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Concept: Lateral internal sphincterotomy

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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

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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

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Fecal incontinence (FI) is the involuntary passage of fecal material. Current treatments have limited successful outcomes. The objective of this study was to develop a large animal model of passive FI and to demonstrate sustained restoration of fecal continence using anorectal manometry in this model after implantation of engineered autologous internal anal sphincter (IAS) biosphincters. Twenty female rabbits were used in this study. The animals were divided into three groups: (a) Non-treated group: Rabbits underwent IAS injury by hemi-sphincterectomy without treatment. (b) Treated group: Rabbits underwent IAS injury by hemi-sphincterectomy followed by implantation of autologous biosphincters. © Sham group: Rabbits underwent IAS injury by hemi-sphincterectomy followed by re-accessing the surgical site followed by immediate closure without implantation of biosphincters. Anorectal manometry was used to measure resting anal pressure and recto-anal inhibitory reflex (RAIR) at baseline, 1 month post-sphincterectomy, up to 3 months after implantation and post-sham. Following sphincterectomy, all rabbits had decreased basal tone and loss of RAIR, indicative of FI. Anal hygiene was also lost in the rabbits. Decreases in basal tone and RAIR were sustained more than 3 months in the non-treated group. Autologous biosphincters were successfully implanted into eight donor rabbits in the treated group. Basal tone and RAIR were restored at 3 months following biosphincter implantation and were significantly higher compared to rabbits in the non-treated and sham groups. Histologically, smooth muscle reconstruction and continuity was restored in the treated group compared to the non-treated group. Results in this study provided promising outcomes for treatment of FI. Results demonstrated the feasibility of developing and validating a large animal model of passive FI. This study also showed the efficacy of the engineered biosphincters to restore fecal continence as demonstrated by manometry. Stem Cells Translational Medicine 2017.

Concepts: Mathematics, Coprophagia, Feces, Fecal incontinence, Defecation, Sphincter, Lateral internal sphincterotomy, Anus

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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

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There is no consensus on the optimal dosage of botulinum toxin (BT) as a sphincter sparing alternative to lateral internal sphincterotomy for chronic anal fissure. The aim of this study was to assess the long-term efficacy of high-dose BT as well as the presence of incontinence following the treatment of chronic anal fissure at a single institution.

Concepts: Medicine, Fecal incontinence, Botulinum toxin, Microbial toxins, Clostridium botulinum, Anal fissure, Lateral internal sphincterotomy

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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

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Childhood constipation is common. Previously, internal anal sphincterotomy has been used for hypertensive/non-relaxing sphincters; however, recent benefit has been shown with Botulinum Toxin (BT) injections. The aim is to investigate BT, including response duration, symptom association and effectiveness in relation to sphincter dynamics.

Concepts: Effectiveness, Sphincter, Botulinum toxin, Microbial toxins, Safe injection site, Anal fissure, Lateral internal sphincterotomy, Anus

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A large proportion of age-related fecal incontinence is attributed to weakness or degeneration of the muscles composing the anal continence organ. However, the individual role of these muscles and their functional interplay remain poorly understood.

Concepts: Stomach, Muscular system, Fecal incontinence, Defecation, Hemorrhoid, Anal fissure, Lateral internal sphincterotomy, Anus

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Anal fissure is a common anorectal problem causing severe pain and discomfort to the patients. Chemical sphincterotomy has emerged as a noninvasive alternative to the surgical methods of fissure treatment. The objective of this study was evaluation of the efficacy and the adverse effects of topically applied minoxidil in chemical sphincterotomy of chronic anal fissure in comparison with topical diltiazem.

Concepts: Medicine, Clinical trial, Medical terms, Effectiveness, Antibiotic, Topical, Anal fissure, Lateral internal sphincterotomy

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Chronic anal fissures (CAF) are common and associated with reduced quality of life. Lateral internal sphincterotomy (LIS) is frequently carried out but carries a significant risk of anal incontinence. Anal advancement flap (AAF) has been advocated as an alternative, ‘sphincter-preserving’ procedure. We aimed to perform a systematic review and meta-analysis to compare the efficacy of both techniques in the treatment of CAF.

Concepts: Fecal incontinence, Botulinum toxin, Hemorrhoid, Anal fissure, Lateral internal sphincterotomy