Monday, January 16, 2006

The Straight Poop on Anal Fissure Therapy

Ever had an anal fissure? Speaking as someone who has treated many folks with them, and who developed one in medical school, I can assure you that they are a wee bit painful. To go along with a baseline of rectal discomfort, they make the normal bodily function of having a bowel movement into an exercise in self torture. Sort of like passing shards of glass. When they are acute, they can be painful beyond your wildest expectations; when chronic, well, they are a real pain in get my drift. Treatment for chronic anal fissures has remained somewhat controversial, as the "gold standard" surgical therapy (lateral internal sphincterotomy) is associated with a small, but clear, risk of incontinence of stool or gas.

A study from USC, presented at the SSAT meeting in May and published in the December issue of the Journal of Gastrointestinal Surgery, produces what I think is one of the best algorithms for the treatment of chronic anal fissure (CAF). Entitled "Cost-Saving Effect of Treatment Algorithm for Chronic Anal Fissure: A Prospective Analysis," the study evaluated a step-wise, escalating treatment protocol for 67 patients with CAF:

All patients were offered a treatment algorithm with stepwise escalation, starting with (1) topical NTG (0.2% Nitroglycerin ointment), (2) injection of BTX (Botox) into the internal anal sphincter, and (3) lateral internal sphincterotomy. Patients were followed at least every 4 weeks to assess the effectiveness of the treatment with regard to pain, bleeding, and healing of the fissure. Lack of either a partial or a complete resolution noted on follow-up or prohibitive side effects from the treatment were considered a failure of that level, and the next level of the algorithm was recommended to the patient. At any moment, patients had the option to shortcut the algorithm and advance to the next level or to proceed with surgery from the beginning.
What was not made clear in the paper, but was subsequently addressed in the discussion at the meeting, is that all patients were requested to initiate stool bulking agent therapy as well (i.e., Metamucil/fiber therapy). This is because anal fissures are direct result of constipation; despite most patients' protestations that they are "never" constipated, all benefit from daily fiber therapy to bulk up, and soften, their stools. I have this conversation with one or more patients every day in the office, and it amazes me how many patients don't follow through with this simple recommended therapy.

OK, some of you may be wondering "Nitroglycerin? Botox?!! On my derriere?" The idea behind these treatments is to relax, or even partially paralyze, the internal sphincter so that stool can pass more easily and prevent the continual re-injury to the fissure, allowing it to heal. The softer the stool, and the more relaxed the internal sphincter, the better the chance that the fissure will heal. Believe me, when you have an anal fissure, you don't want to be "uptight" in any way. But the bottom line (pardon the pun) is, do these non-operative therapies work?
NTG alone was successful in fissure healing in 31 of 67 patients (46.2%). Two developed a recurrent fissure and then received BTX as part of the protocol. Of the 36 patients who failed NTG trial, 3 requested surgery; the others were treated with BTX, which was successful in 84.8%. Five patients (15.2%) failed BTX and subsequently required surgery. The overall surgery rate in the whole study group was 11.9%, whereas CAF healed in 88.1% of our patients with medical treatment alone. Cost for NTG is $10; for 100 units BTX, $528; and for outpatient surgery, $1119.
I think that's a pretty strong argument for adopting an aggressive, non-operative approach for patients initially. Some patients have difficulties with nitroglycerin therapy, developing headaches and mild hypotension, but it is generally well-tolerated. As far as Botox is concerned, the treatment involves two injections of 20 units each; as each vial contains 100 units, that means 60 units must be discarded --- but some patients ask for injections elsewhere (they paid for it, why not?). This approach leaves surgery as an option for those patients who have the most potential benefit, and who have therefore the best understanding of the potential risks. Believe me, if it's my bum, I'd want to exhaust all of my options before having an operation that can (rarely) result in fecal incontinence. And that's the straight poop.