Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1779_Библиотеки_им_академика_М_И_Перельмана.pdf
129
Analkanal
m.sph.ani int.
m.sph.ani ex
t.
Linea dentata
Fig. 11.3 Sphincterotomy
according to Notaras,
position of the scalpel
Fig. 11.4 Sphincterotomy
according to Notaras, up to
the level of the pectinate
line
11.3 Surgical Treatment
130
Selvaggi et al. (1992) and Gatehouse et al. (1978) however, report on equally good
results after surgery under local and general anesthesia.
Duration of Surgery
Leong and Seow-Choen (1995) give 5 min (5–10) as the average duration of surgery,
Renzi et al. (2008) 8 ± 3.5 min, and Tocchi et al. (2004) 7.2 ± 1.4 min.
Mechanism of Action
Each of these methods of sphincterotomy has to be successful on condition that the
hypertonic inner sphincter muscle can count as a possible pathogenetic factor of
anal fissure because it is weakened in consequence of sphincterotomy. Indeed, the
Table 11.19 Management of secondary changes during lateral internal sphincterotomy in 32 trials
Author (year)
Secondary changes
Removed Left in situ Not stated
Abcarian (1980) +
Ammari and Bani-Hani (2004) +
Arma and Fleischer (1978) +
Arroyo et al. (2004) +
Arroyo et al. (2004) +
Boulos and Araujo (1984) +
Brown et al. (2007) +
Changyul (1975) +
Chowcat et al. (1986) +
Evans et al. (2001) +
Fox (1963) +
Gemsenjäger (1972) +
Gingold (1987) + +
Goligher (1965) +
Gordon and Vasilevsky (1985) +
Hananel and Gordon (1997) +
Hashmat and Ishfaq (2007) +
Hiltunen and Matikainen (1991) +
Ho and Ho (2005) +
Kortbeek et al. (1992) +
Leong and Seow-Choen (1995) +
Liratzopoulos et al. (2006) +
Littlejohn and Newstead (1997) +
Notaras (1971) +
Pernikoff et al. (1994) +
Prohm (1993) +
Ravikumar et al. (1982) +
Renzi et al. (2008) +
Rotholtz et al. (2005) +
Stoß (1985) +
Tocchi et al. (2004) +
Vafai and Mann (1987) +
Total 17 5 11
11 Therapy for Chronic Anal Fissure
131
results of this therapy are good with regard to healing tendency and healing rate.
Most patients are pain-free already 1 day after surgery.
This gives the impression, as if sphincterotomy were the method of choice with-
out any restriction. Currently, this kind of surgery is still propagated in English-
speaking countries (Argov and Levandovsky 2000; Perry et al. 2010).
Pressure Conditions Before and After Sphincterotomy
Almost all authors notice a postoperative decrease in anal resting pressure. The
influence on squeeze pressure is observed differently. Some authors find a reduc-
tion, whereas others do not see a change in squeeze pressure. This may be due to the
fact that the measurement of squeeze pressure in comparison to anal resting pres-
sure is a procedure which is even more difficult to reproduce (Table 11.20)
Extent of Myotomy
The internal sphincter muscle is the continuation of the smooth ring muscle of the
rectum. It extends from the anorectal transition to Hilton’s white line. It is about
20–25 mm wide, 2–8 mm thick, and has its strongest formation at its distal end
Table 11.20 Anal pressures before and after sphincterotomy in 19 trials (in cm H2O or mmHg)
Author (year)
Preoperative
anal sphincter pressure
Postoperative
anal sphincter pressure
Anal resting
pressure
Anal squeeze
pressure
Anal resting
pressure
Anal squeeze
pressure
Pressure data in cm H
2
O
a
Hancock (1977) 120.2 ± 29.6 88.2 ± 14.3
Fischer et al. (1978b) 91 ± 20.5 63.9 ± 20.8
Boulos and Araujo (1984) 107.5/97 52.0/47.5
Hiltunen and Matikainen
(1986)
112 ± 23 72 ± 28 80 ± 24 65 ± 30
Chowcat et al. (1986) 52–131 28–92
Xynos et al. (1993) 132 ± 21 178 ± 52 69 ± 11 182 ± 40
Aytac and Cakar (2003) 112.3 ± 8.3 66.2 ± 8.4
Parellada (2004) 72 120 48 136
Mishra et al. (2005) 87.4 ± 28.8 57.4 ± 22.4
Pressure data in mm Hg
a
Cerdan et al. (1982) 105.3 ± 24.2 60 ± 14.6
Olsen et al. (1987) 94 169 68 149
Pescatori et al. (1991) 78 ± 18 61 ± 26
Williams et al. (1995) 85.1 56.4
Zbar et al. (2001) 120.9 ± 8.2 205 ± 82.4 105.8 ± 2.8 125.7 ± 24.3
Ammari and
Bani-Hani (2004)
110.6 ± 20.1 169.1 ± 46.2 82.9 ± 91 115.4 ± 21.8
Arroyo et al. (2004) 109 ± 29 200 ± 79.5 72.5 ± 20.3 178.6 ± 73.4
Tocchi et al. (2004) 90.3 48.6
Ram et al. (2005) 138 ± 28 86 ± 15
Renzi et al. (2008) 96 113.4 63 120.4
a
100 cm H
2
O = 73.556 mm Hg
11.3 Surgical Treatment
132
(Wienert 1978). Women generally have a smaller and rather lean muscle than men.
Due to its permanent tonic contraction, it provides for continuous closure of the
anus during the continence phase.
In sphincterotomy surgery, most authors dissect the internal anal sphincter
muscle purely in mechanical fashion up to the area of the pectinate line or even
higher, without having an idea of the real extension of the muscle. Hawley
dissects the sphincter up to the pectinate line, but calls it a semi-extended dissec-
tion. Crapp, by contrast, dissects a third of the sphincter muscle only (cf.
Table 11.21).
Yet, the pectinate line does not always lie in the middle or at the dividing line
between the distal and medial portion of the internal anal sphincter muscle. The
extent of myotomy seems to be a real problem. Thus, Mentes et al. headlined in
2005, “Extent of lateral internal sphincterotomy: Up to the pectinate line or up to the
fissure apex?” Schematic drawings in the corresponding publications or textbooks
show the divided portions of the internal sphincter muscle. Uniformly, the incision
extends to the pectinate line, although the extent of the muscle from its distal edge
to the pectinate line was different. In some cases, the incision amounted to 33–57%
of the total length of the muscle (Wienert, cf. Fig. 9.1). Granted that the drawings
are schematic, they nevertheless indicate how the authors assess the configuration of
the internal anal sphincter muscle. Therefore, the late complications (continence
disorders) have to be different (Table 11.22).
Result
Healing rates of 68–100% can be calculated from 17 clinical trials with 5171
patients (Table 11.23).
Open Versus Closed Sphincterotomy
Six randomized controlled trials with a total of 1510 patients show that healing rates
are not significantly different (cf. Table 11.24).
Table 11.21 Extent of myotomy according to the authors of 11 studies on sphincterotomy
Author (year)
Sphincterotomy
Dissection of
anal sphincter muscle
Extent of
myotomy
in fractionsMedial Lateral
Up to
pectinate line
Beyond
pectinate line
Hochuli and Allgöwer (1968) × × 2/3
Allgöwer (1969) × × 2/3
Hawley (1969) × × × 1/2
Ruedi and Allgöwer (1970) × × 2/3
Hoffmann and Goligher (1970) × × 1/2
May (1971) × × 2/3
Eisenhammer (1974) × × 1/2
Nwako (1975) × × 1/2
Crapp et al. (1975) × × 1/3
Hunter (1975) × × 1/3–1/4
Abcarian (1975) × × 1/2
11 Therapy for Chronic Anal Fissure
133
Below, controlled trials are presented which compare sphincterotomy with other
therapeutic modalities.
Sphincterotomy Versus Manual Anal Dilatation (MAD)
The healing rates in four randomized controlled trials vary between 51% and 100%
(Table 11.25).
Table 11.22 Percentage
of internal anal sphincter
muscle dissection
deduced from graphics
in 16 studies
Author (year)
Internal anal sphincter
muscle dissection (%)
Stirnemann and Halter (1970) 33
Goligher (1975) 33
Gabriel (1963) 38
Kügler (1976) 39
Lockwood (1965) 45
Brossy (1956) 45
Allgöwer (1969) 47
Nwako (1975) 50
Ruedi and Allgöwer (1970) 50
Roschke (1976) 50
Stelzner (1976) 50
Soullard (1975) 50
Eisenhammer (1974) 50
Netter (1962) 53
Hughes and Cuthbertson (1972) 53
Otto and Ewe (1976) 57
Source: Wienert (1978)
Table 11.23 Healing rates after sphincterotomy in 17 trials with 5171 patients (in %)
Author (year) Patients (n)
Healing after
sphincterotomy
(n) (%)
Abcarian (1975) 22 20 90
Altomare et al. (2005) 153 132 90
Argov and Levandovsky (2000) 2108 1897 90
Garcea et al. (2003) 60 58 97
Hiltunen and Matikainen (1991) 64 44 68
Jonas et al. (1999) 26 26 100
Khubchandani and Reed (1989) 1057 1025 97
Leong and Seow-Choen (1995) 20 20 100
Liratzopoulos et al. (2006) 242 235 97
Littlejohn and Newstead (1997) 287 284 99
Notaras (1971) 82 74 90
Nyam and Pemberton (1999) 487 468 96
Romano et al. (1994) 44 44 100
Rosa et al. (2005) 261 251 96
Rotholtz et al. (2005) 68 66 97
Stoß (1985) 26 26 100
Tocchi et al. (2004) 164 164 100
Total 5171 4834
11.3 Surgical Treatment
134
Lateral Internal Sphincterotomy (LIS) Versus GTN Ointment
In seven randomized controlled trials, the healing rates after lateral internal sphinc-
terotomy vary between 85% and 100% (Table 11.26).
In his trial comparing lateral internal sphincterotomy with 0.2% isosorbide dini-
trate, Parellada (2004) could achieve a healing rate of 100%, 10 weeks after surgery
and a healing rate of 89% after topical therapy (Table 11.27).
Table 11.24 Healing rates after open and closed lateral internal sphincterotomy (LIS) in six trials
with 1510 patients (in %)
Author (year)
Number of patients Healing rate
Open LIS (n) Closed LIS (n)
Open LIS Closed LIS
(n) (%) (n) (%)
Arroyo et al. (2004) 40 40 37 92.0 36 90.0
Boulos and Araujo (1984) 14 14 14 100.0 14 100.0
Garcia- Aguilar
et al. (1996)
521 343 521 82.3 326 79.0
Kortbeek et al. (1992) 54 58 51 94.4 56 96.6
Lewis et al. (1988) 103 247 95 92.2 232 94.7
Wiley et al. (2004) 40 36 38 95.0 35 96.0
Total 772 738 756 699
Table 11.25 Healing rates in four studies on lateral internal sphincterotomy (LIS) versus manual
anal dilatation (MAD) with 472 patients (in %)
Author (year)
Patients treated with Healing rate
LIS MAD LIS MAD
(n) (n) (%) (%)
Marby et al. (1979) 78 78 78.0 93.0
Collopy and Ryan (1979) 86 74 51.0 40.5
Jensen et al. (1984) 30 28 100.0 96.4
Weaver et al. (1987) 39 59 92.3 91.6
Total 233 239
Table 11.26 Healing rates in seven studies on lateral internal sphincterotomy (LIS) versus GTN
therapy with 388 patients (in %)
Author (year)
Patients treated with Healing
LIS (n)
GTN
(n) LIS (%)
GTN
(%)
Brown et al. (2007) 24 27 100 41
Evans et al. (2001) 31 34 97 61
Hashmat and Ishfaq (2007) 28 28 100 64
Libertiny et al. (2002) 35 35 100 54
Mishra et al. (2005) 20 20 85 90
Oettlé (1997) 12 12 100 90
Richard et al. (2000) 38 44 90 30
Total 188 200
11 Therapy for Chronic Anal Fissure
135
LIS Versus BTX
Five RCT with a total of 300 anal fissure patients showed healing rates between
82% and 100% and recurrence rates of 0–10% (Table 11.28). A meta-analysis with
seven RCT (Chen et al. 2014) showed better healing rates and less recurrences for
lateral internal sphincterotomy in comparison to BTX injection.
Sphincterotomy Versus Nifedipine
Ho and Ho (2005) performed lateral internal sphincterotomy in 48 patients and
treated 41 with nifedipine 2 × 20 mg/day for 6 weeks. After 4 months, significantly
more anal fissures had healed after surgery than after pharmacotherapy.
After local application of 0.5% nifedipine three times a day for 8 weeks (n = 32),
93% of anal fissures had healed after 20 months, but 100% after lateral internal
sphincterotomy (Katsinelos et al. 2006).
Early Complications
As a rule, <1% early complications were reported (Table 11.29).
Late Complications
Anal sphincter muscle damages after sphincterotomy can be documented well when
endoanal ultrasonography is used. Apart from the intended defects in the internal
anal sphincter, Farouk et al. (1997) found defects in the external anal sphincter
also. Therefore, frequently occurring continence disorders after surgery are not
Table 11.27 Healing rates in three studies on lateral internal sphincterotomy (LIS) versus local
therapy with 396 patients (in %)
Author (year)
Patients treated with Healing rate
LIS (n)
Local therapy
(n) LIS (%)
Local
therapy (%)
Arslan et al. (2013) 102 105 (ISDN) 86 90
Vaithianathan and
Panneerselvam (2015)
45 45 (DTZ) 69 58
Gandomkar et al. (2015) 50 49 (DTZ+BTX) 86 78
Total 197 199
Table 11.28 Healing rates and recurrence in five studies on LIS versus BTX therapy with 300
patients (in %)
Author (year)
Patients treated with Healing rate after Recurrence
LIS (n)
BTX
(n) LIS (%)
BTX
(%) LIS (%)
BTX
(%)
Arroyo et al. (2005) 40 40 92.0 45 2.5 55
Giral et al. (2004) 11 10 82.0 70 0.0 0
Iswariah et al. (2005) 21 17 91.0 41 9.5 5
Massoud et al. (2005) 25 25 100.0 88 7.0 80
Mentes et al. (2003) 50 61 94.0 75 6.0 11
Total 147 153
11.3 Surgical Treatment
136
astonishing. The severed portions of the internal anal sphincter were too large, and
even striated musculature was damaged.
In 26 trials with 7927 sphincterotomy patients, fecal incontinence rates vary
between 0% and 29%, the rates of incontinence to flatus vary between 0% and 43%,
and the rates of soiling between 0.4% and 45%. These trials clearly document a
direct correlation between fecal incontinence and follow-up period (0.5–
121 months): the more time has elapsed since the lateral internal sphincterotomy
surgery, the higher the incontinence rate. Even if the internal anal sphincter has been
only partially severed, fecal incontinence can occur in old age, because then the
muscle system becomes atrophied or fibroid. Especially women are at risk, because
they have a weaker sphincter muscle (Sultan et al. 1994; Corby et al. 1997).
Table 11.30 shows fecal incontinence rates after lateral internal sphincterotomy
in 28 trials with 8364 patients.
Garg et al. (2013) conducted a systematic review and meta-analysis on inconti-
nence in 4512 patients after a follow-up time of 24–124 months and found inconti-
nence to stool in 2.41%, to flatus in 9%, and to soiling in 6% of his cases.
During the last years, figures of fecal incontinence rates after lateral sphincterot-
omy were published more often (Hasse et al. 2004). Some authors (Blessing 1993;
Cho 2005; Eitan et al. 1989; Littlejohn and Newstead 1997; Mentes et al. 2003;
Pescatori 1999; Rosa et al. 2005; Rotholtz et al. 2005; Sultan et al.; Fiducia and Bosco
2006; Ho and Ho 2005; Pernikoff et al. 1994) therefore perform what they call a con-
trolled, individualized, tailored, and/or calibrated sphincterotomy. That means, only a
small portion of the internal anal sphincter muscle is severed. But even this procedure
cannot provide safe protection against fecal incontinence at a later time.
Contrary to these authors, others even advocate a more liberal sphincterotomy to
avoid recurrences (Garcia-Granero et al. 1998).
In German-speaking countries, the recommendation of lateral internal sphincterot-
omy as standard procedure for surgical therapy for chronic anal fissure has been widely
debated. Today, the recommendation of fissurectomy as therapy of first choice has been
laid down in the German Practice Parameters (“Leitlinien”). Against this background,
the current textbook lines (Lange et al. 2012) are incomprehensible. Although Lange
et al. specifically emphasize the high rates of incontinence, lateral sphincterotomy is
nevertheless recommended in case of raised anal sphincter tonicity:
Table 11.29 Early complications after lateral internal sphincterotomy in eight studies
Author (year)
Anal
bleeding Hematoma
Abscess/
fistula
Anal
thrombosis
Pruritus
ani
Urinary
retention
Kortbeek et al. (1992) + + +
Liratzopoulos et al. (2006) +
Ohm et al. (2000) + + +
Pernikoff et al. (1994) + +
Renzi et al. (2008) + + +
Romano et al. (1994) + + +
Vafai and Mann (1987) + + + +
Walker et al. (1985) + + +
11 Therapy for Chronic Anal Fissure
137
“The only indication for lateral sphincterotomy is an anal fissure with signifi-
cantly increased sphincter muscle tone mainly after the failure of conservative ther-
apy.” (Translated from the German original)
Conclusion
From our point of view, lateral internal sphincterotomy should not be performed
any longer because of the high frequency of fecal incontinence disorders later on.
Moreover, there is a surgical method which achieves equally high healing rates,
but shows minimal rates of fecal incontinence, namely, fissurectomy according to
Gabriel.
Table 11.30 Fecal incontinence after lateral internal sphincterotomy (LIS) in 28 trials with 8364
patients (in %)
Author (year)
Patients
(n)
Follow-up
(Months)
Incontinence to
Stool
(%)
Flatus
(%)
Soiling
(%)
Bennett and Duthie (1964) 127 36 9.0 13.0
Hardy (1967) 59 2 7.0
Arma and Fleischer (1978) 50 1 4.0
Boulos and Araujo (1984) 28 1 18.0
Jensen et al. (1984) 30 18 3.0
Olsen et al. (1987) 10 12 20.0
Vafai and Mann (1987) 700 6 24.0 32.0 1.0
Lewis et al. (1988) 350 37 7.0
Khubchandani and Reed (1989) 1057 35.0 22.0
Prohm (1993) 396 1.5 10.0 15.0
Pernikoff et al. (1994) 500 66 0.4 3.0 4.0
Garcia-Aguilar et al. (1996)
a
521 36 12.0 30.0 27.0
Garcia-Aguilar et al. (1996)
b
343 36 3.0 24.0 16.0
Littlejohn and Newstead (1997) 287 1 1.0
Hananel and Gordon (1997) 265 20 0.4 0.4
Nyam and Pemberton (1999) 487 60 1.0 6.0 8.0
Argov and Levandovsky (2000) 2108 2–3 3.0
Mentes et al. (2003) 50 12 16.0
Garcea et al. (2003) 60 1.5 0.0 3.0
Parellada (2004) 54 24 15.0
Hasse et al. (2004) 209 121 29.0 34.0 45.0
Arroyo et al. (2004) 40 24 5.0
Arroyo et al. (2005) 40 36 5.0
Casillas et al. (2005) 176 48 8.0 30.0
Liratzopoulos et al. (2006) 242 12 3.0
Hashmat and Ishfaq (2007) 28 0.5 7.0 0.0
Ram et al. (2007) 53 1 4.0
Ghayas et al. (2015)
a
47 21.3
Ghayas et al. (2015)
b
47 4.3
Total 8364
a
Open technique
b
Closed technique
11.3 Surgical Treatment
138
11.3.2 Eisenhammer’s Procedure
Eisenhammer described his method of anal fissure excision with subsequent medial
sphincterotomy in the wound bed as a therapy for posterior anal fissure in 1951.
Earlier, Philipowicz had described this technique already in 1927 (cf. Chap. 9). At
first, the anal fissure portions, indurated by scars, are excised from the anocutaneous
line to the pectinate line in the area of the anal commissure. Crypts, anal papillae,
skin tags, or fistulae on the surgical site are removed at the same time. The internal
anal sphincter muscle, exposed in the wound bed, is then divided in its distal part.
As there is a risk of anal incontinence, due to the so-called keyhole deformity in
the surgical wound, some authors myotomized the muscle only sparingly to prevent
the development of atrophic scarring. Healing rates are high, and the recurrence rate
is low, which means that the risk of anal incontinence after myotomy is not higher
than that after lateral internal sphincterotomy. Nevertheless, some authors warn
against this procedure (Bennett and Goligher 1962).
Mazier (1985) operated on 127 patients, and 3 years after surgery, he recorded an
incontinence to flatus in 13% and to stool in 9% of patients.
Jost et al. (1991) compared lateral internal sphincterotomy (n = 15) and fissurec-
tomy with sphincterotomy in the wound bed (n = 113) in a retrospective trial. After
the Eisenhammer surgery (median follow-up of 56.8 months), 19.3% of patients
complained of incontinence to flatus, 2.2% of incontinence to liquid stool, and
13.6% suffered from soiling. Incontinence rates were comparable with those after
lateral internal sphincterotomy: 16.7% incontinence to flatus, 8.3% incontinence to
liquid stool, and 8.3% suffered from soiling.
Tchirkow (1983), however, reports of 94 operated patients with a healing rate of
96%, a recurrence rate of 2.3%, and a persisting anal incontinence rate of 2.3%
only. Brühl and Krause (1985) saw good results, too, and found no case of anal
incontinence in 128 patients. Abcarian (1980) operated 300 anal fissure patients in
two groups either with lateral internal sphincterotomy or following the Eisenhammer
procedure. The recurrence rate in both groups was 1.3%. The patients in the
Eisenhammer group had longer periods of inability to work and a higher inconti-
nence rate (5% vs. 0%).
Regardless of the negative experiences, Memon et al. (2010) advocated the
Eisenhammer procedure even in the year 2010 as the method of choice.
Conclusion
Due to its high incontinence rate, surgery according to Eisenhammer should not be
performed any longer.
11.3.3 Anal Fissurectomy
Following the Gabriel (1939) procedure, a flat excision of the scarred anal fissure
tissue is performed, which means that only the fibrous tissue of the internal anal
sphincter or the subcutaneous portion of the external anal sphincter muscle is
11 Therapy for Chronic Anal Fissure