Temporal trends and treatment patterns in anal fissure management: insights from a multicenter study in Italy.

INTRODUCTION: Anal fissure (AF) poses a common challenge in clinical practice, prompting various treatment approaches. This multicenter study, conducted by the Italian Society of Colorectal Surgery, aimed to assess treatment trends in AF over a 10 year period. METHODS: A survey of proctologists and retrospective analysis of patient records were conducted to evaluate treatment modalities and outcomes across six different clinical scenarios based on AF presentation (acute/chronic) stratified by sphincter function (normal/hypertonic/hypotonic). RESULTS: Analysis of data from 17 principal investigators and 22,016 patients revealed significant variability in treatment approaches, influenced by factors such as symptom duration, anal tone, and surgeon preference. Conservative treatments were commonly utilized, while surgical interventions were reserved for refractory cases. Specifically, pharmaceutical treatment was administered to 66-75% of patients in cases of acute AF and 63-67% for chronic AF, while 10-15% underwent anal dilation, and < 2% received botulinum toxin injection. Among medical treatments, nifedipine with lidocaine and glycerin film-forming ointments were the most utilized. The most performed surgical techniques were fissurectomy and anoplasty, except for patients with chronic AF and hypertonic sphincter where sphincterotomy prevailed. Trends in treatment utilization varied depending on the clinical scenario, with notable shifts observed over time. CONCLUSIONS: This study provides insights into the evolving landscape of AF management, highlighting the need for further research to elucidate optimal treatment strategies and improve patient outcomes.

Belgian consensus guideline on the management of anal fissures.

Introduction: Acute and chronic anal fissures are common proctological problems that lead to relatively high morbidity and frequent contacts with health care professionals. Multiple treatment options, both topical and surgical, are available, therefore evidence-based guidance is preferred. Methods: A Delphi consensus process was used to review the literature and create relevant statements on the treatment of anal fissures. These statements were discussed and modulated until sufficient agreement was reached. These guidelines were based on the published literature up to January 2023. Results: Anal fissures occur equally in both sexes, mostly between the second and fourth decades of life. Diagnosis can be made based on cardinal symptoms and clinical examination. In case of insufficient relief with conservative treatment options, pharmacological sphincter relaxation is preferred. After 6-8 weeks of topical treatment, surgical options can be explored. Both lateral internal sphincterotomy as well as fissurectomy are well-established surgical techniques, both with specific benefits and risks. Conclusions: The current guidelines for the management of anal fissures include recommendations for the clinical evaluation of anal fissures, and their conservative, topical and surgical management.

Comparative Analysis of Open and Closed Sphincterotomy for the Treatment of Chronic Anal Fissure: Safety and Efficacy Evaluation.

BACKGROUND Chronic anal fissure is a common condition that causes pain and discomfort and has a significant impact on quality of life. When conservative management fails, surgical sphincterotomy can be successful. This retrospective study from a single center in Turkey included 188 patients with chronic anal fissures and aimed to compare outcomes from open and closed sphincterotomy. MATERIAL AND METHODS This retrospective study included 188 patients treated with lateral internal sphincterotomy (LIS) for chronic anal fissure between January 2015 and December 2021 in our hospital. Open LIS procedure was performed in 91 patients and closed LIS was performed in 97 patients. Demographic characteristics, postoperative complications, and recurrence were compared for these 2 methods. RESULTS Of the 188 patients included in the study, 47.9% were women and 52.1% were men. The mean age was 42.9 (20-84) years. In the open LIS group, recurrence occurred in 2 patients (2.19%), and no incontinence was observed. In the closed LIS group, recurrence occurred in 3 patients (3%; P=0.703), and incontinence developed in 5 patients (5.15%; P=0.035). CONCLUSIONS Comparing the 2 methods used in chronic anal fissure surgery, and considering the recurrence and risk of incontinence, the most feared outcome by the patient and surgeon, open LIS stands out as a superior technique, especially in young male patients.

Availability of evidence and comparative effectiveness for surgical versus drug interventions: an overview of systematic reviews and meta-analyses.

OBJECTIVES: This study aims to examine the prevalence of comparisons of surgery to drug regimens, the strength of evidence of such comparisons and whether surgery or the drug intervention was favoured. DESIGN: Systematic review of systematic reviews (umbrella review). DATA SOURCES: Cochrane Database of Systematic Reviews. ELIGIBILITY CRITERIA: Systematic reviews attempt to compare surgical to drug interventions. DATA EXTRACTION: We extracted whether the review found any randomised controlled trials (RCTs) for eligible comparisons. Individual trial results were extracted directly from the systematic review. SYNTHESIS: The outcomes of each meta-analysis were resynthesised into random-effects meta-analyses. Egger's test and excess significance were assessed. RESULTS: Overall, 188 systematic reviews intended to compare surgery versus drugs. Only 41 included data from at least one RCT (total, 165 RCTs) and covered a total of 103 different outcomes of various comparisons of surgery versus drugs. A GRADE assessment was performed by the Cochrane reviewers for 87 (83%) outcomes in the reviews, indicating the strength of evidence was high in 4 outcomes (4%), moderate in 22 (21%), low in 27 (26%) and very low in 33 (32%). Based on 95% CIs, the surgical intervention was favoured in 38/103 (37%), and the drugs were favoured in 13/103 (13%) outcomes. Of the outcomes with high GRADE rating, only one showed conclusive superiority in our reanalysis (sphincterotomy was better than medical therapy for anal fissure). Of the 22 outcomes with moderate GRADE rating, 6 (27%) were inconclusive, 14 (64%) were in favour of surgery and 2 (9%) were in favour of drugs. There was no evidence of excess significance. CONCLUSIONS: Though the relative merits of surgical versus drug interventions are important to know for many diseases, high strength randomised evidence is rare. More randomised trials comparing surgery to drug interventions are needed.

Desgarro agudo del esfínter anal postparto con reparación inmediata / Immediate repair of acute postpartum anal sphincter tear: case report

Las lesiones obstétricas del esfínter anal pueden ocurrir durante el parto vaginal espontáneamente o secundariamente a la episiotomía. Su riesgo se estima en un 26% y son la causa más frecuente de incontinencia anal en mujeres jóvenes. Las lesiones de grado 4 de Sultan, también llamadas cloaca traumática, implican la ruptura completa del esfínter y la comunicación de la cavidad vaginal con el canal anal. La reparación es siempre quirúrgica, para lo que se han descrito diferentes técnicas, aunque ninguna ha demostrado ser superior. Presentamos el caso de una paciente primípara de 23 años con una cloaca traumática posparto. La reparación quirúrgica se realizó de inmediato con una técnica de overlapping. El postoperatorio fue sin complicaciones y al año presenta continencia anal completa. (AU)

Obstetric anal sphincter injuries can occur spontaneously or as a consequence of an episiotomy during vaginal delivery. Their risk is estimated at 26% and they are the most frequent cause of anal incontinence in young women. Sultan grade 4 injuries, also called traumatic cloaca, involve complete rupture of the sphincter and communication of the vaginal cavity with the anal canal. The repair is always surgical, for which different techniques have been described, although none have proven to be superior. We present the case of a 23-year-old primiparous patient with a postpartum traumatic cloaca. Surgical repair was performed immediately with an overlapping technique. The postoperative period was without complications and one year later she presents complete anal continence. (AU)

The effect of Trolox on the rabbit anal sphincterotomy repair.

INTRODUCTION: Fecal incontinence (FI) is caused by external anal sphincter injury. Vitamin E is a potential strategy for anal sphincter muscle repair via its antioxidant, anti-inflammatory, anti-fibrotic, and protective properties against myocyte loss. Thus, we aimed to evaluate the water-soluble form of vitamin E efficacy in repairing anal sphincter muscle defects in rabbits. METHODS: Twenty-one male rabbits were equally assigned to the intact (without any intervention), control (sphincterotomy), and Trolox (sphincterotomy + Trolox administration) groups. Ninety days after sphincterotomy, the resting and squeeze pressures were evaluated by manometry, and the number of motor units in the sphincterotomy site was calculated by electromyography. Also, the amount of muscle and collagen in the injury site was investigated by Mallory's trichrome staining. RESULTS: Ninety days after the intervention, the resting and squeeze pressures in the intact and Trolox groups were significantly higher than in the control group (P = 0.001). Moreover, the total collagen percentage of the sphincterotomy site was significantly lower in the Trolox group than in the control group (P = 0.002), and the total muscle percentage was significantly higher in the Trolox group compared to the control group (P = 0.001). Also, the motor unit number was higher in the Trolox group than in the control group (P = 0.001). CONCLUSION: Trolox administration in the rabbit sphincterotomy model can decrease the amount of collagen and increase muscle, leading to improved anal sphincter electromyography and manometry results. Therefore, Trolox is a potential treatment strategy for FI.

Chemical sphincterotomy in posthemorrhoidectomy pain relief: a meta-analysis.

PURPOSE: This study aims to evaluate the pain relief function of chemical sphincterotomy in patients undergoing haemorrhoid surgery and compare, through a meta-analysis, the different drugs used to treat this condition. METHODS: We conducted a search in databases including PubMed, EMBASE and Web of Science. The methodological quality was evaluated using the Revised Cochrane risk-of-bias tool for randomized trials (ROB2). The pain score was assessed using a visual analogue scale (VAS) on day 1, day 2, and day 7, and a meta-analysis was conducted based on the use of random effects models. In addition, the subgroup analysis was evaluated based on the kind of experimental drugs. Heterogeneity and publication bias were assessed. RESULTS: Fourteen studies with a total of 681 patients were included in this meta-analysis, and all studies were randomized controlled trials RCTs. Chemical sphincterotomy showed better pain relief function than placebo on day 1 (SMD: 1.16, 95% CI 0.52 to 1.80), day 2 (SMD: 2.12, 95% CI 1.37 to 2.87) and day 7 (SMD: 1.97, 95% CI 1.17 to 2.77) after surgery. In the subgroup meta-analysis, we found that different drugs for chemical sphincterotomy provided different pain relief. CONCLUSION: Chemical sphincterotomy effectively relieves pain after haemorrhoidectomy, and calcium channel blockers have the best effect.

Extracorporeal shock wave lithotripsy and endoscopic pancreatic stenting without pancreatic sphincterotomy for the treatment of pancreatolithiasis: a case series.

Endoscopic therapy and extracorporeal shock wave lithotripsy (ESWL) are recommended as the first choice in treating pancreatolithiasis. Endoscopic therapy is generally performed using endoscopic pancreatic sphincterotomy (EPST). Herein, we report our experience implementing a treatment protocol, combining endoscopic therapy and ESWL without EPST, for pancreatolithiasis. The inpatient treatment plan was performed every 3 months with a set number of sessions of ESWL with endoscopic pancreatic stenting (EPS) implanted or replaced. Finally, treatment was terminated when the stone was removed after implantation of a 10-Fr stent and crushed to approximately 3 mm or after spontaneous stone discharge. Eight patients were included in this study; the median time to stone disappearance was 208.5 days. The median number of inpatient treatment cycles, endoscopic retrograde cholangiopancreatography, and ESWL sessions was 2.5, 3, and 3, respectively. No serious adverse events were observed in all patients. Therefore, combining ESWL and EPS without EPST can safely treat pancreatolithiasis.

Risk of post-sphincterotomy bleeding with antiplatelet and anticoagulant use: a propensity-matched analysis of the U.S. Collaborative Network.

BACKGROUND AND AIMS: GI bleeding after ERCP is a serious adverse event and most commonly occurs after endoscopic biliary and/or pancreatic sphincterotomy. Although the strength of available evidence for post-sphincterotomy GI bleeding risk is high for therapeutic warfarin and heparin, it remains unknown for antiplatelet agents like clopidogrel and prasugrel. We conducted a retrospective United States-based, propensity-matched cohort study to assess the risk of post-sphincterotomy bleeding in patients receiving anticoagulant (AC) and antiplatelet (APT) therapy. METHODS: We analyzed the U.S. Collaborative Network in the TriNetX platform through December 27, 2022, to include patients receiving APT and AC therapy who underwent ERCP within 7 days of hospitalization. One-to-one propensity score matching was performed. The primary outcome was the incidence of GI bleeding within 7 days of sphincterotomy. Secondary outcomes included need for blood transfusion, intensive care unit care, and all-cause mortality within 30 days of bleeding. RESULTS: Overall, 2806 patients (1806 in the AC cohort and 1000 in the APT cohort) underwent ERCP with sphincterotomy. One-to-one propensity score matching was performed for age, body mass index ≥30 kg/m2, gender, race, ethnicity, diabetes mellitus, nicotine dependence, presence and severity of chronic kidney disease, cirrhosis, and thrombocytopenia between the cohorts. Patients in both cohorts had an increased risk of post-sphincterotomy bleeding compared with matched control subjects (adjusted odds ratios of 3.6 [95% confidence interval, 2.58-5.06] and 2.2 [95% confidence interval, 1.43-3.56], respectively). Although heparin bridging therapy and concurrent use of aspirin did not further increase the risk of GI bleeding, resumption of AC within 24 hours' postprocedure did. Neither cohort of patients was at an increased risk for blood transfusion, intensive care unit care, or all-cause mortality. CONCLUSIONS: Our database analysis shows that patients receiving AC and APT therapy are at a higher risk of post-sphincterotomy bleeding compared with matched control subjects. An appropriate drug cessation period or alternative biliary decompression modalities may be used in these patients.

Comparison between Transpancreatic Sphincterotomy and Needle-Knife Precut in Difficult Cannulation of Endoscopic Retrograde Cholangiopancreatography: An Up-To-Date Meta-Analysis and Systematic Review.

BACKGROUND: Selective cannulation, which is essential for endoscopic retrograde cholangiopancreatography (ERCP), may be difficult. The aim of this study was to compare transpancreatic sphincterotomy (TPS) and needle-knife precut (NKP) in difficult cannulation during ERCP. METHODS: PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched for relevant studies from January 1990 to April 2022. A meta-analysis focusing on cannulation success and post-ERCP complications was performed using Review Manager. RESULTS: Seventeen eligible studies involving 2,340 patients were included. Our results showed that the TPS group had a higher cannulation success rate (odds ratio [OR] 0.48, 95% confidence interval [CI] 0.27-0.87, p = 0.02) and less bleeding (OR 1.94, 95% CI: 1.09-3.47, p = 0.03) compared with the NKP group. There was no significant difference between NKP and TPS in the rates of post-ERCP pancreatitis (OR 0.83, 95% CI: 0.59-1.18, p = 0.30), perforation (OR 2.04, 95% CI: 0.69-6.03, p = 0.20), and adverse events (OR 1.29, 95% CI: 0.94-1.77, p = 0.12). CONCLUSION: TPS appears to be associated with a higher cannulation success rate and less bleeding than those with NKP, with equal post-ERCP pancreatitis, perforation, and adverse event rates between TPS and NKP. Further large-scale trials are warranted to support our findings.

A simulation curriculum for laparoscopic common bile duct exploration, balloon sphincterotomy, and endobiliary stenting: Associations with resident performance and autonomy in the operating room.

BACKGROUND: Laparoscopic common bile duct exploration is safe and effective for managing choledocholithiasis, but laparoscopic common bile duct exploration is rarely performed, which threatens surgical trainee proficiency. This study tests the hypothesis that prior operative or simulation experience with laparoscopic common bile duct exploration is associated with greater resident operative performance and autonomy without adversely affecting patient outcomes. METHODS: This longitudinal cohort study included 33 consecutive patients undergoing laparoscopic common bile duct exploration in cases involving postgraduate years 3, 4, and 5 general surgery residents at a single institution during the implementation of a laparoscopic common bile duct exploration simulation curriculum. For each of the 33 cases, resident performance and autonomy were rated by residents and attendings, the resident's prior operative and simulation experience were recorded, and patient outcomes were ascertained from electronic health records for comparison among 3 cohorts: prior operative experience, prior simulation experience, and no prior experience. RESULTS: Operative approach was similar among cohorts. Overall morbidity was 6.1% and similar across cohorts. The operative performance scores were higher in prior experience cohorts according to both residents (3.0 [2.8-3.0] vs 2.0 [2.0-3.0]; P = .01) and attendings (3.0 [3.0-4.0]; P < .001). The autonomy scores were higher in prior experience cohorts according to both residents (2.0 [2.0-3.0] vs 2.0 [2.0-2.0]; P = .005) and attendings (2.5 [2.0-3.0] vs 2.0 [1.0-2.0]; P = .001). Prior simulation and prior operative experience had similar associations with performance and autonomy. CONCLUSION: Simulation experience with laparoscopic common bile duct exploration was associated with greater resident operative performance and autonomy, with effects that mimic prior operative experience. This illustrates the potential for simulation-based training to improve resident operative performance and autonomy for laparoscopic common bile duct exploration.

Design and execution of sham-controlled endoscopic trials in acute pancreatitis: Lessons learned from the SHARP trial.

Using the ongoing NIDDK-funded multicenter randomized clinical trial, Sphincterotomy for Acute Recurrent Pancreatitis (SHARP) as an example, this article discusses the rationale and key aspects of study design that need to be considered when conducting a clinical trial of endoscopic therapy in acute pancreatitis. SHARP, the first trial using a sham ERCP in the placebo group, is designed to address a decades long controversy in clinical pancreatology, i.e. whether minor papilla sphincterotomy benefits patients with idiopathic acute recurrent pancreatitis who also have pancreas divisum. Although the trial has already enrolled and randomized over 5 times the number of subjects enrolled in the only randomized trial in this area published in 1992 (107 vs. 19), recruitment has been challenging and we are at ∼46% of target recruitment. The review discusses the challenges in the execution of the trial and strategies the SHARP team has used to address these, which investigators planning or considering treatment trials in pancreatitis may find helpful. It will also inform the general gastroenterologists the importance of discussing and referring potentially eligible subjects to centers participating in clinical trials. Developing evidence-based treatment will provide a solid scientific basis for physicians to recommend evidence-based treatments for pancreatitis.

[Angiocholitis on hepatic hydatid cyst fistulised in the main bile duct: two case reports]. / Angiocholite sur kyste hydatique hépatique fistulisé dans la voie biliaire principale: à propos de 2 cas.

Hydatid cyst is a zoonosis that frequently affects the liver, which is endemic in several countries such as Morocco. The hepatic hydatidosis can be complicated by angiocholitis, currently, the treatment of choice is endoscopic retrograde cholangio-pancreatography with sphincterotomy. We report two clinical cases of angiocholitis on hepatic hydatid cyst fistulised in the main bile duct which were treated endoscopically with a favourable outcome. Early diagnosis and adequate management can improve the prognosis of these patients.

Development of upper gastrointestinal cancer in patients with symptomatic gallstones, cholecystectomy, and sphincterotomy: A nationwide cohort study.

BACKGROUND AND OBJECTIVE: Exposures of gallstones and treatments thereof in relation to development of cancer have not been explored before in long-term follow-up studies. Our objective was to determine whether symptomatic gallstones, cholecystectomy, or sphincterotomy were associated with development of upper gastrointestinal cancers. METHODS: This is a nationwide cohort study of persons born in Denmark 1930-1984 included from age 30 years with long-term follow-up (1977-2014). Exposures were hospital admissions with gallstones, cholecystectomy, and sphincterotomy. Time-varying covariates were included in analyses to allow the impact of exposures to change with time. Follow-up periods were 2-5 and > 5 years. Hazard ratios (HR) with 95% confidence intervals (CI) were reported. RESULTS: A total of 4,465,962 persons were followed. We found positive associations between sphincterotomy and biliary (>5 years HR 4.34, CI [2.17-8.70]), gallbladder (2-5 years HR 20.7, CI [8.55-50.1]), and pancreatic cancer (2-5 years HR 3.68, CI [2.09-6.49]). Cholecystectomy was positively associated with duodenal (2-5 years HR 2.94, CI [1.31-6.58]) and small bowel cancer (2-5 years HR 2.75, CI [1.56-4.87]). Inverse associations were seen for cholecystectomy and biliary (>5 years HR 0.60, CI [0.41-0.87]), pancreatic (>5 years HR 0.45 CI [0.35-0.57]), esophageal (>5 years HR 0.57, CI [0.43-0.74]), and gastric cancer (>5 years HR 0.68, CI [0.55-0.86]) and for gallstones and pancreatic cancer (>5 years HR 0.66, CI [0.47-0.93]). Gallstones were positively associated with gallbladder (>5 years HR 3.51, CI [2.02-6.10]) and small bowel cancer (2-5 years HR 3.21, CI [1.60-6.45]). CONCLUSIONS: A positive association between sphincterotomy and biliary cancer was identified. Cholecystectomy seems to be inversely associated with biliary, pancreatic, esophageal, and gastric cancer. Associations should be explored in similar large cohorts.

ERCP in patients with prior sphincterotomy has a 50% lower rate of post-ERCP pancreatitis and fewer unplanned hospital admissions.

OBJECTIVES: ERCP is essential in managing pancreaticobiliary disease, with well-documented complications. Rates of clinically significant complications are about 10%, approximately half of which is related to post-ERCP pancreatitis (PEP). We aimed to quantify the effect of previous sphincterotomy on post-endoiscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). MATERIALS AND METHODS: Data were collated from a contemporaneously collected database of 2876 consecutive ERCP procedures of a single operator in a tertiary referral centre. Analysis was conducted using R software, and logistic regression models. RESULTS: Of 2876 procedures (mean age 63 years, 56% female), 120 (4.2%) developed PEP and 268 (9.3%) had prolonged/unplanned hospital admission. Univariate analysis showed patients with previous sphincterotomy 28/1054 (2.7%) had decreased risk of PEP compared with those without sphincterotomy 92/1822 (5.0%) (OR 0.52, p = .0021). This difference was not evident when multivariate analysis for age, sex and indication was undertaken due to a particularly low risk of PEP in stent change patients (1.4%), which were disproportionately represented in the previous sphincterotomy group. The rate of prolonged/unplanned hospital admission was recorded for a total of 2876 patients, occurring in 184/1802 (10.1%) in the native ampulla group, versus 84/1045 (8.0%) in the previous sphincterotomy group. CONCLUSIONS: The risk of PEP is halved by prior sphincterotomy. The presence of a biliary stent conferred an even lower risk of PEP (1.4%), but those without an in situ stent at the time of ERCP had a similar risk of PEP (4.6%) of prolonged/unplanned hospitalisation to those with a native ampulla.