Correspondence

Treatment of Chronic Anal Fissure

N Engl J Med 1998; 338:1698-1699June 4, 1998

Article

To the Editor:

In the study by Maria et al. (Jan. 22 issue)1 comparing botulinum toxin and saline for the treatment of chronic anal fissure, the injection of botulinum toxin is referred to as noninvasive. Although obviously less invasive than surgery, local injection into the anal sphincter can be complicated by sepsis or impairment of continence,2 which makes the term inaccurate. Minor or transient incontinence could easily be missed at the one-month follow-up if not specifically sought. We are not told whether this outcome was included in the study, as pointed out in the accompanying editorial.3

Endoscopic anal dilation is a nonoperative treatment option for chronic anal fissure. The use of a standardized technique of anal dilation with either a Parks' retractor or a balloon precludes the possibility of permanent incontinence or wound complications and was found to be safe (1.3 percent frequency of transient minor incontinence) and effective (94 percent cure rate) in a study of 146 patients with chronic anal fissures.4 This technique was subsequently adapted for endoscopic use with a two-valved anoscope and assessed prospectively in 62 patients with chronic anal fissures. The cure rate was 52 percent at 1 week and 95.2 percent at 1 month, with a recurrence rate of 2.2 percent at 24 months. No defects in continence were noted.5

The general disrepute into which forced anal dilation has fallen should not be extended to controlled or precise anal dilation, a different technique with widely differing results. Endoscopic anal dilation can be accomplished in one outpatient session, usually at the time of sigmoidoscopy, which most patients with chronic anal fissures undergo during their evaluation. Comparative trials that include endoscopic anal dilation are warranted if the entire range of nonoperative treatment choices for chronic anal fissure is to be analyzed.

Manuel Pérez-Miranda, M.D.
Hospital Del Río Hortega, 47010 Valladolid, Spain

José Maté Jiménez, M.D., Ph.D.
Hospital de la Princesa, 28006 Madrid, Spain

5 References

1
Maria G, Cassetta E, Gui D, Brisinda G, Bentivoglio AR, Albanese A. A comparison of botulinum toxin and saline for the treatment of chronic anal fissure. N Engl J Med 1998;338:217-220
Full Text | Web of Science | Medline

2
Lund JN, Scholefield JH. Aetiology and treatment of anal fissure. Br J Surg 1996;83:1335-1344
CrossRef | Web of Science | Medline

3
Madoff RD. Pharmacologic therapy for anal fissure. N Engl J Med 1998;338:257-259
Full Text | Web of Science | Medline

4
Sohn N, Eisenberg MM, Weinstein MA, Lugo RN, Ader J. Precise anorectal sphincter dilatation -- its role in the therapy of anal fissures. Dis Colon Rectum 1992;35:322-327
CrossRef | Web of Science | Medline

5
Perez-Miranda M, Robledo P, Alcalde M, Gomez-Cedenilla A, Mate Jimenez J. Endoscopic anal dilatation for fissure-in-ano: a new outpatient treatment modality. Rev Esp Enferm Dig 1996;88:265-268
Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Since 1838 the popularity of anal stretching for the treatment of a fissure has waxed and waned. In general, dilation is remarkably simple, but the technique is difficult to standardize and has been criticized for causing uncontrolled tearing of the sphincter. Results are difficult to compare, and the length of follow-up differs among trials. Several studies reported rapid and effective symptomatic relief after the procedure and a recurrence rate of 2.2 to 12 percent; the rate rises with longer follow-up.1 The dilation stretches the external sphincter as well as the internal sphincter,1 and in fact, the rate of incontinence of flatus or soiling ranges from 0 to 62 percent, with fecal incontinence reported in up to 16 percent of cases. Anal endosonography showed disruption of the internal anal sphincter and an increase in connective tissue in 11 of 12 men with fecal incontinence after anal dilation.2 Three patients also had defects of the external sphincter.

Nielsen and coworkers3 used anal endosonography to study 20 patients two to six years after anal dilation: 2 reported a minor disturbance in continence, and both had defects of the internal sphincter. However, 11 of the 18 patients who were continent also had sphincteric defects, and 4 had fragmentation of the internal sphincter. Although these patients did not report incontinence, they may be at risk for it if the sphincter weakens with age or further anal surgery is performed. Pérez-Miranda and colleagues4 had excellent results with their dilation technique (rate of recurrence, 2.2 percent; no complications); however, they did not report manometric or sonographic findings, nor did they demonstrate the integrity of the internal anal sphincter.

Giorgio Maria, M.D.
Daniele Gui, M.D.
Giuseppe Brisinda, M.D.
Università Cattolica del Sacro Cuore, I-00168 Rome, Italy

4 References

1
Corman ML. Colon and rectal surgery. 3rd ed. Philadelphia: J.B. Lippincott, 1993.

2
Speakman CT, Burnett SJ, Kamm MA, Bartram CI. Sphincter injury after anal dilatation demonstrated by anal endosonography. Br J Surg 1991;78:1429-1430
CrossRef | Web of Science | Medline

3
Nielsen MB, Rasmussen OO, Pedersen JF, Christiansen J. Risk of sphincter damage and anal incontinence after anal dilatation for fissure-in-ano: an endosonographic study. Dis Colon Rectum 1993;36:677-680
CrossRef | Web of Science | Medline

4
Perez-Miranda M, Robledo P, Alcalde M, Gomez-Cedenilla A, Mate Jimenez J. Endoscopic anal dilatation for fissure-in-ano: a new outpatient treatment modality. Rev Esp Enferm Dig 1996;88:265-268
Web of Science | Medline

Author/Editor Response

Sphincter injury and consequent defects in continence are well-documented complications of therapeutic anal dilation.1,2 Although the use of standardized dilation with either an anoscope3,4 or a balloon3 may indeed reduce these risks, data supporting this hypothesis are limited to uncontrolled case series. Prospective trials and endoanal ultrasound evaluation of patients who have undergone precise anal dilation would go a long way toward clarifying the issue.

Robert D. Madoff, M.D.
University of Minnesota, Minneapolis, MN 55455

4 References

1
Speakman CT, Burnett SJ, Kamm MA, Bartram CI. Sphincter injury after anal dilatation demonstrated by anal endosonography. Br J Surg 1991;78:1429-1430
CrossRef | Web of Science | Medline

2
Nielsen MB, Rasmussen OO, Pedersen JF, Christiansen J. Risk of sphincter damage and anal incontinence after anal dilatation for fissure-in-ano: an endosonographic study. Dis Colon Rectum 1993;36:677-680
CrossRef | Web of Science | Medline

3
Sohn N, Eisenberg MM, Weinstein MA, Lugo RN, Ader J. Precise anorectal sphincter dilatation -- its role in the therapy of anal fissures. Dis Colon Rectum 1992;35:322-327
CrossRef | Web of Science | Medline

4
Perez-Miranda M, Robledo P, Alcalde M, Gomez-Cedenilla A, Mate Jimenez J. Endoscopic anal dilatation for fissure-in-ano: a new outpatient treatment modality. Rev Esp Enferm Dig 1996;88:265-268
Web of Science | Medline

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