SAN FRANCISCO — A stepwise algorithm favoring medical alternatives can spare many patients from surgery for chronic anal fissure, Dr. Andreas M. Kaiser and his associates reported in a poster at the annual clinical congress of the American College of Surgeons.
The study, conducted at the University of Southern California, Los Angeles, looked at patients who had experienced chronic anal fissure for a median duration of 16 weeks.
The patients voluntarily agreed to participate in a sequenced protocol involving anywhere from one to three treatment strategies. The prospective cohort of 72 patients included 30 males and 42 females.
Criteria that were used to exclude potential participants included cardiac disease, use of a prescription muscle relaxant for another diagnosis, pregnancy, HIV ulcers, inflammatory bowel disease, current chemotherapy, and a history of receiving pelvic radiation therapy.
The treatment protocol called for initial therapy with topical nitroglycerin in a concentration of 0.2%. If that approach failed, two injections of 20 U of botulinum toxin type A (Botox) were administered.
The last resort treatment in the study protocol was surgical: lateral internal sphincterotomy. Two-week intervals were built into the algorithm to allow time for each successive therapy to work.
Five eligible patients refused to follow the treatment protocol. Three of these five desired immediate therapy with Botox, and two requested immediate surgery.
Among the 67 patients who agreed to follow the algorithm, 31 had healing of their chronic anal fissures with nitroglycerin alone. Two developed recurrent fissures, and Botox successfully resolved both cases.
Of 36 patients who failed initial nitroglycerin therapy, 3 required surgery as the next step. The other 33 went on to receive Botox per the algorithm; 5 of them failed to heal with Botox and went on to surgery.
The overall surgery rate was 13.9% (10 of 72 patients). Among patients who agreed to be treated according to the algorithm, just 11% (8 of 67) required surgery.
Lateral internal sphincterotomy, while effective in treating chronic anal fissure, is irreversible and has been associated with a 5%–10% rate of incontinence of stool or gas, Dr. Kaiser noted in an interview after the meeting.
The algorithm “is a very practical approach,” he said. “Our approach was to observe what happens if we try to maximize the conservative approach. How often can we get to a successful result, starting with the cheapest, most simple treatment and working from there?” said Dr. Kaiser, a faculty member in the colorectal surgery department.
“We already knew beforehand it [the simplest approach] was not going to be 100% effective in all patients,” he said, adding that most patients are willing to try something else first before resorting to surgery.
“Based on our prospective data, we suggest that the treatment algorithm for chronic anal fissure with stepwise escalation is an effective tool in achieving fissure healing and avoiding irreversible surgical sphincterotomy in [almost] 85% of the patients,” Dr. Kaiser and his associates concluded.
Medical therapy “should be considered the first-line treatment and surgery be reserved for refractory cases,” they said.