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Article
11.INTER SPHINCTERIC BOTULINUM TOXIN A INJECTION FOR THE MANAGEMENT OF CHRONIC ANAL FISSURE

Authors: Nashwan Q. Mahgoob نشوان محجوب --- Muhammed M. kamal محمد كامل
Journal: IRAQI JOURNAL OF MEDICAL SCIENCES المجلة العراقية للعلوم الطبية ISSN: P16816579,E22244719 Year: 2017 Volume: 15 Issue: 2 Pages: 181-187
Publisher: Al-Nahrain University جامعة النهرين

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Abstract

Background: Surgical sphincterotomy (SS) has been the most commonly used treatment for chronic anal fissure (CAF). Although effective, it is associated with gas and or fecal incontinence in (0-20%) inter-sphincteric Botulinum Toxin A (BTXA) injection is a non-surgical technique that may be used as an option under certain circumstances for treatment of such condition.Objective: To verify the effectiveness of the BTXA injection in relieving symptoms and healing of chronic anal fissures.Methods: Thirty patients with CAF were treated by BTXA 1 U/kg injected into the inter-sphincteric plane; as an outpatient procedure, patients were re-evaluated after 1 week, and then every 2 weeks until the fissure healed or surgery was required. The patients were followed up for one year by regular attachment through phone call or visit, to evaluate the effects of treatment. Results, complications and follow up were recorded.Results: In 25 patients (83%), the pain was disappeared after the first week; 20 patients (66%) presented with a complete healing of the fissure in a period ranging between 1 to 3 months. Gas incontinence was reported in 2 patients (6%) and solved spontaneously. No major complications were found, in 3 cases (10%) surgery was needed later on.Conclusion: Since it avoids the greater risk of incontinence associated with SS, and it can be done as outpatient procedure without admission or general anesthesia. We recommend the use of BTXA as the first therapeutic approach for patients with chronic anal fissure.Keywords: Botulinum Toxin A, anal fissure.Citation: Nashwan Q. Mahgoob, Muhammed M. kamal. Inter sphincteric botulinum toxin A injection for the management of chronic anal fissure. Iraqi JMS. 2017; Vol. 15(2): 181-187. doi: 10.22578/IJMS.15.2.11


Article
LATERAL INTERNAL SPHINCTEROTOMY FOR TREATMENT OF CHRONIC ANAL FISSURE IN PEDIATRICS
قص العضلة العاصرة الداخلية لعلاج الفطر الشرجي المزمن عند الأطفال

Authors: SAHNED S. JAAFAR سهند جعفر --- QADER M.SALIH قادر محمد صالح --- AZAD A. HALEEM ازاد عبدالجبار حليم
Journal: Duhok Medical Journal مجلة دهوك الطبية ISSN: ISSN: 20717334 (online)/ ISSN: 20717326 (Print) Year: 2018 Volume: 12 Issue: 1 Pages: 24-30
Publisher: University of Dohuk جامعة دهوك

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Abstract

Background: Lateral internal sphincterotomy is a well established surgical technique fortreatment of chronic anal fissure in the adult. The aim of this study was toevaluate theoutcome of lateral internal sphincterotomy in Pediatrics.Subject and Methods: This is a prospective study performed over a period of 4 years fromOctober 2008 to October 2012 on 37 patients with the chronic anal fissure of a durationexceeding three months and history of failure to conservative treatment. All patientsunderwent left lateral internal sphincterotomy through an open technique. The outcome wasevaluated by assessing the effectiveness of this procedure in relieving the symptoms, fissure.Results: There were 26 boys and 11 girls, mean age was 11 months with a range of (6months 12 years), and symptoms were relieved within two weeks in 28 cases and withinone month in 5 cases. 4 patients require postoperative oral laxative for 1-3 months toovercome the withholding behavior. Fissures healed in 34 by eight weeks postoperatively.Parents were satisfied with the outcome in 32 patients. Four patients developed postoperativebleeding, and only one of them was serious and required cauterization, soiling occurred in 3cases. No permanent incontinence was reported.Conclusions: Lateral internal sphincterotomy is an effective and safe surgical technique fortreatment of chronic anal fissure not responding to medical therapy in pediatric.Complications are uncommon, and the risk of incontinence is very minimal if the propersurgical technique is performed

الخلفية والأهداف قص العضلة العاصرة الداخلية الجانبي هي تقنية جراحية راسخة لعلاج الفطر الشرجي المزمن عند البالغين. اجرينا هذه الدراسة لتقيم نتائج هذه التقنية عند الأطفال.طرق البحث: هذه الدراسة الأستطلاعية اجريت على مدى 4 سنوات من أكتوبر 2008 الى أكتوبر 2012 و شملت الدراسة 37 مريضا يعانون من الفطر الشرجي المزمن لمدة تتجاوز الثلاثة اشهر مع عدم الأستجابة للعلاج التحفظي, خضع جميع المرضى لعملية القص الجانبي للعضلة العاصرة الداخلية بالتقنية المفتوحة ثم تم تقيم النتيجة من خلال تقييم فعالية هذه التقنية في تخفيف الأعراض, شفاء الفطر, رضا الوالدين و نسبة حدوث المضاعفات.النتائج: شملت الدراسة 26 صبيا و 11 فتاة مع متوسط عمر 11 شهر( 6 شهر-12 سنة), تم ملاجظة تخفيف الأعراض في غضون اسبوعين في 28 حالة وخلال شهر واحد في 5 حالات, في 4 حالات تم اعطاء الأدوية الملينة لمدة 1-3 شهر للتغلب على الأمساك. شفي الفطر في 34 حالة خلال 8 اسابيع من تاريخ العملية. كانت النتيجة مرضية جدا للوالدين في 32 حالة, في 4 حالات حدث نزف دموي ولكن في حالة واحدة تطلب الوضع اجراء كوي للنزف, حدث التهاب في 3حالات استجابت للمضادات الحيوية, لم تحدث اية حالة سلس غوطي.الاستنتاجات : القص الجانبي للعضلة الداخلية العاصرة هي تقنية جراحية فعالة و أمنة لعلاج الفطر الشرجي المزمن الذي لايستجيب للعلاج التحفظي عند الأطفال. المضاعفات هي غير شائعة و خطر سلس الغوط هي في الحد الأدنى اذا تم تنفيذ هذه التقنية بصورة صحيحة.


Article
EFFICACY OF BOTULINUM TOXIN TYPE A IN THE TREATMENT OF CHRONIC ANAL FISSURE

Author: Ibrahim Falih Noori
Journal: Basrah Journal of Surgery مجلة البصرة الجراحية ISSN: 16833589 / ONLINE 2409501X Year: 2015 Volume: 21 Issue: 1 Pages: 69-75
Publisher: Basrah University جامعة البصرة

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Abstract

Lateral partial internal sphicterotomy has been the goal standard for the treatment of chronic anal fissure. The main drawback of this approach remains its effect on the anal continence. Intrasphincteric of botulinum toxin seems to be a reliable and safe option resulting in temporary paralysis of the internal sphincter spasm and so promoting the chronic fissure to heal. The aim of this prospective control randomized study was to compare the effectiveness and the outcome of botulinum toxin injection with the lateral internal sphicterotomy in the treatment of the chronic anal fissure. Ninety male patients who have been presented with chronic uncomplicated anal fissure, were randomized to either lateral internal sphincterotomy or intrasphincteric injection of botulnium toxin. Postoperative complications and pain, healing rate of the fissure, anal incontinence and recurrence of the fissure after treatment during six months follow up period were studied and assessed. The healing rate was 95.5% in the surgical group with recurrence noted in only one patient and one patient had a partial permanent incontinence while in the botulnium toxin group the healing rate was 84.4%. Two patients had transient incontinence which improved spontaneously over six months period. Five patients had recurrence within the same follow period. Lateral internal sphicterotomy and botulinum toxin injection both seems to be effective treatment of the chronic anal fissure. Although surgical approach is still the most common and gold standard treatment for the chronic anal fissure, It shows a higher incidence of incontinence and greater morbidity and pain than botulinum toxin injection. We conclude that the use of botulinum toxin to treat chronic anal fissure is safe, simple and effective approach especially in patients older than 50 years or those with risk of anal incontinence despite the higher rate of recurrence which can be minimized by the second session of botulinum toxin injection.


Article
Anal Fissure Treatment by Medication and Surgery

Author: Ali Abdulhaleem Kadhim
Journal: Medical Journal of Babylon مجلة بابل الطبية ISSN: 1812156X 23126760 Year: 2016 Volume: 13 Issue: 2 Pages: 323 -329
Publisher: Babylon University جامعة بابل

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Abstract

Anal fissure is a most common cause of anal pain [1].This prospective study includes 236 patients complaining of anal fissure treated from a period of September 2013 to December 2015 to assess options of management of anal fissure. Male patients were 121 (51%) and female were 115 (49%). All patients were clinically assessed in an outpatient clinic and conservative treatment started to all patients that shown to be effective in 141 patient (60%). Surgical treatment applied to 95 patients (40%)whom not responded to conservative treatment, or, patients with recurrent fissure. Lateral sphenectrotomy was the surgical procedure applied in open or close method (62 and 33 patients respectively), under local or general anesthesia (54 and 41 respectively). Local anesthesia was associated with a significant low duration of admission from 1 to 24 hours (mean of 3 hours) while general anesthesia with a significant higher duration of 12 to 36 hours (mean of 19 hours). The healing rate following surgery in a local or general anesthetic approach was 95%. No difference in a healing rate between open or closed technique of sphenectrotomy. Flatus incontinence was reported in 3 patients. Initial treatment of anal fissure should be conservative, lateral sphenectrotomy is a safe procedure with a high cure rate, low incidence of complications and could be performed under local or general anesthesia.


Article
Establishing the Superiority of Topical Diltiazem Over Compound Cream in the Treatment of Chronic Anal Fissure: A Prospective Analytical Study

Author: Ahmed Nasser Hussein, Maytham Hatam Shahid, Abd Alkhaliq S Abdullah
Journal: Iraqi Academic Scientific Journal المجلة العراقية للاختصاصات الطبية ISSN: 16088360 Year: 2017 Volume: 16 Issue: 4 Pages: 434-437
Publisher: The Iraqi Borad for Medical Specialization المجلس العراقي للاختصاصات الطبية

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Abstract

ABSTRACT:BACKGROUND:Anal fissure is an elliptical ulcer in the anal canal extending from the dentate line to the anal verge; chronic anal fissure is a common problem across the world treated largely by surgical methods. The treatment for chronic anal fissure (CAF) has undergone a transformation in recent years from surgical to medical as the common goal is reducing the internal anal sphincter spasm.OBJECTIVE:To assess the efficacy of topical treatment with 2% diltiazem gel (DTZ) in patient with chronic anal fissure versus combination cream.MATERIAL AND METHODS:Consecutive 400 adult male patients with symptomatic chronic anal fissure attending the surgery clinic were enrolled in the study form February 2014- July 2016, 200 patients were treated with topical application of 2% DTZ cream, other 200 patients were treated with combination cream. Patients were followed up for 6 month at regular intervals for symptomatic relief and healing of fissure.RESULT &CONCLUSION:In our study diltiazem 2% gel was more effective than combination cream in the treatment of chronic anal fissure..


Article
Topical Combination of Nifedipine with Lidocaine is a Promising Medical Treatment for Anal Fissure
استخدام النفدبين و الليدوكائين كعلاج واعد للفطر الشرجي

Authors: Nahedh R Alammar ناهظ العمار --- Adel Musa Al-Rekabi عادل موسى الركابي --- Rasha Kadim Albayati رشا كاظم البياتي
Journal: Diyala Journal of Medicine مجلة ديالى الطبية ISSN: 97642219 Year: 2018 Volume: 15 Issue: 2 Pages: 98-103
Publisher: Diyala University جامعة ديالى

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Abstract

Background: A fissure consist of crack or tear in the vertical axis of the anal canal between the anal verge and the dentate line. Anal fissure is the most common cause of sever anal pain and bleeding. Anal fissure is an elongated ulcer in the anoderm below the dentate line, and is commonly located posteriorly due to more adherence of the anoderm to the underlying tissue in the posterior midline, so the blood supply is significantly low as shown by the Doppler flowmetry study. Anal fissure is treated by two ways either medical or surgical treatment or both.Objective:To evaluate the healing response of the anal fissure to topical application of nifedipine with lidocaine. Patients and Methods: A randomized prospective study of one hundred patients who presented with anal fissure to outpatient surgical clinic in Al-Diwaniyah teaching hospital. The patients were divided into two groups. The first group involve 40 patients (15 males and 25 females) with acute anal fissure; the second group 60 patients (25 males and 35 females) with chronic anal fissure. Both groups were treated with the topical application of nifedipine and lidocaine 3 times daily for 6 weeks, and more prolonged therapy (up to 8 weeks) was applied for resistant cases. Results: Both groups registered good response to topical therapy; the healing response was 85%. The healing response of those with acute anal fissure was better and faster than patients with chronic anal fissure.Conclusion: Anal fissure can be simply and effectively treated medically without the risk of incontinence associated with lateral internal sphincterotomy.

خلفية الدراسة: الفطر الشرجي هو من اكثر الأسباب المسببة للأم والنزف الشرجي وعادة يكون مكانه في الجزء الخلفي لفتحة الشرج حيث يكون تدفق الدم اقل من الأماكن الأخرى للشرج. السبب الرئيسي للفطر الشرجي هو الأمساك المزمن.اهداف الدراسة: هدفت هذه الدراسة لتقييم الاستجابة للعلاج الموضعي للفطر الشرجي بأستعمال مرهم النيفدبين مع مرهم الليدوكائين.المرضى والطرائق: دراسة مستقبلية تم فيها اخذ 40 مريض يعانون من فطر شرجي حاد و 60 مريض يعانون من فطر شرجي مزمن (المجموع مائة مريض) تم استقبالهم في العيادة الاستشارية الخارجية لمستشفى الديوانية التعليمي ولمدة سنة ابتداءاً من شهر كانون الثاني 2017 الى شهر كانون الثاني 2018 .كلا المجموعتين عولجوا باستعمال مرهم نفدبين مع مرهم ليدوكائين ثلاثة مرات يوميا لمدة 6 اسابيع واسبوعين اضافيين للحالات غير المستجيبة للعلاج.النتائج: كانت الاستجابة للعلاج 85% بعد ثمانية اسابيع من العلاج وكانت الاستجابة في حالة الفطر الشرجي الحاد اسرع واحسن.الاستنتاجات : اظهرت النتائج استجابة جيدة للعلاج الموضعي يأستخدام مرهم النيفيديبين ومرهم الليديوكائين وهذا بالتالي يجنب تحول الفطر الحاد الى فطر مزمن وهذا الأخير يكون أضعف أستجابة للعلاج الموضعي.


Article
Anal Fissure: Is it becoming a medical disorder?

Author: Ali Al-shaham, CABS*. Kadhim Jawad, CABS**, Serene A.A, MS***
Journal: Al-Kindy College Medical Journal مجلة كلية الطب الكندي ISSN: 18109543 Year: 2014 Volume: 10 Issue: 2 Pages: 1-4
Publisher: Baghdad University جامعة بغداد

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Abstract

An anal fissure which does not heal with conservative measures as sits baths and laxatives is a chronic anal fissure. Physiologically, it is the high resting tone of the internal anal sphincter that chiefly interferes with the healing process of these fissures. Until now, the gold standard treatment modality is surgery, either digital anal dilatation or lateral sphincterotomy. However, concerns have been raised about the incidence of faecal incontinence after surgery. Therefore, pharmacological means to treat chronic anal fissures have been explored.A Medline and pub med database search from 1986-2012 was conducted to perform a literature search for articles relating to the non-surgical treatment of chronic anal fissure.Pharmacological sphincterotomy using Glyceryl trinitrate , Isosorbide dinitrate or calcium channel blockers are exciting alternative treatment , that relaxes the anal sphincter and, therefore, promote healing, the drawback of such medications are headache and poor compliance. With the introduction of Botulinum toxin as mean of chemical sphincterotom, topical injection of Botulinum toxin reduces the anal hypertonia which lasts for few months, allows the fissure to heal, thus eliminating the need for surgery without incidence of incontinence. Cure rates are over 60%, and the procedure can be repeated safely. Therefore, Botulinum toxin is a reasonable first-line management of chronic anal fissure and the relapses can be managed by surgeryKeywords: Non-surgical treatment of anal fissure, fissure in ano, sphicterotomy,botulinum toxin in anal fissures, glyceryl trinitrate. Chemical sphincteratomy, pharmacological sphincteratomy.


Article
Cutting Whole Length or Partial Length of Internal Anal Sphincter in Management of Fissure in Ano

Author: Furat Shani Aoda,
Journal: Journal of University of Babylon مجلة جامعة بابل ISSN: 19920652 23128135 Year: 2018 Volume: 26 Issue: 1 Pages: 238-246
Publisher: Babylon University جامعة بابل

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Abstract

A chronic anal fissure is a common painful perianal condition. The main operative procedure to treat this painful condition is a lateral internal sphincteretomy (LIS).The aim of study is to compare the outcome and complications of closed LIS up to the dentate line (whole length of internal sphincter) or up to the fissure apex (partial length of internal sphincter) in the treatment of anal fissure. It is a prospective comparative study including 100 patients with chronic fissure in ano. All patients assigned to undergo closed LIS. Those patients were randomly divided into two groups: 50 patients underwent LIS to the level of dentate line (whole length) and other 50 patients underwent LIS to the level of fissure apex (partial length). Patients were followed up weekly in the 1st month, twice monthly in the second month then monthly for next 2 months and finally after 1 year. There was satisfactory relief of pain in all patients in both groups & complete healing of the fissure occurred. Regarding post operative incontinence no major degree of incontinence occur in both group but minor degree of incontinence persists In 7 patients after whole length LIS after one year. In conclusion, both whole length & partial length LIS associated with improvement of pain, good chance of healing but whole length LIS associated with more chance of long term flatus incontinence. Hence, we recommend partial length LIS as treatment for chronic anal fissure.

الفطر الشرجي المزمن هو حالة شائعه مؤلمة في المنطقه حول الشرج. والاجراء الجراحي الرئيسي لعلاج هذه الحالة المؤلمة هو استئصال جانبي للمصرة الداخلية .الهدف من هذه الدراسة هو مقارنة النتيجة ومضاعفات قص المصرة الداخلية الجانبية بالطريقه المسدوده الى الخط المسنن (كل طول المصرة الداخلية) او الى قمة الفطر (جزء من طول المصرة الداخلية) كعلاج للفطر الشرجي. هذه الدراسة قائمة على المنهج المقارناجريت في مستشفى البصرة العام للفتره من الشر العاشر 2008 حتى الشهر العاشر 2013 حيث تضمنت 100 حالة مرضية تعاني من الفطرالشرجي المزمن. جميع المرضى وافقوا على استئصال المصرة الداخلية بالطريفه المسدوده ,ثم تم تقسيم المرضى بالطريقة العشوائية الى مجموعتين .50 مريضا خضع الى استئصال المصرة الداخلية الى الخط المسنن( طوله كله)و 50 مريضا خضعوا الى عملية الاستئصال الى مستوى قمة الفطر(جزء من الطولة). تم متابعة المرضى أسبوعيا خلال الشهر الأول. ومرتين في الشهر الثاني وبعد ذلك شهريا في الشهرين التاليين ومرة اخيرة بعد سنة كاملة. حيث كان هناك ارتياح جيد من الألم لدى كل المرضى وشفاء كامل للشق لدى المجموعتان. فيما يخص السلس بعد العملية لا وجود للسلس بدرجة كبيرة (عدم السيطره على الخروج)لدى المجموعتان لكن ظهر سلس من الدرجه البسيطه (عدم السيطره على خروج الهواء) لدى 7 حالات فقط للذين خضعوا للاستئصال الكامل للمصرة بعد سنة كاملة. نستنتج ان كلتا الاستئصالان الكامل و الجزئي للمصرة الداخلية أدى الى تحسن حالة المريض والتخلص من الألم لكن الاستئصال الكامل كان مصحوب لفترة طويلة للدرجه البسيطه من السلس. ولذلك ننصح بالاستئصال الجزئي للمصرة الداخلية الجانبية كعلاج للفطر الشرجي المزمن.

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