Tranqui Philippe, Trottier Daniel C, Victor Charles, Freeman Joel B
Division of General Surgery, University of Ottawa, The Ottawa Hospital - General Campus, Ottawa.
Can J Surg. 2006 Feb;49(1):41-5.
Surgical sphincterotomy for chronic anal fissure can cause fecal incontinence. This has led to the investigation of nonsurgical treatment options that avoid permanent damage to the internal anal sphincter.
We conducted a retrospective, ongoing chart review with telephone follow-up of 88 patients treated for chronic anal fissure between November 1996 and December 2002. During the first half of the study period, patients were treated with topical nitroglycerin and pneumatic dilatation. With the availability of new therapies in June 1999, subsequent patients received topical nifedipine and botulinum toxin injections (30-100 units). Lateral anal sphincterotomy was reserved for patients who failed medical treatment.
In 98% of patients the fissure healed with conservative nonsurgical treatment. The combination of nifedipine and botulinum toxin was superior to nitroglycerin and pneumatic dilatation with respect to both healing (94% v. 71%, p < 0.05) and recurrence rate (2% v. 27%, p < 0.01). There was no statistical difference between the number of dilatations and botulinum toxin injections needed to achieve healing. Three patients who received botulinum toxin reported mild transient flatus incontinence. At an average telephone follow-up of 27 months, 92% of patients reported having no pain or only mild occasional pain with bowel movements.
Chronic anal fissures can be simply and effectively treated medically without the risk of incontinence associated with sphincterotomy. Topical nifedipine and botulinum toxin injections are an excellent combination, associated with a low recurrence rate and minimal side effects.
慢性肛裂的手术括约肌切开术可导致大便失禁。这促使人们对避免对内括约肌造成永久性损伤的非手术治疗方案进行研究。
我们对1996年11月至2002年12月期间接受慢性肛裂治疗的88例患者进行了一项回顾性、持续的病历审查，并通过电话随访。在研究期的前半段，患者接受局部硝酸甘油和气囊扩张治疗。随着1999年6月新疗法的出现，随后的患者接受局部硝苯地平和肉毒杆菌毒素注射（30 - 100单位）。肛门外括约肌切开术仅用于药物治疗失败的患者。
98%的患者肛裂通过保守非手术治疗愈合。硝苯地平和肉毒杆菌毒素联合治疗在愈合（94%对71%，p < 0.05）和复发率（2%对27%，p < 0.01）方面均优于硝酸甘油和气囊扩张治疗。实现愈合所需的扩张次数和肉毒杆菌毒素注射次数之间无统计学差异。3例接受肉毒杆菌毒素治疗的患者报告有轻度短暂的排气失禁。在平均27个月的电话随访中，92%的患者报告排便时无疼痛或仅有轻度偶尔疼痛。
慢性肛裂可以通过药物简单有效地治疗，而无括约肌切开术相关的失禁风险。局部硝苯地平和肉毒杆菌毒素注射是一种极佳的联合治疗方法，复发率低且副作用最小。
