Fisura anal, opciones terapéuticas actuales: [revisión] / Anal fissure, actually treatment options: [review]

La fisura anal es una patología frecuente y probablemente la causante de la mayor parte de las proctalgias agudas severas. Esta revisión tiene por objetivo, evaluar los procedimientos actualmente utilizados para el tratamiento de esta enfermedad. En principio se describen algunos aspectos ligados a la etiopatogenia y a la evolución natural con la intención de comprender la utilización de las distintas modalidades terapéuticas. Posteriormente se analizan las características de cada método en particular, como así también sus beneficios, efectos adversos y resultados. Al final del trabajo, se expone el algoritmo de tratamiento seguido por los autores.

The anal fissure is a frequent pathology and probably the cause of most of the severe acute proctalgias. This revision has by objective, to evaluate the procedures at the moment used for the treatment of this disease. In principle some aspects related to etiopatogenia are described and to the natural evolution, with the intention to understand the use of different therapeutic modalities. Later the characteristics of each method in individual are analyzed, like thus also their benefits, adverse effects and results. At the end of the work, the algorithm of treatment followed by the authors is exposed.

Current techniques in imaging of fistula in ano: three-dimensional endoanal ultrasound and magnetic resonance imaging.

Perianal fistula is an abnormal communication between the anal canal and perianal skin. The majority of perianal fistulous disease results from either cryptoglandular inflammation or Crohn's disease. These groups differ in pathophysiology, prognosis, and strategies for imaging and treatment. Endoanal ultrasound and magnetic resonance imaging represent current imaging strategies for evaluating perianal fistulas and may be used alone or in combination. The use of three-dimensional technique and peroxide fistulography optimize the ultrasound evaluation of perianal fistula. The use of multiple imaging planes and sequences including fat suppression and contrast enhancement optimize the magnetic resonance imaging protocol. Examples of the imaging appearance of perianal fistulas and a proposed flowchart for imaging modality selection are provided.

Tratamiento de la fisura anal / Treatment of the anal fissure

La fisura anal es una lesión que aparece en la porción epidérmica del canal anal, con sintomatología muy florida de dolor y sangrado defecatorio. Existen dos formas típicas, la primaria o idiopática, relacionada con la isquemia relativa del anodermo debida al incremento del tono basal esfintérico interno, y la secundaria a patologías infecciosas o del tubo digestivo. Objetivo y diseño: En los últimos años surgió el concepto de esfinterotomía química. El motivo de este trabajo es la comparación entre estas técnicas incruentas y la esfinterotomía quirúrgica, evaluando en forma prospectiva randomizada los pacientes tratados con diltiazem al 2 por ciento en vaselina sólida, trinitrato de glicerilo aplicados tópicamente y la esfinterotomía lateral interna.Material y Métodos: Durante el período comprendido entre el 31 de diciembre de 2002 y el 31 de diciembre de 2004 se trataron 174 pacientes; 56 con diltiazem al 2 por ciento, 60 con trinitrato de glicerilo y 58 por medio de esfinterotomía lateral interna 10 abierta y 48 cerrada, (Nottaras). La ubicación de la fisura fue en el 76.8 por ciento o 134 pacientes en hora VI, y en el 23.2 por ciento o 40 en hora XII. La distribución según sexo fue 96 (55.3 por ciento) varones y 78 ( 44.7 por ciento) mujeres. Resultados: Luego de una media de seguimiento de 87 días (7 a 330 días), en el grupo tratado con diltiazem, 33 pacientes presentaron la desaparición de los síntomas en la primer semana, con una curación y epitelización, sin recidiva, en 38 pacientes a las 6 semanas. 7 pacientes evolucionaron mal y necesitaron cirugía, y 9 no se presentaron al control y seguimiento.En el grupo tratado con trinitrato de glicerilo, 36 pacientes tuvieron una buena evolución, 5 necesitaron cirugía, 10 no volvieron a control y 9 suspendieron el tratamiento por reacciones adversas. El grupo de 58 pacientes tratado quirúrgicamente evolucionó favorablemente excepto 2 de ellos que necesitaron una anoplastía con deslizamiento de colgajo. Conclu...

Assessment of anal fistulas with high-resolution subtraction MR-fistulography: comparison with surgical findings.

PURPOSE: To investigate a new MR-imaging protocol defined as subtraction MR-fistulography for the detection of fistula-in-ano. MATERIALS AND METHODS: A total of 36 patients (18 men, 18 women) with the clinical diagnosis of anal fistula or abscess who were scheduled for surgical exploration were preoperatively imaged at 1.5 T in the supine position; coronal STIR sequences and axial T1-weighted three-dimensional FLASH sequences before and after intravenous injection of gadobenate dimeglumine (Gd-BOPTA) were obtained. Image subtraction was routinely used. The image findings were compared with the findings at surgical exploration according to a uniform classification system. RESULTS: A total of 46 fistulas were seen on subtraction MR-fistulography, whereas surgery described 41 fistulas. MRI and surgery concordantly depicted a total number of 40 fistulas, six fistulas were only described by MRI, and one fistula was only seen during surgery. A total of 27 abscesses were detected with MRI, compared to 22 during surgery. A total of 22 abscesses were concordantly diagnosed. Complete agreement between subtraction MR-fistulography and surgery occurred in 32 (89%) of the 36 patients. The four patients in whom both procedures disagreed had complex anal sepsis with multiple fistulas and/or abscesses due to Crohn disease. CONCLUSION: High-resolution subtraction MR-fistulography is an important complement to surgical exploration and especially suitable for investigating complex anal sepsis.

Current treatment options for fissure-in-ano.

BACKGROUND: Fissure-in-ano is a painful condition that affects a sizable majority of the population. Selecting a method of treating the condition that could achieve optimal clinical results and the least pain and inconvenience to the patient has always posed a challenge to the surgeons. This led to the innovation of a number of surgical and pharmacological methods that relax the anal muscle. While acute fissures could be managed with medical therapy alone, chronic fissures do need some form of manipulation to relieve internal sphincter spasm. MATERIALS AND METHODS: The present study discusses various techniques advocated for the treatment of acute and chronic fissure-in-ano. It also elaborates on the advantages and deficiencies of each. DISCUSSION: Despite the initial success with pharmacological agents in the treatment of patients with chronic anal fissures, a growing concern is developing about their use. Increasing incidence of adverse effects and decreasing long-term efficacy have been the major drawbacks. CONCLUSION: Surgery still remains the preferred option which should be offered to patients with relapse or therapeutic failure with prior pharmacological treatment. Nevertheless, the patient should be informed about the pros and cons of each mode of treatment with details of cure rates and possible complications.

Different anal pressure profiles in patients with anal fissure.

BACKGROUND: A consistent debate exists about the association between anal fissure and hypertonic anal canal. The aim of this study was to determine if the manometric findings in patients with chronic anal fissures varied according to the topography of the fissure. PATIENTS AND METHODS: Seventy-three outpatients (52 men, 71%) with chronic anal fissures and nine healthy volunteers (5 men, 55%) were examined. Patients were classified according to the topography of the anal fissures: posterior midline (group A), anterior midline (group B), and lateral position (group C). We use computerized anorectal manometry to evaluate anal resting pressure, maximal voluntary contraction, recto-anal inhibitory reflex, rectal sensations and rectum compliance. RESULTS: In Group A, the mean pressure was higher than that of controls (p<0.05), and the resting pressure 2 cm from anal verge was higher than that of other groups and controls (p<0.05). Normotonic anal canal was found in 49.1% of patients in group A, in 66% of those in group B and in 57.1% of those in group C. Four elderly patients (7%) of group A had a hypotonic anal canal. No differences were found regarding maximal voluntary contraction, recto-anal inhibitory reflex, rectal sensations and rectum compliance between patients and controls. CONCLUSIONS: Patients with chronic anal fissures may have several anal pressure profiles. The anal canal is often normotonic. Fissures with hypertonic or normo-hypotonic anal canal need different therapies.

[Etiology, pathogenesis and classification of anal fissure]. / Atiologie, Pathogenese und Klassifikation der Analfissur.

Anal fissure is one of the most common causes of anal pain but its etiology and pathophysiology remain obscure. Many theories have been advanced to explain the origin of anal fissures but trauma of faecal mass and hypertonicity of the internal sphincter seem to be the most important factors. The initial lesion in anal fissure is a tear in the anoderm mostly in its posterior midline caused by overstretching of the anal canal. Secondary fissures may occur on a commonly lateral position as a result of inflammatory bowel disease, previous anal surgery, venereal, dermatologic, infectious or neoplastic disease. As the fissure becomes deeper and more chronic the sclerotic fibres of the internal anal sphincter are seen as well as a sentinel pile and a hypertrophied anal papilla. The disease enters in a vicious circle of anal pain, constipation, faecal trauma and sphincter spasm.