIIIhemorrhoids,whilesomeauthorsfinditusefulforGradeIIIhemorrhoidsaswell26.

Bipolar(Bicap)coagulationiselectrocauteryinwhichheatdoesnotpenetrateasdeeplyaswithmonopolarcoagulation.Cauteryisappliedinonesecondpulsesattheapexofthehemorrhoid,untiltheunderlyingtissuecoagulates.ItseffectissimilartothatofIRC,butunlikeIRC,thedepthofinjurydoesnotincreasewithmultipleapplicationsatthesamesite,whichissometimesnecessarywithhighergradehemorrrhoids27.Itdoesnoteliminateprolapsingtissue,andupto20%ofpatientsrequireexcisionalhemorrhoidectomy.

Directcurrentelectrotherapy(Ultroid)issimilarlyappliedthroughaprobeplacedviaananoscopeontothemucosaattheapexofthehemorrhoid.Thecurrentissettothemaximaltolerablelevelandcontinuedfor10minuteswithmultipletreatmentsrequiredtothesamesiteinupto30%ofpatientswithhigherdegreehemorrhoids.Bipolarcoagulationcomparedtodirectcurrentcoagulationhastheadvantagethattreatmentapplicationlastsonlyseveralsecondscomparedwitheighttotenminutesperapplicationfordirectcurrent.Becauseofthelimitedeffectinhigherdegreehemorrhoidsandlengthytreatmenttimes,directcurrentcoagulationhasneverbecomepopular.Butbothbipolaranddirectcurrentcoagulationareassociatedwithaminorcomplicationrateof10%(pain,bleeding,fissure,orsphincterspasm)andrecurrenceratesbetween25and35%26,28.

Monopolarcoagulation,usingeithertheballtiporthespatulatip,isthecoagulationmethodofchoiceforsomeauthors29,asanalternativetorubberbandligation.Bipolarcoagulationwascomparedtomonopolarcoagulationinarandomizedtrialof81patients.Monopolarcoagulationwasassociatedwithmorepain,buthighersuccessratesandalowerincidenceofcomplications30.Thekeytosuccessistocoagulatethetopsofthehemorrhoidsuntiltheyarecharred,sothemucosawillulcerateandfixtotheanorectalring.

c.CryotherapyCryotherapyusescoldcoagulation(nitrousoxideorliquidnitrogen)todestroythehemorrhoidalcushions.However,thisprocedureresultsinprofusedischargeassociatedwithafoulsmell,irritationandpainduetonecrosis,andthehealingtimeisverylong.Inaddition,ifitisnotproperlyperformed,destructionoftheanalsphinctercancauseanalstenosisandincontinence.Forthesereasons,cryotherapyisnolongerrecommendedforthetreatmentofinternalhemorrhoids.

d.Dopplerguidedhemorrhoidalarteryligation(DGHAL)DGHALwasintroducedin1995byMorinaga,aJapanesesurgeon.Thistechniqueusesaspeciallydesignedproctoscope(Moricorn)housingaDopplertransducerthatcanidentifyhemorrhoidalarteriesandpermitstheirligationwithsixtotenfigureofeightsuturesabovethedentatelineintheinsensateregion.Theinsertionofaringofsutures,whichbunchesupthemucosa,resultsinpullinguptheprolapsewhileinterruptingitsbloodsupply.HALwasdesignedasaminimallyinvasivealternativetoEHforprolapsinghemorrhoidsthatdonotrespondtoorarenotamenabletoofficeprocedures.However,DGHALhaslittlevalueforGradeIVhemorrhoidswherethemainproblemismucosalprolapse(notbleeding)evenwithappropriatetechniquetheprolapsedmucosaremainsinplacealongwithsymptoms.DGHALisperformedasanoutpatientprocedureunderlocal(withsedation),spinalorgeneralanesthesia.Thesuccessratehasbeenreportedtobegreaterthan90%forgradeIIIhemorrhoids3135,withaminimalrateofcomplications(milddiscomfort,tenesmus,limitedrectalbleeding,thrombosis).There



isnoanalwoundtoheal.Thereisnoriskofincontinenceorstricture.Thefailurerateisabout10%(nearly70%forgradeIVhemorrhoids).Inasmallrandomizedstudy,DGHALshowedmuchlessanalpain,shorterhospitalstayandearlierreturntoworkcomparedtohemorrhoidectomy,andlongtermrecurrenceratesat1yearfollowupweresimilarinboth36.DGHALappearstobeaneffective,simple,minimallyinvasivealternativetohemorrhoidectomyforprolapsing(butreducible)hemorrhoidsthatfailtorespondtoofficeprocedures.However,morecomparativestudiesandlongerfollowupdataareneeded.

e.Analstretch/dilationPopularizedbyLordin1968,andstillemployedinEurope,theanalstretchprocedureisbasedonthebeliefthathemorrhoidsareduetoanarrowingoftheanalcanalcausedbyafibrousdeposit(pectenband)thatresultsinabnormalstrainingandsubsequentvenouscongestionleadingtohemorrhoids.Thisprocedureisperformedunderintravenoussedationorgeneralanesthesia,andtheanalcanalisstretcheduntilfourfingerscanbeinserted.Patientsthenuseananaldilatorintermittentlyoverthenextsixmonths.However,endosonographyhasshownsphincterinjuryassociatedwithanaldilation37andseveralclinicalserieshavereportedhighratesofassociatedincontinence,especiallylongterm38.Inaddition,whencomparedtosurgicalhemorrhoidectomy,analdilationhasahigherfailurerate,withsomepatientsrequiringhemorrhoidectomy39.Mostauthoritiestodayadvocateabandoningthisapproach.

III.Surgicaltreatment

SurgicalhemorrhoidectomyisthemosteffectivetreatmentforhemorrhoidsoverallandforGradeIIIinparticular19,withrarerecurrences.However,nonoperativetechniquesarepreferredwhenfeasibleinthefirstinstancebecausesurgeryisassociatedwithmorepain,postoperativedisabilityandcomplications.Indicationsforsurgicalhemorrhoidectomyincludefailureofofficeprocedures,patientinabilitytotolerateofficeprocedures,largeexternalhemorrhoidsorcombinedinternal/externalhemorrhoidswithsignificantprolapseandconcomitantconditions(suchasfissureorfistula)thatrequiresurgery.About510%ofpatients,usuallythosewithgardeIIIorIVhemorrhoids,needsurgicalhemorrhoidectomy.Overtime,severaldifferenttechniqueshavebeendescribed.

a.ExcisionalhemorrhoidectomyExcisionalhemorrhoidectomycanbeperformedwitheitheropenorclosedtechniques.IntheMilliganMorgan(open)hemorrhoidectomy,usedmostlyinGreatBritain,theinternalandexternalcomponentsofeachhemorrhoidareexcisedandtheskinisleftopeninathreeleafcloverpatternthathealssecondarilyforfourtoeightweeks.IntheFerguson(closed)hemorrhoidectomy,thehemorrhoidcomponentisexcisedandthewoundsareclosedprimarily.Fourrandomizedtrialshavecomparedopenversusclosedhemorrhoidectomy4043.Bothtechniquesaresafeandeffective.Themajorityoftrialsshowednodifferenceinpostoperativepain,analgesicuse,hospitalstayandcomplications,whereascompletewoundhealingshowedmixedresultswithasuggestionthatclosedhemorrhoidectomypromotesfasterwoundhealing.AsopposedtotheUnitedKingdom,moremembersoftheAmericanSocietyofColonandRectalSurgeonsreportusingaclosedratherthanopentechnique44.

Postoperativepainremainsthemajorobstacletopatientsseekingsurgicalmanagementoftheirhemorrhoids.Narcoticsaregenerallyneededtocontrolpain,andmostpatientsdonotreturntoworkfor24weeksaftersurgery4548.RandomizedtrialshaveshownnodifferenceinpainscoresbetweentheuseofdiathermyorscissorsforEH4951.Earlyreportssuggestedthatlaserhemorrhoidectomywasassociatedwithlesspostoperativepainhowever,arandomizedtrialoftheNd:YAGlaserversuscoldscalpeldidnotshowanydifferenceinpostoperativepainoranalgesicuse5254.Furthermore,laserhemorrhoidectomywasassociatedwithhighercostsandimpairedwoundhealing.NewerinstrumentshavecomeintovogueforperforminghemorrhoidectomysuchastheHarmonicScalpelorLigaSureTM.Fourrandomizedcontrolledtrialsevaluatedtheultrasonicallyactivated,HarmonicScalpelandshowedconflictingresultswithrespecttopostoperativepain5558.Twosmallrandomizedtrialssuggestedapossibleminoradvantagewithbipolardiathermy(LigaSureTM),butpainscoresdidnotdiffersignificantly5960.Theadditionalcostsoftheseinstrumentsandthelackofsuperiorresultsprecludetheirrecommendationforroutineuse.

Manydifferentattemptsatreducingpainhaveincludedlimitingtheincision,suturingonlythevascularpediclewithoutanincision,usingaconcomitantlateralinternalsphincterotomy,administeringmetranidazole,injectinglocalanesthetics,usinganalsphincterrelaxantsincludingnitroglycerin,usinganxiolyticsandusingparasympathomimetics(toavoidurinaryretention)6170.However,eachofthesestrategieshashadlimitedormixedresultsandthereforecannotberecommendedforroutineuse.However,postoperativeanalgesicsaswellaslaxativesarenecessarytoreducepainduringthefirstpostoperativemotion.

Thecomplicationsofhemorrhoidectomyincludeurinaryretention(236%),bleeding(0.03%6%),infection(0.55.5%),analstenosis(06%)usuallyasaresultofinadequatemucosalbridgesandincontinence(212%)21.Sphincterdefectsassociatedwithincontinencehavebeendocumentedbyendoanalultrasoundandanalmanometryinupto12%ofpatientsafter



hemorrhoidectomy7174,probablyduetoexcessiveretractionanddilationoftheanalcanal.

OtherhemorrhoidectomytechniquesdescribedintheliteratureincludetheWhiteheadhemorrhoidectomyandtheParkshemorrhoidectomy.TheWhiteheadhemorrhoidectomy,involvescircumferentialexcisionofthehemorrhoidalcomplexesbeginningatthedentatelineandproceedingproximallyinasimilarmannertoaDelormeprocedureforrectalprolapse.ThisprocedurehasbeenbyinlargeabandonedintheUnitedStatesduetothehighcomplicationrates,includingstricture,lossofanalsensationanddevelopmentofmucosalectropion.Parksdescribedasubmucosalhemorrhoidectomythatreconstructedtheanalcanalandthereforewasexpectedtopreservebettersensorycontinenceandreducepostoperativepain.Thistechniqueisnotfrequentlyused,becauseitdoesnotofferasolutiontotheexternalhemorrhoidalcomponent.

Emergencyexcisionalhemorrhoidectomyforstrangulated,gangrenoushemorrhoidscanbeperformedsafely75.Asdiscussedearlier,arandomizedtrialcomparingexcisionalhemorrhoidectomytoRBLwithincisionforacutestrangulatedhemorrhoids,showedthatbothtechniquescanbeperformedsafely,althoughearlyrecoveryisslightlyimprovedafterRBLandincision18.

Thereisnoscientificdatacomparingtreatmentoptionsforexternalhemorrhoidalthrombosis.Clinicalexperiencehasledtotherecommendationthatindividualswhopresentwithsymptomsforlessthan4872hoursarebesttreatedbylocalexcision,whereasthosepatientswhosesymptomshavebeenpresentformorethan72hourscanbetreatedconservatively(avoidanceofconstipation,analgesia,sitzbaths).Incisionandclotevacuationshouldbeavoided5.Perianalskintagscanbeexcisedifsymptomatic.

Lateralinternalsphincterotomyduringconventionalhemorrhoidectomywasassumedtoreducethepostoperativepain,evenwhentherewasnoevidenceofanalfissure.Currently,thereisnoevidencethatpatientswithoutconcomitantanalfissurewillbenefitfromthisprocedure.Infact,studieshavesuggestedthatthisproceduredoesnotreducepainandmayhavedeleteriouseffectsoncontinence76.

b.StapledhemorrhoidectomyStapledhemorrhoidectomy,alsoknownascircularstapledhemorrhoidectomy[CSH],procedureforprolapsedhemorrhoids[PPH]andstapledanopexy,hasbeendevelopedasaminimallyinvasive,lesspainfulalternativetoexcisionalhemorrhoidectomy.Thisprocedure,likeRBL,essentiallyremovesredundantanalmusosaatthetopofthehemorrhoids.However,itresectsmuchlargerredundantrectalmucosathanRBLandshouldbeperformedinGradeIIandIIIwhichdonotrespondtoRBLandGradeIVhemorrhoidsthatarereducibleunderanesthesia.ItisLongowhopopularizedthetechniqueusingaspeciallydesignedcircularstapler(EthiconEndoSurgery)whichperformsacircumferentialresectionofmucosaandsubmucosaabovethehemorrhoidsandthenstaplesclosedthedefect.Thegoalistoresuspendtheprolapsinghemorrhoidaltissuebackintotheanalcanal,aswellastointerruptthearterialinflowthattraversestheexcisedsegment.So,infactthisprocedureisastapledhemorrhoidopexyratherthanhemorrhoidectomysincethehemorrhoidsarenotremoved,butratherreturnedtotheiranatomicposition.

Thepreservationoftheanalcushionsmayinfactcontributetothelowrateofincontinenceafterthisoperation.Noexternalwoundsarecreatedandthestaplingdevicecutswellabovethedentateline,thereforepostoperativepainisminimalandusuallyabsent.Incontrasttoconventionalhemorrhoidectomy,however,skintagsandenlargedexternalhemorrhoidsarenotremovedusingthestapledtechnique.Thoughcomplicationsarerare,severalseriouscomplicationshavebeenreportedafterstapledhemorrhoidopexy,includingrectalperforation,retroperitonealsepsis,anovaginalfistulaandpelvicsepsis,whicharelikelyduetoexcisionoffullthicknessrectalwallratherthanmuscosaandsubmucosaonly.Smoothmusclefibershavebeendetectedinavariablepercentageofstapledhemorrhoidopexyspecimens,althoughsuchfibershavealsobeendetectedfollowingconventionalhemorrhoidectomy.Ofpotentiallymorefunctionalconsequence,fragmentationoftheinternalsphincterwasnotedin14%ofpatientswhounderwentstapledhemorrhoidectomyusingastandard37mmanaldilator.Themaincomplicationoftheprocedureisbleedingfromthestapleline,whichcanbeeasilyoversewn.Withthesecondgeneration33mmhemorrhoidalcircularstaplerandaclosedheightof.75mm,bleedinghasbeenmarkedlydecreased.21

AsingletrialcomparedstapledhemorrhoidopexytoRBLandfoundmorepainwithstapling,butimprovedreliefofsymptoms77.AmetaanalysisperformedbyNisaretal78in2004demonstratedthatpatientsundergoingstapledhemorrhoidopexyhaveimprovedperioperativeoutcomes,particularlywithrespecttopainandreturntonormalactivitiescomparedtotheconventionaltechniques.AmorerecentCochranesystematicreview79ofstapledhemorrhoidopexyconcludedthattheprocedurewasassafeasconventionalhemorrhoidectomywithveryfewcomplicationsreported.However,stapledhemorrhoidopexyisassociatedwithahigherlongtermriskofhemorrhoidrecurrenceandthesymptomofprolapse.Itisalsolikelytobeassociatedwithahigherlikelihoodoflongtermsymptomrecurrenceandtheneedforadditionaloperationscomparedtoconventionalexcisionalhemrroidsurgeries.Theauthorsconcludedthatifhemorrhoidrecurrenceandprolapsearethemostimportantclinicaloutcomes,thenconventionalexcisionalsurgeryremainsthegoldstandardinthesurgicaltreatmentofinternalhemorrhoids.



IV.Specialsituations

a.HemorrhoidsinPregnancy.Hemorrhoidalsymptomscommonlyoccurandintensifyduringpregnancy(particularlyduringthelasttrimester)anddelivery.Constipationshouldbeavoidedduringpregnancy.Mildlaxativesshouldbegivenduringthelastthreemonthsofpregnancyandpostpartumperiodparticularlyforpatientswithconstipationproblems.Hemorrhoidsthatintensifyduringdeliverytendtoresolve.Hemorrhoidectomyisindicatedduringpregnancyonlyifacuteprolapseandthrombosisoccur.Itshouldbeperformedunderlocalanesthesiaintheleftlateralposition.Anoperationisindicatedintheimmediatepostpartumperiodifprolapseandthrombosisoccurduringdelivery,orsymptomatichemorrhoidsthatwerepresentpriortopregnancyandaggravatedduringpregnancypersistafterdelivery.

b.Hemorrhoids,VaricesandPortalHypertension.Portoystemiccommunicationsexistintheanorectalcanalthesuperiorhemorrhoidalveins,whichdraintheupperanalcanalandrectumintotheportalcirculation,aredecompressedviathemiddleandinferiorhemorrhoidalveinsofthesystemiccirculationinpatientswithportalhypertension.Anorectalvaricesdevelopcommonlyinportalhypertension,butunlikeesophagealvaricestheyrarelybleed.Intherarecaseofsymptomatic,bleedinganorectalvarices,sutureligationin34columnsrunningfromtheashighintherectumaspossibletojustoutsidetheanuswillusuallystopthebleeding.Othertreatmentsincludestapledhemorrhoidopexy,portaldecompressionviaatranshepaticpotosystemicshunt(TIPS)ligationoftheinferiormesentericvein,andpotosystemicshunts.

Themajorityofpainlessrectalbleeding,evenincirrhotics,isduetointernalhemorrhoids.Massivebleedingfromprolapsedhemorrhoidsinsuchpatients,thoughrare,canbelifethreatning.Thiscommonlyoccursduringtreatmentforencephalopathywhichresultsinseverediarrhea.Sutureligationisnecessarytostopthebleeding.Hemorrhoidectomyisreservedfortheraresituationinwhichsutureligationfailstocontrolthebleeding.Itisalsoimportanttocorrectanycoagulopathyandcontrolthediarrhea.

c.Hemorrhoidsininflammatoryboweldisease.MostanalproblemsinIBDresultfromdiarrhea.Hemorrhoidscanbetreatedoperatively,ornonoperativelyinpatientswithulcerativecolitis.However,patientswithanorectalCrohnsdiseaseorCrohnsproctitishaveasubstantialriskoflocalcomplicationsthatcanbesevereenoughtorequireproctectomy.IfnecessaryhemorrhoidectomycanbeperformedintheCrohnspatientwithquiescentilealorcolonicdisease.

d.Hemorrhoidsintheimmunocompromised.Correctionofanycoagulopathyandadministrationofantibioticsisthemainstaytherapyforhemorrhoidaldiseaseinthesepatients.Operativetreatmentcanresultinpoorwoundhealingandabcessformation,andisthereforeusedasalastresorttorelievepainandsepsisinthispopulation.

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199712:296297.72.HoYH,SeowchoenF,GohHS.Haemorrhoidectomyanddisordredrectalandanalphysiologyinpatientswithprolapsedhemorrhoids.BrJSurg199582:596598.73.FeltBersmaRJ,vanBarenR,KoorevaarMetal.Unsuspectedsphincterdefectsshownbyanalendosonographyafteranorectalsurery.Aprospectivestudy.DisColonRectum199538:249.74.AbbasakoorF,NelsonM,BeynonJetal.Analendosonographyinpatientswithanorectalsymptomsafterhaemorrhoidectomy.BrJSurg199885:15221524.75.EuKW,SeowChoenF,GohHS.Comparisonofemergencyandelectivehaemorrhoidectomy.BrJSurg199481:308.76.KhubchandaniIT.Internalsphincterotomywithhemorrhoidectomydoesnotrelievepain:aprospective,randomizedstudy.DisColonRectum200245:14521457.77.PengBC,JayneDG,HoYH.Randomizedtrialofrubberbandligationvs.stapledhemorrhoidectomyforprolapsedpiles.DisColonRectum200346:291297.78.NisarPJ,AchesonAG,NealKR,ScholefieldJH.Stapledhemorrhoidopexycomparedwithconventionalhemorrhoidectomy,asystematicreviewofrandomizedcontrolledtrials.DisColonrectum200447:18371845.79.JayaramanS,ColquhounPHD,MalthanerRA.Stapledversusconventionalsurgeryforhemorrhoids.CochraneDatabaseofSystematicReviews2006,Issue4.Art.No.:CD005393.

FissureinAno

Ananalfissureisalinearulcerinthesquamousliningoftheanalcanalextendingfromthedentatelinetotheanalverge.Patientstypicallycomplainofseveresharppainduringandafterdefecation,lastingminutestohours.Brightredbloodiscommonlyseenbutscant,mostlyonthetoilettissueorstreakingthestoolsurface.Fissuresaremostcommonlyfoundintheposteriormidlinebutcanbeseenintheanteriormidlineinupto13%ofwomenand8%ofmen,orinbothlocationsinupto3%ofpatients1.Anacutefissureappearsasasimpletearintheanodermthatusuallyhealsspontaneouslywithin68weeks.Achronicfissurepersistsmuchlongerandtendsnottohealwithoutintervention.Chronicfissuresaremarkedbysecondarychangessuchasasentinelpile,ahypertrophiedanalpapilla,fibrousindurationofthefissureedges,andfinallyfibrosisofthebaseoftheulcer(internalanalsphincter)whichcanresultinaspastic,contractedinternalsphincter.Aprecipitatingcauseshouldbesought,typicallyconstipationordiarrhea,andcorrectedotherwisethefissurewilllikelyfailtohealorrecur.Secondarycausesmaybeduetotraumapostanalsurgeryorchildbirthinwomen.Atypicalfissuressuchasthoseoccurringinthelateralpositions,multiple,painlessornonhealingfissuresshouldpromptanevaluationforotherdiseasessuchasIBD,HIV/AIDS,syphilis,tuberculosis,leukemia,sarcoidoranalSCCwhichmustbeexcluded.

EtiologyandPathogenesisItisgenerallyacceptedthattheinitiatingfactorinthedevelopmentofafissureistraumatotheanalcanal,usuallyduetothepassageofalarge,hardstool.However,ahistoryofconstipationisnotalwaysobtained,andinfact,somepatientsdescriberepeatedepisodesofdiarrheapriortotheonsetofsymptoms.Theellipticalarrangementoftheexternalsphincterintheposteriormidlinemayofferlesssupporttotheposterioraspectoftheanalcanalduringdefecation,contributingtotheformationofamidlinefissureduringthepassageofalarge,hardstool.Perpetuatingfactorsincludepersistentlyhardorliquidstool,whichcontinuouslyaggravatetheanalcanal.Increasedrestingpressureswithintheinternalanalsphincter(IAS)inpatientswithfissures210,hasbeendescribedasanotherperpetuatingfactor.IthasbeendemonstratedthatpatientswithanalfissureshaveanabnormalovershootcontractionoftheirIASfollowingexpectedreflexrelaxationduetorectaldistension2.WhetherincreasedrestingpressureswithintheIASarethecauseortheeffectofdevelopmentofananalfissureremainsunclear.Inaddition,anumberofstudieshaveshownthattheposteriorcommisureisperfusedmorepoorlythantherestoftheanalcanal11,afactorwhichispostulatedtoplayaroleinthepathogenesisoffissureinano.ItisbelievedthattheincreasedIAStoneinpatientswithafissureresultsindecreasedbloodflowandpathogeneticallyrelevantischemiaintheposteriormidlinewhichpreventsthefissurefromhealing.SphincterotomyhasbeenshowntodecreasepressureoftheIASandimproveanodermalbloodflowattheposteriormidline,resultinginfissurehealing12.

AnunderstandingofthephysiologyoftheIASshedssomelightonthepathophysiologyofanalfissuresasrelatedtoincreasedIAStoneandresponsetononsurgicaltreatment.ThebasaltoneoftheIASisdependentonintracellularcalcium.ThereforecontractionofthesmoothmusclecellswithintheIASismediatedbyinfluxofcalciumthroughcalciumchannels,butitisalsoaffectedbyneurohormonalstimulationof1adrenoreceptorsatthesmoothmusclecells.Activationof2adrenoreceptorsinthemyentericinhibitoryneuronsmostlikelypresynapticallyinhibitsnonadrenergic,noncholinergic(NANC)relaxation.RelaxationofthesecellsismediatedthroughdirectlydecreasingintracellularcalciumconcentrationaswellasincreasingcGMPandcAMP.Potassiuminfluxhyperpolarizesthecellmembraneanddecreasescalciumentry.Activationof2adrenoreceptorsincreasescAMP,returningintracellularcalciumtothesarcoplasmicreticulum.Inaddition,thereareinhibitoryneurotransmittersthatmediateNANCrelaxation,includingnitricoxide(NO)andvasoactiveintestinalpeptide(VIP).NOisthe



majorneurotransmittermediatingNANCrelaxationoftheIASbyincreasingcGMP.VIP,like2adrenoreceptorsincreasescAMP13,14.Larginine,aprecursorofnitricoxide,hasbeenfoundtorelaxIASsmoothmuscleperhapsbyincreasingsubstratefornitricoxidesynthase(NOS),theenzymeinvolvedinNOsynthesis15.ApreliminarystudyhasshownreducedNOSintheIASofpatientswithanalfissurescomparedtocontrols16.ThereducedproductionofNOprovidesapossibleexplanationforthehighIASpressuresseeninmostfissurepatientsandalsowhypressuresreturntopretreatmentvaluesinpatientswhosefissureshavehealedwithnonsurgicalmethods17.

Treatment

I.ConservativemanagementTheaimoftreatmentofanacutefissureistobreakthecycleofahardstool(orloosestool),painandreflexspasm.Thiscanbeaccomplishedbytheingestionofadequatefluidandfibertocreatealargebutsoftbulkystool,warmsitzbathsorlocalapplicationofheattorelievesphincterspasmandifnecessarystoolsoftenerssuchasdocusate.Upto50%ofpatientsdiagnosedwithacutefissureswillhealwiththesemeasures1.However,fibershouldbecontinuedforlifetopreventrecurrence,asupto25%offissureswillrecuriftherapyisstopped18.Thegoalforadultsistoconsume2530goffiberdailyeitherthroughmealsorsupplements.Topicalanestheticsareequivalenttoplaceboandmaycauseperianaldermatistis19.Antiinflammatory(hydrocortisone)suppositorieshavenoadvantageoverfiberandsitzbaths19andinsertioncanbepainful.

II.NonsurgicaltherapyThegoalinthetreatmentofnonhealinganalfissuresistorelievetheabnormallyhighIASpressures.Thegoldstandardfortreatmenthasbeenalateralinternalsphincterotomy(LIS)toproduceapermanentreductioninIASpressures.However,duetoincreasingconcernsoflongtermimpairedcontinenceasaconsequenceofsuchanintervention,physicianshaveturnedtochemicalsphincterotomy.Chemicalagentshavebeenusedtocreateareversiblereductioninsphincterpressureuntilthefissurehashealed.ACochranereviewofnonsurgicaltherapyforanalfissure20,hasconcludedthatmedicaltherapyfornonhealingfissuresmaybeappliedwithachanceofcurethatismarginallybutsignificantlybetterthanplacebo,butfarlesseffectivethansurgeryandrecurrencesarehigher.Nonetheless,theriskofusingsuchtherapiesisnotgreat,withoutapparentlongtermadverseeffectandthetherapycanberepeated.Thesetherapiesmightthereforebeusedinindividualswantingtoavoidsurgicaltherapy,withsurgerybeingreservedfortreatmentfailures.Thatsaid,thesemedicationsareonlyeffectivewhileinuse,explainingthehigherriskofrecurrencecomparedtooperativemanagement.

a.TopicalNitratesNitratesaremetabolizedbysmoothmusclecellstoreleaseNO.NOistheprinciplenonadrenergic,noncholinergicneurotransmitterintheIAS,anditsreleaseresultsinIASrelaxation.StudieshaveshownthattopicalnitroglycerineffectivelyreducesmeanrestingIASpressure2123transientlyfor90minutes,andsignificantlyincreasesanodermalbloodflow24.Topicalnitroglycerinointment0.2%administered23timesdailyfor48weeksiscurrentlythefirstlinetreatmentinmanycentersfornonhealingfissures.Thistreatmentsignificantlyreducespainondefecationafter2weeks,eveninpatientswhodontheal28.Higherdosingdoesnotimproveoutcome2527.Repeatedapplicationsmaybenecessary.Theprinciplesideeffectisheadachein27%ofpatients,oftenaffectingcomplianceinthosepatients,andhypotensionin6%.TheoverallhealingrateintheCochranemetaanalysisis48.6%comparedto37%withplacebo,butlaterecurrenceoffissureiscommon,intherangeof50%ofthoseinitiallycured.Thereisnoadvantagetoeitherbotoxorcalciumchannelblockerswhencomparedtonitroglycerin20.SecondlineBotoxandcalciumchannelblockerscanbeusedinpatientswhofailtohealwithnitroglycerinorwhocannottolerateitssideeffectswithhealingratesnear5077%insmallstudies29,30,36.

b.CalciumChannelBlockersCalciumchannelblockerspreventinfluxofcalciumintosmoothmusclecells,decreasingintracellularcalciumandpreventingmusclecontraction.CalciumchannelblockersthereforepromotefissurehealingbyreducingrestingIASpressure3135.Oralagentsappeartohavepoorerhealingratesandhigherratesofsideeffectsthantheirtopicalcounterparts31.Untilrecently,moststudiesshowedthattopicalcalciumchannelblockers(diltiazem2%,nifedipine0.3%)achievefissurehealingtoasimilardegreereportedwithtopicalnitrates20,butwithoutsideeffects.However,thereportedadverseeffectsduringtopicaldiltiazemtreatmentmaybemorecommonthanpreviouslythought36.Inarecent2yearfollowupofpatientstreatedwithtopicaldiltiazem,21%reportedsideeffects(perianalitching,mildheadaches,nauseaandflushing),althoughtheyrarelyledtoreducedcompliance.Inaddition,forthefirsttime,thisstudylookedatrecurrencerateoveralongtermperiod.Disappointingly59%ofpatientsrequiredfurthertreatment,nobetterthanrecurrencerateswithnitroglycerintreatment.Unliketopicalnitroglycerin,neitherdiltiazemnornifedipinehasundergonecomparativestudieswithplacebo.However,topicalnifedipinehasbeencomparedtolidocaineandhydrocortisonewithsignificantlybetterhealingrates(95%vs35%)39,40.Untilrecently,therehavebeennostudiescomparingtopicalcalciumchannelblockerstosurgicalsphincterotomy.ArandomizedstudybyKatsinelosetal38in2006showedthattopical0.5%nifedipinet.i.dfor8weekscouldachievecompletehealingin96.7%ofpatients,notsignificantlydifferentfromthegrouptreatedwithLIS.Althoughthedosagewasmorethandoublethatofpreviousstudies,therewasnoincreaseinadverseeffects.However,recurrenceremainedaproblemcomparedtoLIS.This



grouphashypothesizedthatthehighhealingrateofnifedipinemaybeattributednotonlytothereductionoftheanalcanalpressurebutalsototheantiinflammatoryactionofnifedipineaswellasitsantioxidant,antiulcereffects.

c.NeurotoxinsNeurotoxinsaremetalloproteinasesthatenterperipheralnervesandinhibitreleaseofneurotransmitters,therebycausingmusclerelaxation.Botulinumtoxin(BT)isanexotoxinproducedbythebacteriumClostridiumbotulinum.Wheninjectedintoskeletalmuscletotreathypertoniaorcosmeticdisorders,BTbindstothepresynapticnerveterminalattheneuromuscularjunctionpreventingreleaseofacetylcholineandresultingintemporaryparalysisoftheinjectedmuscle.BotulinumtoxinisunlikelytobepreventingacetylcholinereleaseattheIASneuromuscularjunction,asacetylcholinecausesrelaxationinthistissue,andarise,notafallinanaltonewouldbeexpected.IntheIASitisbelievedthatbotulinumtoxinactsonthepostganglionicsympatheticnervestoreducenoradrenalinerelease41therebyblockingsympatheticoutputandproducingsphincterrelaxationthatoccursinafewhoursandlastsforapproximately23monthsallowingfissurehealing.Relapseisduetoreinnervationwhichoccursthroughsproutingofnerveendings.

Reporteddataisdifficulttointerpretbecauseofvariedinjectiontechniqueswithdosesvaryingfrom10to100units,injectionsiteslocatedatvariouslocationsaroundtheanalcanalineithertheEASortheIAS,varyingnumberofinjections,aswellasvaryingfollowupprotocols.Theoptimumdoseandmethodofinjectionhavenotbeendetermined,though2025unitsisusuallyappliedoneithersideofthefissuredirectlyintotheinternalsphincter.Forpatientswithaposteriorfissure,injectionofBTanteriorlyresultsinearlierhealingprobablyduetothescarofthefissurelimitingdiffusionofthetoxin48.ForthoseauthorswhorecommendinjectionofBTintotheEAS,themechanismofactionmustbediffusionofthetoxinintotheIAS,asthefundamentalpathogenesisinchronicanalfissureformationisanelevatedIASpressure.

BTtemporarilydecreasesmeananalcanalrestingpressures42,43for23months44,healing6080%offissuresataratehigherthanplacebo45andlidocaine46.ThedoseofBTinjectedappearstobecriticaltosuccessfulhealingoffissures44,47,48withhigherdosesproducingbetterhealingrateswithoutanincreaseinadverseeffects.Themostcommonsideeffectistemporaryincontinencetoflatusinupto10%ofpatients44,45,48andtostoolinapproximately5%ofpatients52.Althoughpatientsreturntofullactivitysooner,BTremainsinferiortosurgeryincuringfissures49,50,withlongertimetohealing49andrecurrencesofhealedfissureexceeding4050%after1year50,51.However,failuresandrecurrencescanberetreatedwithareasonablerateofhealing48,52.StillapproximatelyonequarterofpatientsfailBTtherapyandgoontosurgery49.IncombinedanalysesBTwasfoundtobenobetterorworsethantopicalnitrates20,butBTiseffectiveinhealing5070%ofpatientswithfissuresresistanttotopicalnitrates53,29andmaybemoreeffectiveinrefractoryfissuresifcombinedwithtopicalnitrates54,55.

Gonyautoxin,aphycotoxinproducedbyshellfish,hasalsobeenusedinanalfissuremanagement.Inarecentreport56,23patientswereinjectedwith100unitsintheIASevery4days.Totalremissionwasachievedinallpatientswithin714days.Norelapseswereobservedduringthe10monthfollowup.Nosideeffectswerenoted.Allpatientsshowedimmediatesphincterrelaxationdetectedbydigitalexamandconfirmedafter4minutesbymanometry,withimmediatepainrelief.However,arandomizedcontrolledtrialhasyettobeconducted

d.OtherPharmacologicAgents

1.Larginine,aprecursorofNO,appearstopromotefissurehealingin60%ofpatientswhenappliedtopically57byreducinganaltone15.However,thiseffectappearstobeindependentofNO59,whichperhapsexplainstheabsenceofsignificantheadacheswithitsuse.Noeffectonrestinganalpressureswasobservedwithoralpreparations58.

2.Adrenergicantagonists,particularlyalpha1adrenoreceptorblockers,areeffectivesmoothmusclerelaxantsthathavebeenshowntoreducerestinganalpressuresinopossums60aswellasinpatientswithanalfissuresandhealthycontrols61.Howeveralpha1adrenoreceptorsarecurrentlynotadvocatedinthetreatmentofanalfissuresduetothelackofefficacyshowninaplacebocontrolledtrialwhereindoramin,analpha1adrenoreceptoradministeredorallysucceededinhealingonly1in23patientsdespitea30%reductioninMARPafter6weeksoftreatment,withalargenumberofsideeffectsleading50%ofpatientstowithdraw62.

3.Cholinergicagonists,suchasbethanechol,areinhibitorytotheIAScausingrelaxationoftheIAS.A24%reductioninMARPhasbeendocumentedinhealthyvolunteersusing0.1%topicalbethanecol63.Asubsequentnonrandomizedstudyreportedfissurehealingin60%ofpatientswithoutsideeffects,resultsequivalenttodiltiazem35.Howeverarandomizedcontrolledtrialandlongtermfollowuparelacking.

4.PhosphodiesteraseInhibitorsinhibitthebreakdownofintracellularcyclicguanylatemonophosphate(cGMP),therebyproducingsmoothmusclerelaxation.Topicalsildenafil(Viagra),aphosphodiesterase5inhibitor)usedinerectiledysfunction,hasbeenreportedtoreduceanaltonebyanaverageof18%inlessthan3minutesinpatientswithchronicanalfissures64.



Thesefindingshavebeenconfirmedininvitrostudies65,66.However,therearenopublishedstudiesonitseffectonfissurehealing.

5.Potassiumchannelopenersareknowntorelaxsmoothmuscleandhavebeenpostulatedtoreduceanaltone.Adoubleblindrandomizedtrialcomparedtheefficacyoftopicalminoxidil,apotassiumchannelopener,withtopicallidocaineandacombinationofthetwo67.Therewasnosignificantdifferenceinhealingratesorpainreliefbetweenall3groupsat6weeks,howeverpatientshealedfasterwiththecombinationoftreatmentscomparedtothesingletreatments.Comparativestudiesarerequiredandthesafetyofthesetopicalpotassiumchannelopenersmustbeconfirmedasanumberofcasestudiesreportanalulcersassociatedwiththeuseoftheoralpotassiumchannelopenernicorandilinanginapatients6870.

6.Angiotensinconvertingenzymeinhibitors(ACEI).Thereninangiotensinsystem(RAS)isfoundinvascularsmoothmuscleandhasbeenshowntobepresentwithintheIAS71.ReninconvertsangiotensinogentoangiotensinI,whichisthenconvertedtoangiotensinIIbyangiotensinconvertingenzyme(ACE)resultingincontractionofsmoothmusclecells.ACEIpreventtheproductionofangiotensinIIresultinginrelaxationofsmoothmuscle.Recently,0.28%topicalcaptopril,anACEI,wasshowntoreduceMARPin50%ofvolunteersbyupto44%at20minutes72,73.Furtherstudiesareneededtodemonstrateitsuseinthetreatmentofanalfissures.

7.Hyperbaricoxygentherapyprovidesasignificantincreaseintissueoxygenationinhypoperfusedwounds,enhancingfibroblastreplication,collagensynthesisandneovascularizationandtherebypromotingwoundhealing.Itwashypothesizedthatrecalcitrantchronicanalfissureswouldhealwithhyperbaricoxygentherapy.Inasmallnonrandomizedstudy74,5of8patientswithfissuresrefractorytotopicalnitrateshealedwith15treatmentsofhyperbaricoxygengivenover3weeks.2patientsfailedtohealandonerelapsedafter3months.Thistreatmentiscostlywithrespecttotimeandresources,butmaybeofbenefitinrecalcitrantfissuresthatarenotamenabletoorhavefailedsurgery.

III.Surgicaltherapy

A.Lateralinternalsphincterotomy(LIS)LISiscurrentlythesurgicaltreatmentofchoiceformanagementofanalfissuresrefractorytononsurgicaltherapyandmaybeofferedwithoutatrialofpharmacologictreatmentafterfailureofconservativetherapy75.Theinitiallyadvocatedposteriormidlinesphincterotomythroughthefissurebed82oftenresultedinakeyholedeformitycomplicatedbyincontinencetogasand/orstoolorfecalsoiling.LISissuperiortofissurectomyandposteriormidlinesphincterotomywithrespecttohealingrates,painreliefandincontinence85,86.Theprocedureinvolvesdivisionoftheinternalanalsphincterlaterally76,81fromitsdistalmostenduptothedentateline,orforadistanceequaltothatofthefissure77,anapproachthatcutslessmuscleinattempttodiminishtheriskofimpairedcontinence.Thesphinctercanbedividedinanopen(througharadialorcircumferentialincision)orclosed(throughastabwound)fashionwithsimilarresults78,79,80.Woundhealingistwiceasfastwithprimaryclosureofthewoundascomparedwithhealingbysecondaryintention87.Thefissureitselfdoesnotrequiresurgicaltherapy(fissurectomy),butverylargesentinelpilesorprolapsing,hypertrophiedanalpapillaemightberemovedforcosmeticorcleansingpurposes84.Theproceduremaybedonewiththepatientunderlocal,regionalorgeneralanesthesia,andcanbecombinedwithotheranorectalprocedures85suchashemorrhoidectomy.

LISisusuallysuccessfulwithoverallhealingratesof90100%88.Complicationssuchasecchymosisandhemorrhage,perianalabcess,fistulainanoandprolapsedhemorrhoidsarerare.However,ratesofcontinenceimpairmentvarywidelythroughouttheliteraturerangingfrom0%to50%88,butincontinencesufficienttocauseanymeasurableimpairmentinqualityoflifeisuncommon,intherangeof3%89,90.Inaddition,arecentstudyreportedthatratesofincontinencefollowingLISaresimilartothoseinpatientsundergoingtopicaltherapy91,althoughincontinenceaftertopicaltherapyisusuallytransient.Recurrenceratesarelow(themajorityintherangeof13%88)andgenerallyattributedtoinadequatesphincterotomythatcanbeconfirmedbyendoanalultrasound92.Insuchcases,asecondlateralinternalsphincterotomycouldbeperformedontheoppositeside5,83,butoutcomedataislimited.

Notallpatientswithfissureshavetheclassichypertonicinternalsphincter.Somepatientsarenormoorevenhypotonic93.Therefore,carefulpatientselectionandabsenceofpreoperativecontinenceproblemsonhistoryarenecessarypriortoperformingsurgery.Cautionshouldbeexercisedbeforeperforminginternalsphincterotomyinpatientswithdiarrhea,irritablebowelsyndrome,diabetes,andintheelderlyorpostpartumwomen,particularlyiftheyhaveundergoneanepisiotomyorsufferedatearduringlabor,aswellaspatientswhohaveundergoneprevioussphinctersurgery83.Preoperativeanalmanometryandendoanalultrasoundshouldbeperformedinthosepatientsathighriskofprevioussphincterdamage,particularlyinthosepatientswithrecurrentfissuresafterLISandinwomenwhohaveundergoneanepisiotomyorsufferedatearduringlabor94.



B.AnaladvancementflapsEarlystudiescomparingadvancementflapstoLISshowedcomparablehealingrates95andwereespeciallysuccessfulinthosepatientswithoutsphincterhypertonia96.Howeverfurtherprospective,randomizedstudieswithlongtermfollowupareneeded.Currentlyadvancementflapsarerecommendedforchronicanalfissuresinpatientswithnormalorhypotonicanalsphincterssuchasthosewhodevelopfissurespostpartumorhavehadprevioussphincterinjury97.

C.AnaldilationAnaldilationforthetreatmentofanalfissureiscurrentlyobsolete.Analstretch(manualorpneumatic)carriesahigherriskoffissurepersistenceorrecurrencethaninternalsphincterotomyandalsoasignificantlyhigherriskofimpairedcontinencethansphincterotomy98duetouncontrolledsphincterdisruption.Useofmedicaltherapyinconjunctionwithdilationdoesnotimproveoutcome.Inarecentsmallrandomizedtrial,hecombinationofcryothermaldilatorswithtopicalNTGprovedtobeeffective,safeandwithstatisticallybetterratesofhealing,recurrence,andreductioninanaltonethandilationorNTGalone,withoutimpairedcontinence101.Confirmationoftheseresultsinlargerrandomizedtrialsarenecessary.

IV.Specialsituations

A.CrohnsdiseaseCrohnsfissuresarefrequentlymultipleandoffthemidline,andaresometimesasymptomatic.Traditionally,anorectalsurgeryhasbeenavoidedinpatientswithCrohnsdiseasebecauseoffearsregardingpostoperativeincontinence,exacerbatedbypreexistingdiarrheathatmayresultinproctectomy.Forthisreason,treatmentshouldbefocusedoncontrollingthediarrhea.TherearenodatatosupporttheuseoftopicalsphincterrelaxantsorBTinthetreatmentoffissuresinCrohnsdisease.Ifthefissurepersistsdespiteconservativemeasures,examinationunderanesthesiaandlimitedsphincterotomyshouldbeperformed.In2smallretrospectivereviews,surgeryhasbeenreportedtoresultinuncomplicatedwoundhealingin>80%ofcases99,100.

B.HIV/AIDSItisessentialtodifferentiatebetweentypicalfissuresinHIVpositivepatientswhichmaybetreatedasusualandHIVassociatedanalulcerswhicharebroadbasedanddeep,occuranywherewithintheanalcanalandareassociatedwithalowratherthanhighsphinctertone.STDsmustbeexcludedandtreatedifpresent.Typicallyantiretroviraltreatmentcombinedwithconservativemeasuresiseffective.ThereisnodataavailableabouttheriskofpostoperativeincontinenceortheuseoftopicalsphincterrelaxantsorBTastreatmentoptions.

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