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Concept: Anal fissure


Honey is a bee-derived, supersaturated solution composed mainly of fructose and glucose, and containing proteins and amino acids, vitamins, enzymes, minerals, and other minor components. Historical records of honey skin uses date back to the earliest civilizations, showing that honey has been frequently used as a binder or vehicle, but also for its therapeutic virtues. Antimicrobial properties are pivotal in dermatological applications, owing to enzymatic H2 O2 release or the presence of active components, like methylglyoxal in manuka, while medical-grade honey is also available. Honey is particularly suitable as a dressing for wounds and burns and has also been included in treatments against pityriasis, tinea, seborrhea, dandruff, diaper dermatitis, psoriasis, hemorrhoids, and anal fissure. In cosmetic formulations, it exerts emollient, humectant, soothing, and hair conditioning effects, keeps the skin juvenile and retards wrinkle formation, regulates pH and prevents pathogen infections. Honey-based cosmetic products include lip ointments, cleansing milks, hydrating creams, after sun, tonic lotions, shampoos, and conditioners. The used amounts range between 1 and 10%, but concentrations up to 70% can be reached by mixing with oils, gel, and emulsifiers, or polymer entrapment. Intermediate-moisture, dried, and chemically modified honeys are also used. Mechanisms of action on skin cells are deeply conditioned by the botanical sources and include antioxidant activity, the induction of cytokines and matrix metalloproteinase expression, as well as epithelial-mesenchymal transition in wounded epidermis. Future achievements, throwing light on honey chemistry and pharmacological traits, will open the way to new therapeutic approaches and add considerable market value to the product.

Concepts: Protein, Medicine, Enzyme, Glucose, Skin, Fructose, Sucrose, Anal fissure


Idiopathic chronic anal fissure is believed to be a consequence of a traumatic acute anodermal tear followed by recurrent inflammation and poor healing due to relative tissue ischaemia secondary to internal sphincter spasm. This pilot trial compared the efficacy of a novel manufactured ano-coccygeal support attached to a standard toilet seat (Colorec) to the standard procedure of lateral internal sphincterotomy (LIS) for chronic anal fissure.

Concepts: Medical terms, Fecal incontinence, Anal fissure, Lateral internal sphincterotomy


AIM: An evaluation was performed of the one-year outcome of open haemorrhoidectomy (Milligan-Morgan alone or with posterior mucosal anoplasty [Leopold Bellan procedure]). METHOD: A prospective, multicentre, observational study included all patients having a planned haemorrhoidectomy from January 2007 of June 2008. Data were collected before surgery, at three months and one year after surgery. Patients assessed their anal symptoms and quality of life (SF-36). RESULTS: 633 patients (median age 48 years, 56.5% female) underwent haemorrhoidectomy including Milligan-Morgan alone (n=231, 36.5%) or the Leopold Bellan procedure (posterior mucosal anoplasty) for resection of a fourth haemorrhoid (n=345, 54.5%), anal fissure (n=56, 8.9%) or low anal fistula (n=1, 0.16%). Median healing time was 6 weeks. Early complications included urinary retention (n=3), bleeding (n=11), local infection (n=7) and faecal impaction (n=9). At one year, main complications included skin tags (n=2) and anal stenosis (n=23). There were three recurrences requiring a second haemorrhoidectomy. On a visual analogue scale, anal pain at one year had fallen from a median of 5.5/10 before treatment to 0.1/10 (p<0.001), anal discomfort from 5.5/10 to 0.1/10 (p<0.001) and the KESS constipation score from 9/45 to 6/45 (p<0.001). The median Wexner score for anal incontinence was unchanged (2/20). De novo anal incontinence (Wexner >5) affected 8.5% of patients at one year, but preoperative incontinence disappeared in 16.7% of patients with this symptom. All physical and mental domains of quality of life significantly improved and 88% of patients were satisfied or very satisfied. CONCLUSION: Complications of open haemorrhoidectomy were infrequent. Anal continence was not altered. Comfort and well-being were significantly improved at one year after surgery. Patient satisfaction was high despite residual anal symptoms. © 2012 The Authors. Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland.

Concepts: Surgery, Gastroenterology, Dietary fiber, Fecal incontinence, Hemorrhoid, Anal fissure, Lateral internal sphincterotomy, Proctology


BACKGROUND: In 1988, Longo proposed a new treatment for haemorrhoidal disease. In western countries day surgery procedures are becoming more and more common. We propose a new protocol for outpatient haemorrhoidopexy. PATIENTS AND METHODS: From 2003 to 2010, we performed 403 out-patient stapled haemorrhoidopexies under spinal anaesthesia, on patients with symptomatic grade III and IV haemorrhoid disease. We used PPH 01 and PPH 03 staplers (Ethicon Endosurgery, Cincinnati, OH, USA). We assessed early and late postoperative pain with a Visual Analogue Scale (VAS), and clinical postoperative examinations were performed 7 days, 6 months, and 1, 3 and 5 years after surgery. RESULTS: The mean surgery time was about 20 min (range 13-39 min). Out of 403 patients, 41 were not dischargeable as a result of urine retention, severe pain or mild bleeding. Twenty-two patients reported transient faecal urgency, while no patient complained of anal incontinence. CONCLUSIONS: Our experience with 403 patients demonstrated that stapled haemorrhoidopexy is feasible and safe as a day surgery procedure. However, careful preoperative planning is necessary in order to evaluate the patients' health status and the consequent perioperative and postoperative risk. Our results are positive in terms of surgical safety and postoperative recovery time.

Concepts: Patient, Hospital, Surgery, Physician, Doctor-patient relationship, Anesthesia, Hemorrhoid, Anal fissure


Abstract Background: Pruritus ani (PA) is defined as intense chronic itching affecting perianal skin. Objective: We aimed to determine the efficacy of topical tacrolimus treatment in atopic dermatitis (AD) patients who have PA. Methods: The study included 32 patients with AD who were suffering PA. Patients were randomized into two groups. In total, 16 patients used 0.03% tacrolimus ointment and 16 patients used Vaseline® as placebo. All groups applied topical treatments to their perianal area twice daily for 4 weeks. The treatments were then reversed for 4 weeks after a 2 weeks wash out period. Results: In total, 32 patients with AD who had refractory anal itching were enrolled in the present study. None of the patients had obtained successful results with previous treatments. There was a statistically significant decrease in the recorded EASI, DLQI and itching scores for the tacrolimus group compared to the placebo groupat weeks 4 and 6 of treatment (p < 0.05). Conclusion: Topical tacrolimus treatment was well tolerated and effective in controlling persistent PA in AD patients.

Concepts: Allergy, Symptoms, Tacrolimus, Hemorrhoid, Itch, Anal fissure, Atopic dermatitis, Pruritus ani


INTRODUCTION: Anal fissures can be resistant to treatment and some patients may undergo several trials of medical therapy before definitive surgery.. It would be useful to identify predictors of poor response to medical therapy.. This study assesses the role of anorectal physiological criteria to identify patients with anal fissure predicted to fail Botulinum toxin (BT) treatment METHOD: A retrospective analysis of anorectal physiological data collected for patients with resistant chronic anal fissures referred to one consultant surgeon between 2007-2011 was undertaken. These were correlated with treatment plans and healing rates. RESULTS: Twenty-five patients with idiopathic chronic anal fissures underwent anorectal physiology studies and were subsequently treated with BT injection. Eleven had a characteristic high-frequency low-amplitude ‘saw tooth’ waveform or Anal Sphincter Fibrillation (ASF) and higher anal sphincter pressures. Nine of these patients (82%) had resolution of their anal fissure symptoms following treatment with BT. Of 14 patients with no evidence of ASF and a greater range of anal sphincter pressures, only 1 (7%) had resolution following BT.. CONCLUSION: ASF appears to be an anorectal physiological criterion that helps predict response of anal fissures to BT injection. This could help streamline fissure management. © 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland.

Concepts: Medicine, Prediction, Anatomy, Dietary fiber, United Kingdom of Great Britain and Ireland, Botulinum toxin, Anal fissure, Proctology


Chronic anal fissures (CAF) are frequently encountered in coloproctology clinics. Chemical sphincterotomy with pharmacological agents is recommended as first-line therapy. Topical nitrates (TN) heal CAF effectively but recurrences are common. An alternative treatment modality is injection of botulinum toxin (BT) into the anal sphincter. We aimed to perform an updated systematic review and meta-analysis to compare the effectiveness of BT and TN in the management of CAF.

Concepts: Medicine, Randomized controlled trial, Botulinum toxin, Microbial toxins, Hemorrhoid, Anal fissure, Lateral internal sphincterotomy, Proctology


The ideal management for fistula-in-ano would resolve the disease while preserving anal continence.

Concepts: Hemorrhoid, Anal fissure


Anal incontinence is a devastating condition that significantly reduces the quality of life. Our aim was to evaluate the effect of human adipose stem cell (hASC) injections in a rat model for anal sphincter injury, which is the main cause of anal incontinence in humans. Furthermore, we tested if the efficacy of hASCs could be improved by combining them with polyacrylamide hydrogel carrier, Bulkamid®. Human ASCs derived from a female donor were culture expanded in DMEM/F12 supplemented with human platelet lysate. Female virgin Sprague-Dawley rats were randomized into four groups (n = 14-15/group): hASCs in saline or Bulkamid® (3 × 105 /60 μl) and saline or Bulkamid® without cells. Anorectal manometry (ARM) was performed before anal sphincter injury, at two (n=58) and at four weeks after (n = 33). Additionally, the anal sphincter tissue was examined by micro-computed tomography (μCT) and the histological parameters were compared between the groups. The median resting and peak pressure during spontaneous contraction measured by ARM were significantly higher in hASC treatment groups compared with the control groups without hASCs. There was no statistical difference in functional results between the hASC-carrier groups (saline vs. Bulkamid®). No difference was detected in the sphincter muscle continuation between the groups in the histology and μCT analysis. More inflammation was discovered in the group receiving saline with hASC. The hASC injection therapy with both saline and Bulkamid® is a promising nonsurgical treatment for acute anal sphincter injury. Traditional histology combined with the 3D μCT image data lends greater confidence in assessing muscle healing and continuity. Stem Cells Translational Medicine 2018.

Concepts: Cell, Human, Cell division, Stem cell, Cell biology, Sphincter, Anal fissure, Anus


Women with an obstetric anal sphincter injury are concerned about the risk of recurrent obstetric anal sphincter injury in their second pregnancy. Existing studies have failed to clarify whether recurrence of obstetric anal sphincter injury affects the risk of anal- and fecal incontinence at long term follow up.

Concepts: Childbirth, Surgery, Fecal incontinence, Defecation, Hemorrhoid, Anal fissure, Lateral internal sphincterotomy, Anus