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BMJ Open Jan 2024This study aims to examine the prevalence of comparisons of surgery to drug regimens, the strength of evidence of such comparisons and whether surgery or the drug...
OBJECTIVES
This study aims to examine the prevalence of comparisons of surgery to drug regimens, the strength of evidence of such comparisons and whether surgery or the drug intervention was favoured.
DESIGN
Systematic review of systematic reviews (umbrella review).
DATA SOURCES
Cochrane Database of Systematic Reviews.
ELIGIBILITY CRITERIA
Systematic reviews attempt to compare surgical to drug interventions.
DATA EXTRACTION
We extracted whether the review found any randomised controlled trials (RCTs) for eligible comparisons. Individual trial results were extracted directly from the systematic review.
SYNTHESIS
The outcomes of each meta-analysis were resynthesised into random-effects meta-analyses. Egger's test and excess significance were assessed.
RESULTS
Overall, 188 systematic reviews intended to compare surgery versus drugs. Only 41 included data from at least one RCT (total, 165 RCTs) and covered a total of 103 different outcomes of various comparisons of surgery versus drugs. A GRADE assessment was performed by the Cochrane reviewers for 87 (83%) outcomes in the reviews, indicating the strength of evidence was high in 4 outcomes (4%), moderate in 22 (21%), low in 27 (26%) and very low in 33 (32%). Based on 95% CIs, the surgical intervention was favoured in 38/103 (37%), and the drugs were favoured in 13/103 (13%) outcomes. Of the outcomes with high GRADE rating, only one showed conclusive superiority in our reanalysis (sphincterotomy was better than medical therapy for anal fissure). Of the 22 outcomes with moderate GRADE rating, 6 (27%) were inconclusive, 14 (64%) were in favour of surgery and 2 (9%) were in favour of drugs. There was no evidence of excess significance.
CONCLUSIONS
Though the relative merits of surgical versus drug interventions are important to know for many diseases, high strength randomised evidence is rare. More randomised trials comparing surgery to drug interventions are needed.
Topics: Humans; Databases, Factual; Sphincterotomy; Systematic Reviews as Topic; Meta-Analysis as Topic
PubMed: 38195174
DOI: 10.1136/bmjopen-2023-076675 -
International Journal of Surgery Case... Jan 2024Pemphigus Vulgaris (PV) is a low incidence autoimmune mucocutaneous bullous disease, in which pathogenic antibodies are directed against the keratinocyte cell surface....
INTRODUCTION AND IMPORTANCE
Pemphigus Vulgaris (PV) is a low incidence autoimmune mucocutaneous bullous disease, in which pathogenic antibodies are directed against the keratinocyte cell surface. Although anal involvement is unusual, correlations between its appearance and disease severity have been recently reported.
CASE PRESENTATION
A 42-year-old male presented with an anal fissure and a year of recurrent oral and pharyngeal aphtha. A chemical sphincterotomy with botulinum toxin plus fissurectomy was performed. 3 years later an upper eyelid injury raised suspicion of pemphigus vulgaris (PV), tested negative for specific antibodies. A couple years later, an anal fissure, and suspected Crohn's disease, led to a second intervention. Surgical analysis unveiled characteristics indicative of a vegetating variant of PV.
CLINICAL DISCUSSION
Anal involvement in PV varies in prevalence, with studies reporting rates between 2 % and 27.98 %. This manifestation often accompanies late disease stages and may indicate severity, notably in association with oral lesions. Patients might not readily discuss anal symptoms, leading to potential underreporting. Anal PV is linked to other lesions (ocular, nasal, genital) and the severity of oral PV. Even when other sites are in remission, anal recurrence can occur. Early recognition and follow-up are crucial, highlighting the need for routine anal examination and confirmatory diagnostics.
CONCLUSION
PV lesions can present on the skin or mucosa, although oral lesions are the most common site of initial presentation. Anal PV is a diagnostic challenge, and this case illustrates the importance of a careful evaluation.
PubMed: 38150999
DOI: 10.1016/j.ijscr.2023.109185 -
Scientific Reports Nov 2023Chronic anal fissure is one of the most common benign anorectal health conditions, causing significant morbidity, quality of life, and economic loss. Eight randomized... (Meta-Analysis)
Meta-Analysis
Chronic anal fissure is one of the most common benign anorectal health conditions, causing significant morbidity, quality of life, and economic loss. Eight randomized controlled trials with a total population size of 1035 were eligible for analysis. Seven studies included both males and female, while one only included females. The majority of randomized controlled trials involved female dominance [54.9% (43.5-66.3)] and posterior midline location [86.1% (95% CI 81.5-90.8%)]. This meta-analysis of randomised control trials found that overall postoperative healing was 90.2%, recurrent anal fissure was 3.7%, and postoperative incontinence was 8.9% after LIS. Even though there was no statistically significant difference, closed lateral internal sphincterotomy (LIS) had higher rates of recurrent anal fissure (RR = 1.73 (95% CI 0.86-3.47, p = 0.90, I2 = 0%) and lower rates of postoperative incontinence rate (RR = 0.60 (95% CI 0.37-0.96, p = 0.76, I2-0) as compared with open LIS. We recommended that closed lateral internal sphincterotomy (LIS) is a safe and effective surgical treatment option for chronic anal fissures.
Topics: Female; Humans; Male; Anal Canal; Chronic Disease; Fissure in Ano; Lateral Internal Sphincterotomy; Quality of Life; Treatment Outcome; Randomized Controlled Trials as Topic
PubMed: 38017243
DOI: 10.1038/s41598-023-48286-z -
Revista Espanola de Enfermedades... Nov 2023We are thrilled to present a new technique for treating chronic anal fissures using ultrasound-guided botulinum toxin injections. Our approach involves injecting...
We are thrilled to present a new technique for treating chronic anal fissures using ultrasound-guided botulinum toxin injections. Our approach involves injecting botulinum toxin into the internal anal sphincter (IAS) guided by ultrasound for maximum effectiveness. We believe that our technique has significant potential to improve outcomes. We could not find any studies where ultrasound-guided TB puncture was used to treat chronic anal fissures.
PubMed: 37929998
DOI: 10.17235/reed.2023.10031/2023 -
Journal of the Anus, Rectum and Colon 2023Conventional anal dilatation for anal fissures has long been abandoned because of the high incidence of anal incontinence. However, less invasive and more precise...
OBJECTIVES
Conventional anal dilatation for anal fissures has long been abandoned because of the high incidence of anal incontinence. However, less invasive and more precise dilation techniques have been developed that have shown high healing and low incontinence rates. This study aimed to evaluate the efficacy and safety of controlled anal dilatation (CAD) using a standardized maximum anal diameter.
METHODS
This study included 523 patients who underwent CAD for chronic anal fissures between January 2010 and December 2014. CAD was performed under sacral epidural anesthesia. The index fingers of both hands were placed in the anus and dilated evenly in various directions. CAD was completed when the anus was dilated to the sixth scale (35 mm in diameter) using a caliber ruler.
RESULTS
The mean anal scale size expanded from 3.1 to 5.8 (p<0.001). Non-healing was observed in nine patients (1.7%) at 1 month postoperatively, six of whom underwent additional CAD. The mean maximal anal resting pressure (mmHg) decreased from 90.2 to 79.7 at three months postoperatively (p<0.001). Postoperative complications were observed in 11 (2.1%) patients, of whom three patients with thrombosed hemorrhoids underwent resection. None of the patients complained of anal incontinence during the mean follow-up period of 16.6 months. The cumulative recurrence-free rates at three and five years were 87.9% and 69.2%, respectively.
CONCLUSIONS
CAD is technically simple and safe and can achieve reasonable long-term outcomes. Thus, CAD appears to be the preferred procedure for patients with chronic anal fissures who do not respond to conservative treatments.
PubMed: 37900697
DOI: 10.23922/jarc.2023-019 -
Journal of the Anus, Rectum and Colon 2023
PubMed: 37900688
DOI: 10.23922/jarc.2023-031 -
BMC Surgery Oct 2023The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana...
INTRODUCTION
The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colon-Proctologia) on the diagnosis and management of anal fissure, with the purpose to guide every physician in the choice of the best treatment option, according with the available literature.
METHODS
A panel of experts was designed and charged by the Board of the SIUCP to develop key-questions on the main topics covering the management of anal fissure and to performe an accurate search on each topic in different databanks, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in different rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to the PICO criteria, and the statements developed adopting the GRADE methodology.
CONCLUSIONS
In patients with acute anal fissure the medical therapy with dietary and behavioral norms is indicated. In the chronic phase of disease, the conservative treatment with topical 0.3% nifedipine plus 1.5% lidocaine or nitrates may represent the first-line therapy, eventually associated with ointments with film-forming, anti-inflammatory and healing properties such as Propionibacterium extract gel. In case of first-line treatment failure, the surgical strategy (internal sphincterotomy or fissurectomy with flap), may be guided by the clinical findings, eventually supported by endoanal ultrasound and anal manometry.
Topics: Humans; Fissure in Ano; Colorectal Surgery; Lidocaine; Colon; Chronic Disease; Anal Canal; Treatment Outcome
PubMed: 37833715
DOI: 10.1186/s12893-023-02223-z -
Medicine Sep 2023Chronic anal fissure is called the reaching the muscle layer under the skin by deepening of the fissure in the breech skin. Our purpose is to enable the tissue to heal... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Chronic anal fissure is called the reaching the muscle layer under the skin by deepening of the fissure in the breech skin. Our purpose is to enable the tissue to heal by relaxing the anal sphincter with caudal epidural injection.
METHODS
One hundred twenty cases were included in this randomized, controlled study. The cases were categorized into 2 groups; Under ultrasound guidance, the first group, caudal epidural injection group (Group CE, n = 60) was treated with 5 cc bupivakain + 5 cc isotonic from a caudal epidural for a total of 3 sessions at the beginning, 1 week and 2 weeks later; the second group, control group (Group C, n = 60) were provided medical treatment (cream, pill etc.) every day for 2 weeks. Wexner's constipation score was used to assess constipation severity and visual analog scale was used to assess pain severity. Short Form-36 was used to determine the patient's quality of life.
RESULTS
This study was conducted with 2 groups of 60 people and a total of 120 patients. There was no statistically significant difference between the groups in terms of demographic characteristics (age, body mass index, gender, American Society of Anesthesiologist, mean blood pressure, heart rate) (P > .05). Out of the detected fissures, 32 (26.7%) were located anteriorly and 88 (73.3%) were located posteriorly. The groups were statistically same in terms of fissure location (P = .423). When groups were compared with pain, Wexner constipation and visual analog scale scores decreased significantly in Group CE compared to Group C after 2.and 3.sessions (P = .001 and P = .002, respectively). In Group CE, the Short Form-36 subscales increased significantly (P = .003).
CONCLUSION
Caudal epidural injection has a potential to be an alternative treatment option for chronic anal fissure.
Topics: Humans; Fissure in Ano; Quality of Life; Wound Healing; Constipation; Injections, Epidural
PubMed: 37713828
DOI: 10.1097/MD.0000000000035160 -
BMJ Open Gastroenterology Aug 2023Haemorrhoids are one of the most common gastrointestinal and anal diseases. In olive oil and honey propolis, flavonoids have beneficial effects on improving vascular... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
Haemorrhoids are one of the most common gastrointestinal and anal diseases. In olive oil and honey propolis, flavonoids have beneficial effects on improving vascular function and decreasing vascular resistance. In this study, we aimed to produce a combination of these two substances in the form of lotions and assess their healing and side effects in comparison with routine treatment, anti-haemorrhoid ointment (containing hydrocortisone and lidocaine).
DESIGN
In this randomised clinical trial study, 86 patients with grade 2 or more haemorrhoid degrees, diagnosed by colonoscopy, were divided into two groups, the case (n=44) and control (n=42). The case group was treated with flavonoid lotion, and the control group was treated with anti-haemorrhoid ointment two times per day for 1 month. Patients were followed weekly with history and physical examination. The data of the two groups were collected before and after the intervention and statistically analysed.
RESULTS
Post-treatment reduction in haemorrhoid grade was significant in the case group (p=0.02). This ratio was insignificant in the control group (p=0.139). Flavonoid lotion (p<0.05) significantly reduced the signs and symptoms of haemorrhoids more than anti-haemorrhoid ointment.
CONCLUSION
According to the results, flavonoid lotion can be an excellent alternative to topical chemical drugs, such as anti-haemorrhoid ointment, in treating haemorrhoid disease. Besides its effectiveness and safety, it can be easily manufactured and widely available to patien.
Topics: Humans; Ointments; Colonoscopy; Flavonoids
PubMed: 37597875
DOI: 10.1136/bmjgast-2023-001158 -
Prilozi (Makedonska Akademija Na... Jul 2023: Anal fissure is a longitudinal tear of the mucosa of the anal canal extending from the outer anal orifice in the direction of the dentate line of the inner anal...
The Value of Injection Therapy with Botulinum Toxin in Pain Treatment of Primary Chronic Anal Fissures Compared to Anal Dilation, and Local Nifedipine in Combination with Lidocaine.
: Anal fissure is a longitudinal tear of the mucosa of the anal canal extending from the outer anal orifice in the direction of the dentate line of the inner anal opening. Fissures are divided into primary and secondary, and acute or chronic. Besides minimal rectal bleeding, itching and soiling, primary chronic anal fissures (PCAF) manifest with anal pain as theirs main determinant. It is described as the most troubling symptom. : To compare the effect of injection therapy with botulinum toxin A (ITBT) vs. anal dilation (AD), and local nifedipine with lidocaine (LNL) in pain treatment of PCAF. : This controlled retrospective prospective longitudinal study covered 94 patients, divided in 3 groups. The first was treated with ITBT, the second with AD and third using LNL (31, 33 and 30 patients respectively). Clostridium botulinum toxin A was used, dissolved with saline to concentration of 200 U/ml. The solution was applied to both sides of PCAF at dose of 40U. Modified technique of AD was done using 3 fingers of a single hand, progressively introduced into the anal canal, followed by gradual lateral distraction during 1 min. LNL therapy was conducted using nifedipine (0.3%) with lidocaine (1.5%) ointment, applied twice daily for 3 weeks. To measure pain, a visual analog scale (VAS) was used. The follow-up period was 12 weeks with checkup at week 4. : The median age of participants was 46.6±13.9 years (50 males vs. 44 females). The type of therapy had a significantly different effect on pain at week 4 (p=0.0003). Severe pain was present in only 2 ITBT patients, 16 AD, and 6 LNL patients. Post hoc analyses showed different pain disappearance time by week 12 (p <0.0001). The mean time was shortest in ITBT group (6.1±1.5 weeks). Anal pain intensity significantly differed among the 3 groups (Fisher exact, p=0.002). Namely, 71% in ITBT group rated the pain as weakest (VAS score 1) compared to 18.2% in AD and 30% of patients in LNL group. The overall pain reduction significance was in favor of ITBT, due to the differences between the ITBT and AD groups (p=0.00024) and ITBT compared to LNL group (p=0.018). : ITBT is superior to AD and LNL in reducing pain in PCAF.
Topics: Male; Female; Humans; Adult; Middle Aged; Nifedipine; Fissure in Ano; Botulinum Toxins; Lidocaine; Anal Canal; Prospective Studies; Retrospective Studies; Dilatation; Longitudinal Studies; Treatment Outcome; Chronic Disease; Pain
PubMed: 37453106
DOI: 10.2478/prilozi-2023-0029