What’s New from Down What’s New from Down UnderUnder

Jeanne Yu, M.D.Jeanne Yu, M.D.Grand Rounds, Roosevelt HospitalGrand Rounds, Roosevelt Hospital

August 31, 2005August 31, 2005

New Treatments for Old New Treatments for Old ProblemsProblems

Anal FissuresAnal Fissures Anal FistulasAnal Fistulas Anal WartsAnal Warts Procedure of Prolapsed Procedure of Prolapsed

Hemorrhoids Hemorrhoids

Anal FissuresAnal Fissures Fissure-in-ano is a cut in the Fissure-in-ano is a cut in the

anal canalanal canal

Location is mostly posteriorLocation is mostly posterior Lockhart-MummeryLockhart-Mummery

Sphincter structureSphincter structure KlosterhalfenKlosterhalfen

Ischemia due to decreased Ischemia due to decreased perfusion posteriorly in 85% perfusion posteriorly in 85% of postmortem specimensof postmortem specimens

SchoutenSchouten Reduced anal pressureReduced anal pressure

Acute or ChronicAcute or Chronic

EtiologyEtiology Constipation, straining, Constipation, straining,

diarrhea, IBDdiarrhea, IBD High fiber diet decreases riskHigh fiber diet decreases risk

History and PhysicalHistory and Physical

SymptomsSymptoms Extreme, cutting Extreme, cutting

painpain Rectal bleedingRectal bleeding Chronic fissureChronic fissure

Lump or sentinel tag, Lump or sentinel tag, drainage, pruritusdrainage, pruritus

ProctosigmoidoscopProctosigmoidoscopyy

TreatmentsTreatments Acute fissureAcute fissure

High fiber diet, bulking High fiber diet, bulking agents, fluids agents, fluids

Warm baths Warm baths Topical anestheticTopical anesthetic

Ela-Max5Ela-Max5

Chronic fissure (> Chronic fissure (> one month) one month) Manometry Manometry EUAEUA

Chemical Chemical SphincterotomySphincterotomy

Glyceryl Trinitrate Ointment (GTN)Glyceryl Trinitrate Ointment (GTN) Nitric oxide is a neurotransmitter that leads to Nitric oxide is a neurotransmitter that leads to

relaxation of the internal sphincterrelaxation of the internal sphincter Primary side effects: HeadachePrimary side effects: Headache 0.2% GTN (68%) vs. placebo (8%)0.2% GTN (68%) vs. placebo (8%)

Diltiazem (DTZ)Diltiazem (DTZ) Ca2+ channel blockerCa2+ channel blocker Kocher found no difference in healing rates, Kocher found no difference in healing rates,

but there was fewer side effectsbut there was fewer side effects

Botulinum Toxin (BNT)Botulinum Toxin (BNT) Inhibits neuromuscular transmissionInhibits neuromuscular transmission Transient incontinence for flatusTransient incontinence for flatus

Chemical Chemical SphincterotomySphincterotomy

Cochrane Collaboration meta analysis (2003)Cochrane Collaboration meta analysis (2003)

32 randomized controlled trials, 2446 patients32 randomized controlled trials, 2446 patients

Summarized resultsSummarized results GTN vs. placebo (OR 0.73, CI 0.50-1.07)GTN vs. placebo (OR 0.73, CI 0.50-1.07) GTN vs. Ca2+ channel blockers (OR 0.66, CI 0.22-GTN vs. Ca2+ channel blockers (OR 0.66, CI 0.22-

2.01)2.01) Botox vs. placebo (OR 0.75, CI 0.32-1.77)Botox vs. placebo (OR 0.75, CI 0.32-1.77) Botox vs. GTN (OR 0.48, CI 0.21-1.10)Botox vs. GTN (OR 0.48, CI 0.21-1.10)

Medical therapy for acute and chronic anal Medical therapy for acute and chronic anal fissures may be applied with a chance of cure fissures may be applied with a chance of cure that is only marginally better than placebothat is only marginally better than placebo

Surgical ManagementSurgical Management Sphincter StretchSphincter Stretch

Described in 1838Described in 1838 Manual stretchManual stretch No longer done in No longer done in

this countrythis country

Surgical ManagementSurgical Management

Internal Anal Sphincterotomy Open TechniqueInternal Anal Sphincterotomy Open Technique Radial incision across intersphincteric grooveRadial incision across intersphincteric groove Separate internal sphincter from anodermSeparate internal sphincter from anoderm

More than 90% of patients who require surgery for this problem More than 90% of patients who require surgery for this problem have no further trouble from fissures. have no further trouble from fissures.

Complications: infection, incontinence, recurrenceComplications: infection, incontinence, recurrence

Surgical ManagementSurgical Management Cochrane meta-analysis Cochrane meta-analysis

(2002)(2002)

24 trials, 3475 patients24 trials, 3475 patients

ResultsResults Anal stretch has a higher Anal stretch has a higher

risk of fissure persistence risk of fissure persistence and minor incontinence and minor incontinence than internal than internal sphincterotomy. sphincterotomy.

Minimal difference in Minimal difference in fissure persistence and fissure persistence and incontinence risk between incontinence risk between open vs. closed lateral open vs. closed lateral internal sphincterotomy. internal sphincterotomy.

Anal FistulasAnal Fistulas An anal fistula, An anal fistula,

almost always the almost always the result of a previous result of a previous abscess, is a small abscess, is a small tunnel connecting tunnel connecting the anal gland from the anal gland from which the abscess which the abscess arose to the skin of arose to the skin of the buttocks the buttocks outside the anus.outside the anus.

Anal FistulasAnal Fistulas

Intersphincteric

Extasphincteric

Suprasphincteric

Trans-sphincteric

History and PhysicalHistory and Physical SymptomsSymptoms

Swelling, pain, Swelling, pain, dischargedischarge

AnoscopyAnoscopy Bidigital palpation Bidigital palpation

for the tractfor the tract IdentificationIdentification

Methylene blueMethylene blue MilkMilk Hydrogen peroxideHydrogen peroxide FistulographyFistulography Transrectal Transrectal

ultrasoundultrasound

TreatmentTreatment

FistulotomyFistulotomy Seton divisionSeton division Endorectal advancement flapEndorectal advancement flap Fibrin GlueFibrin Glue

TreatmentTreatment Fibrin PlugFibrin Plug

Suturable biodegradable plugSuturable biodegradable plug

TreatmentTreatment

TreatmentTreatment

TreatmentTreatment

Anal WartsAnal Warts Condyloma Condyloma

acuminatumacuminatum HPVHPV

ComplaintsComplaints Discharge, pruritus, Discharge, pruritus,

pain, odor, bleedingpain, odor, bleeding

AnoscopyAnoscopy Lesions usually Lesions usually

confined to squamous confined to squamous epithelium and epithelium and transitional zonestransitional zones

TreatmentTreatment PodophyllinPodophyllin Bichloracetic acidBichloracetic acid ImmunotherapyImmunotherapy ImmunomodulationImmunomodulation ChemotherapyChemotherapy CryotherapyCryotherapy ElectrocoagulationElectrocoagulation Laser therapyLaser therapy Surgical excisionSurgical excision

AldaraAldara Imiquimod cream Imiquimod cream

5%5%

Induces local Induces local production of production of interferon and other interferon and other cytokines in cytokines in patients applying patients applying ALDARA cream to ALDARA cream to external genital external genital warts warts

AldaraAldara In early multicenter, double-blind, trials, 311 In early multicenter, double-blind, trials, 311

patients (1997)patients (1997)

ResultsResults Three times weekly completely cleared warts in Three times weekly completely cleared warts in

50% of patients50% of patients

IndicationsIndications First line therapy for patients who do not demand First line therapy for patients who do not demand

immediate removal of warts (8weeks) immediate removal of warts (8weeks) Alternative therapy for failures or recurrencesAlternative therapy for failures or recurrences In combination therapy for patients with In combination therapy for patients with

large/multiple large/multiple

HemorrhoidsHemorrhoids

HemorrhoidsHemorrhoids Fibrovascular cushions (or hemorrhoids) Fibrovascular cushions (or hemorrhoids)

are part of the normal anatomy within are part of the normal anatomy within the anal canal and are believed to be the anal canal and are believed to be important in maintaining continence. As important in maintaining continence. As an individual coughs, strains or sneezes, an individual coughs, strains or sneezes, these fibrovascular cushions engorge these fibrovascular cushions engorge and maintain closure of the anal canal in and maintain closure of the anal canal in order to prevent leakage of stool in the order to prevent leakage of stool in the presence of increased intrarectal presence of increased intrarectal pressure. pressure.

History and PhysicalHistory and Physical SymptomsSymptoms

Discomfort, bleeding, painDiscomfort, bleeding, pain AnoscopyAnoscopy

Consider flexible proctoscigmoidoscopy Consider flexible proctoscigmoidoscopy to asses for neoplasmto asses for neoplasm

TreatmentTreatment Diet and lifestyle Diet and lifestyle

modificationmodification ““Get off the pot!”Get off the pot!”

Rubber band ligation Rubber band ligation

Infrared coagulationInfrared coagulation

SclerotherapySclerotherapy

Surgical ManagementSurgical Management Ferguson Ferguson

hemorrhoidectomyhemorrhoidectomy

Procedure for Prolapsed Procedure for Prolapsed Hemorrhoids (PPH)Hemorrhoids (PPH)

Transanal, circular stapling of Transanal, circular stapling of redundant anorectal mucosaredundant anorectal mucosa

Redundant mucosa is drawn into Redundant mucosa is drawn into stapler and submucosal blood flow is stapler and submucosal blood flow is interrupted by the circular staple line. interrupted by the circular staple line.

No incisions are made in the No incisions are made in the somatically innervated, highly sensitive somatically innervated, highly sensitive anoderm theoretically resulting in anoderm theoretically resulting in significantly less postoperative pain.significantly less postoperative pain.

PPH vs. Ferguson PPH vs. Ferguson HemorrhoidectomyHemorrhoidectomy

Prospective, Randomized, Controlled, Multicenter Prospective, Randomized, Controlled, Multicenter Trial comparing stapled hemorrhoidopexy and Trial comparing stapled hemorrhoidopexy and ferguson hemorrhoidectomy: perioperative and one ferguson hemorrhoidectomy: perioperative and one year results (2004).year results (2004).

156 patients156 patients

Conclusions: Stapled hemorrhoidopexy had less Conclusions: Stapled hemorrhoidopexy had less postop pain, less requirement of analgesics, less postop pain, less requirement of analgesics, less pain at first bowel movement, while providing pain at first bowel movement, while providing similar control of symptoms and need for additional similar control of symptoms and need for additional hemorrhoid treatment at one year follow-uphemorrhoid treatment at one year follow-up

PPH vs. Ferguson PPH vs. Ferguson HemorrhoidectomyHemorrhoidectomy

Meta-analysis Nisarl’s group (2004) Meta-analysis Nisarl’s group (2004) 15 trials, 1,077 patients15 trials, 1,077 patients Follow-up ranged from 6 weeks to 37 Follow-up ranged from 6 weeks to 37

monthsmonths PPH less painful.PPH less painful. Shorter return to normal activity of 4.03 Shorter return to normal activity of 4.03

days (days (PP=0.007). =0.007). Stapled hemorrhoidopexy has a higher Stapled hemorrhoidopexy has a higher

recurrence rate (OR 3.64, recurrence rate (OR 3.64, PP = 0.008) at a = 0.008) at a minimum follow-up of six months.minimum follow-up of six months.

PPHPPH

PPHPPH

There is less postoperative pain secondary There is less postoperative pain secondary to less operative trauma to the anodermto less operative trauma to the anoderm

PPHPPH

PPHPPH

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Nisarl P, et al. Stapled hemorrhoidopexy compared with Nisarl P, et al. Stapled hemorrhoidopexy compared with conventional hemorrhoidectomy: systematic review of conventional hemorrhoidectomy: systematic review of randomized, controlled trials. Dis Colon Rectum randomized, controlled trials. Dis Colon Rectum 2004:47:1847.2004:47:1847.

Edwards L, et al. Comparison of results from two vehicle Edwards L, et al. Comparison of results from two vehicle controlled clinical trials evaluatingtopical imiquimod for controlled clinical trials evaluatingtopical imiquimod for the treatment of genital/perianal warts. Clinical Derm the treatment of genital/perianal warts. Clinical Derm 2000.2000.

The End.The End.