[Influence of acupuncture and moxibustion on defecation in postoperative patients of anal fissure: a randomized controlled trial].

OBJECTIVE: To verify the clinical efficacy of acupuncture and moxibustion on defecating and pain symptoms in postoperative patient of anal fissure. METHODS: Two hundred cases of postoperation of anal fissure were randomly divided into an acupuncture-moxibustion group and a medication group, 100 cases in each one. The basic treatment after the surgery was the same in two groups, besides, acupuncture was applied at Zhongliao (BL 33) and Xialiao (BL 34) in the morning of first 5 days of postoperative 24 h in the acupuncture-moxibustion group, and suspended moxibusiton was applied at Changqiang (GV 1) within 5 to 10 min after defecation; while two bags of forlax was orally administrated in the morning of first 5 days of postoperative 24 h in the medication group. The pain intensity, defecation willingness, defecation difficulty and stool texture during postoperative defecation were observed. RESULTS: The defecation pain on the first two days after the treatment was not statistically significant between two groups (both P > 0.05). From the third day of treatment, the improvements of defecation pain in acupuncture-moxibustion group were more obvious than those in the medication group (all P < 0.05). The patients in the acupuncture-moxibustion group had more positive defecation willingness than those in the medication group (all P < 0.05). The differences of defecation difficulty and stool properties in two groups had no statistical significance (both P > 0.05). CONCLUSION: The intervention treatment of acupuncture and moxibustion has clinical significance on relieving pain symptoms and improving defecation willingness in postoperative patient of anal fissure.

Transcutaneous electrical posterior tibial nerve stimulation for chronic anal fissure: a preliminary study.

PURPOSE: Recent studies showed that sacral nerve stimulation might be an effective treatment option for chronic anal fissure. We aimed to evaluate the efficacy of transcutaneous electrical nerve stimulation as a noninvasive alternative treatment for chronic anal fissure by stimulating the sacral nerve in the ankle via the posterior tibial nerve. METHOD: In this prospective study, transcutaneous electrical nerve stimulation was applied for 10 days in addition to conventional medical treatment in ten patients. Wexner's constipation score, visual analog scale for pain, quality of life (Short Form-36), Hamilton anxiety and depression scores, symptom relief, compliance, fissure healing, and side effects were evaluated before and after treatment (days 0, 5, and 10). RESULTS: Ten patients (eight females/two males) with a mean age of 50.7 ± 18.5 years were enrolled in the study. Pain and bleeding resolved in all patients 2 days after the treatment, and mucosal healing was observed in six patients 10 days after the treatment. Wexner's constipation and visual analog scale scores for pain decreased significantly (p = 0.001 and p = 0.002, respectively). Hamilton anxiety and depression scores decreased as well (p = 0.001 and p = 0.01, respectively). Among Short Form-36 subscales, only mental health score increased significantly (p = 0.003). One patient underwent surgery at follow-up due to recurrence of symptoms, and rubber band ligation was applied to another patient who had internal hemorrhoidal rectal bleeding at the end of 10 days. CONCLUSIONS: Transcutaneous electrical nerve stimulation application to the posterior tibial nerve has the potential to be an alternative treatment option for chronic anal fissure patients who seek noninvasive treatment modality.

Conservative versus surgical treatment for chronic anal idiopathic fissure: a prospective randomized trial.

Anal fissure is a tear in the lining of the anal canal distal to the dentate line, which most commonly occurs in the posterior midline. Anal fissure was defined chronic if the patient presented with history of anal pain during defecation for at least 2 months with the observation of sphincter fibers at the base of the lesion. One hundred and forty-two consecutive patients with a chronic anal fissure with hypertonicity of internal sphincter on proctological examination were selected for this study from October 2008 to October 2010. Patients enrolled for the study were randomized to two groups by using a computer-generated list. Patients who underwent lateral internal sphincterotomy (LIS) were operated as day surgery procedures under local or epidural anesthesia. Patients randomized to conservative treatment were prescribed to use warm anal dilator with a nifedipine ointment 5 min twice daily for 4 weeks. Patients were clinically examined after 2, 4 and 8 weeks of treatment to evaluate if there was complete healing of the fissure. All patients were required to record pain after the first defecation, on 3rd and 7th postoperative day on a self-administered VAS scale in cm (0-10). Sixty-eight patients were randomly assigned to LIS, 74 to the conservative approach. Fifty-one patients of topical nifedipine group (68.9 %) and 60 patients of LIS group (88.2 %) presented an anal fissure healed at 8 weeks with a p value of 0.0077. As regards post-operative pain, 43 patients of LIS group (63.2 %) and 25 patients of topical nifedipine group (33.7 %) referred first defecation as painless. In the topical nifedipine group 43 (58.1 %) after 3 days since treatment and 35 (47.3 %) after 7 days had pain. In the LIS group 22 (32.3 %) after 3 days and 9 (13.2 %) after 7 days referred pain. There was no statistical difference between LIS and topical nifedipine group concerning side effects. Lateral internal sphincterotomy is an effective, less painful, fast recovery treatment for chronic anal fissure. Incontinence rate is overestimated and often the fear of a continence disturbance, albeit with a low incidence following surgery, may obscure the need to relieve symptoms which may be so severe as to make the patient's life intolerable.

The effect of topical nifedipine in treatment of chronic anal fissure.

Chronic anal fissure is the most common cause of anal pain associated with internal anal sphincter hypertonia. Reduction of hypertonocity is a special treatment for fissure healing. For this purpose chronic anal fissures were conventionally treated by anal dilatation or by lateral sphincterotomy. However, both of these methods may cause a degree of incontinence in some patients. The uptake of medical therapies that create a reversible chemical sphincterotomy has recently become widespread. The aim of this prospective clinical trial study was to assess the effectiveness of nifedipine in healing anal fissure, a calcium channel blocker that reduces sphincter pressure. A single-blind randomized comparative trial was setup to compare traditional treatment with stool softeners and 2% lidocaine cream against 0.5% nifedipine cream for 4 weeks. 110 patients were included in this study, 60 patients in the nifedipine group and 50 patients in the control group and the therapeutic outcome and side effects were recorded. Healing had occurred in 70% of patients in the nifedipine group and in 12% of patients in the control group after 4 weeks treatment (P < 0.005). Recurrence of symptoms occurred in four of healed patients in the nifedipine group and three patients in the control group in two months. The final result of nifedipine application after 12 months follow up was recurrence in 11 patients (26.19%). Mild headache occurred in four patients (6.6%) of the nifedipine group. Patients in the nifedipine group showed significant healing and relief from pain compared with patients in the control group. Recurrence rate with nifedipine use in spite of control of predisposing factors such as constipation was significant. Another finding was low complication rate with this treatment.

Esfinterotomía lateral interna abierta con anestesia local como gold standard en el tratamiento de la fisura anal crónica. Estudio prospectivo clínico y manométrico a largo plazo / No disponible

Introducción: la fisura anal crónica sigue siendo uno de los problemas proctológicos más frecuentes e incapacitantes en la población occidental actual. La esfinterotomía lateral interna abierta es una de las opciones terapéuticas descritas y aceptadas como tratamiento de elección de la fisura anal crónica, ya que reduce la hipertonía esfinteriana (mecanismo etiopatogénico fundamental de la fisura), permitiendo por tanto, disminuir la proctalgia y así la curación de la fisura. Material y métodos: realizamos un estudio prospectivo de 120 pacientes intervenidos por fisura anal crónica con esfinterotomía lateral interna abierta con anestesia local (20 cc mepivacaína al 2%) tratados ambulatoriamente en la consulta de la Unidad de Proctología entre los años 1998-2001. No se requirió estudios preoperatorios, preparación con enemas, profilaxis antibiótica, accesos venosos, ingreso ni observación hospitalaria. Los pacientes fueron revisados a la 1a semana, 2o mes, 6o mes y al año. Resultados: complicaciones precoces (1a semana): 3 hematoma-equimosis de la herida (2,5%), 3 hemorragias autolimitadas (2,5%). No encontramos trombosis hemorroidales, fístulas, abscesos perianales ni mortalidad. Complicaciones tardías (2o mes): 9 pacientes con incontinencia (7,5%) y 3 pacientes (2,5%) con recurrencia de la fisura. Al 6o mes, la incontinencia disminuyó al 5% (6 pacientes), y aparecieron 3 pacientes más con recurren- cia de la fisura (2,5%). Al año se mantuvo la tasa de incontinencia del 5% (a gases y líquidos) y aparecieron otros 3 pacientes con recurrencia de la fisura (2,5%). Recurrencia global del 7,5%. Los hallazgos en la manometría fueron, PMB (presión máxima basal) pre-tratamiento similar a la PMB en pacientes con recurren- cia de la fisura, así como la PMB del grupo control similar a la PMB de pacientes con curación. La PMB en pacientes incontinentes fue más baja que la PMB en pacientes continentes (55 ± 7 frente a 80,7 ± 21). La diferencia entre la PMCV (presión máxima de contracción voluntaria) en pacientes incontinentes y pacientes continentes no fue estadísticamente significativa. Conclusiones: la esfinterotomía lateral interna abierta con anestesia local tiene una tasa de curación a largo plazo y unos índices de morbilidad equiparables a otras técnicas, por lo que puede ser considerada como un tratamiento adecuado y eficaz para esta patología (AU)

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Open lateral internal anal sphincterotomy under local anesthesia as the gold standard in the treatment of chronic anal fissures. A prospective clinical and manometric study.

BACKGROUND: Chronic anal fissure is one of the most frequent proctological disorders in Western populations. Open lateral internal sphincterotomy is one of the therapeutic options accepted as the treatment of choice for chronic anal fissure, since it reduces the hypertonia of the internal anal sphincter (the main etiopathogenic mechanism of fissures), decreases anal pain, and allows the fissure to heal. MATERIAL AND METHODS: We carried out a prospective study of 120 patients operated on for chronic anal fissure with open sphincterotomy under local anesthesia at our Proctology Outpatient Unit from 1998 to 2001. No preoperative studies, bowel preparation, or antibiotic prophylaxis were carried out. All patients were followed up after 1 week, 2 months, 6 months, and 1 year, and underwent an anal manometry before and after surgery. RESULTS: Early complications: 3 hematoma-ecchymosis of the wound (2.5%), 3 self-limited hemorrhage events (2.5%). No hemorrhoidal thrombosis, fistulas, or perianal abscesses occurred. Fissures recurred in nine patients (7.5%) within one year. The initial rate of incontinence of 7.5% at two months dropped down to 5% at six months. The mean resting pressure (MRP) in incontinent patients was lower than in continent patients (55 +/- 7 mmHg versus 80.7 +/- 21 mmHg). The difference in mean squeeze pressure (MSP) between incontinent patients and continent patients was not statistically significant. CONCLUSIONS: Open sphincterotomy under local anesthesia has a long-term rate of healing and a morbidity rate similar to other techniques. It may therefore be considered an effective treatment for chronic anal fissure.

Results of behavioral treatment (biofeedback) for solitary rectal ulcer syndrome.

BACKGROUND: Treatment of solitary rectal ulcer syndrome with behavioral techniques (biofeedback) has been shown to be successful in a majority of patients in the short term. We aimed to determine the longer-term outcome of patients treated with this therapy. PATIENTS AND METHODS: Thirteen consecutive patients (3 male; median age, 34 years) with solitary rectal ulcer who had been treated by biofeedback and assessed a median of nine months after treatment were reassessed by questionnaire. Three patients were also examined using rigid sigmoidoscopy. RESULTS: Median follow up was 36 (range, 32-59) months after initial biofeedback treatment. One patient (previously reported as failing biofeedback therapy) was lost to follow-up. Of the four patients previously reported as asymptomatic, one remained asymptomatic, one maintained marked improvement, and another slight improvement; one had reverted to pretreatment status. Of the three patients previously reported as having marked improvement, one maintained moderate improvement, and two had reverted to pretreatment status. The patient previously reporting slight improvement had reverted to pretreatment status. Of the five previously reported failures, two patients experienced no improvement after further courses of biofeedback. At the three different times of review (pretreatment vs. 9 months vs. 36 months after biofeedback), reported bowel function was as follows: the need to strain (12 vs. 5 vs. 9 patients), anal digitation (10 vs. 3 vs. 8 patients), laxative use (9 vs. 4 vs. 4 patients), median time spent in the toilet per attempt at defecation (30 vs. 10 vs. 25 minutes), median visits to the toilet (5.5 vs. 2 vs. 4 per day), and ability to maintain employment (3 vs. 7 vs. 6 patients). CONCLUSION: Improvement in symptoms of solitary rectal ulcer syndrome after biofeedback retraining deteriorates in some patients with time. Half the patients with an early clinical response to retraining, however, can be expected to have ongoing clinical benefit at a median of three years.

The management of chronic fissure in-ano with botulinum toxin.

Five patients with a chronic fissure in-ano each received an injection of Clostridium botulinum type A toxin into the lower internal anal sphincter. A mean lowering of maximum resting anal pressure by 23.3 (SEM 5.6) cm H2O was achieved within seven days. Maximum voluntary squeeze pressures were not significantly altered. Anal compliance increased in all cases. Healing of the fissure with an apparent reduction in anal sensation occurred in three of the patients and partial resolution of symptoms in the other two. No adverse effects resulted from injections of the toxin. A controlled trial to compare the relative efficacies of botulinum toxin and lateral sphincterotomy is required.

A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. XXXI. "Strainodynia": an etiopathologic study.

"Strainodynia" is the name I give to the excessive and exhaustive straining that may accompany defecation. Eighty-six patients with strainodynia were studied; the investigations comprised study of the stool character, proctoscopy, colonoscopy, barium enema, intestinal transit rate, EMG, manometry, and rectal biopsy. These patients were classified into 3 groups: band, diet, and levator strainodynia. The first, band strainodynia, more common in men, presented with a normal stool character. However, the rectal neck pressure was elevated, and a fibrous band could be demonstrated by a rectal neck biopsy. Bandotomy relieved the strainodynia. Diet strainodynia, more common in women, presented with stool frequency and weight less than normal. Rectal neck pressure was normal or elevated, and the rectosphincteric reflex was diminished. There was internal sphincter fibrosis. Improvement occurred after dietary management or internal sphincterotomy. Levator strainodynia was due to levator dysfunction syndrome. Stools were repeatedly obstructed at defecation despite normal stool character. Rectal neck pressure was elevated only on straining. There was reduced levator myoelectric activity. Levatorplasty cured the condition.