الفهرس 
Pathology of Anal fissureOnly 14 pages are availabe for public view
 |  | from | 157 |  |  |
| | | from | 157 | | |
Abstract
Chronic anal fissure is one of the most frequent and painful perianal conditionsFissures persisting for longer than 4 weeks, or recurrent fissures, are generally defined as chronic anal fissure has distinct anatomical features, such as visible sphincter fibers at the fissure base, anal papillae, sentinel piles, and indurated margins. Clinical symptoms are anal pain during or after defecation accompanied by bright red rectal bleeding and pruritus ani.
The treatment strategies focus on the spasm of the internal sphincter, which is the most consistent finding because the relief of the spasm has been associated with relief of pain and healing of the fissure.
Treatment guidelines for chronic anal fissure include nonsurgical management as well as surgical management.
In the treatment of chronic anal fissure, surgical interventions are the most effective therapies. The standard surgical procedure is lateral internal sphincterotomy (LIS), and the healing rates are over 90 %.
In addition to sphincterotomy, fissurectomy is the first-line surgical therapy in many countries
Despite its efficacy, complications have already been described after sphincterotomy, such as bleeding, abscess formation and hematomas. This issue in turn severely affects the quality of life especially in young people.
Another problem after surgical treatment is recurrence of the fissure, which can be seen approximately in 1–8 % of the patients, or non- healing of the fissure. By virtue of the patients’ ability to choose their treatment, studies demonstrate that patients are willing to try less invasive modalities with the hope of avoiding surgery, with its risk of disability.
Sacral Nerve Stimulation (SNS) has recently been shown to be effective for the management of chronic anal fissure; however, it is an invasive technique.
The Posterior Tibial Nerve (PTN) comes from the sciatic nerve, and by stimulating this nerve in the ankle, it may mimic the effects of SNS and may improve chronic anal fissure. The technique PTN TENS has shown promising results for urinary incontinence and fecal incontinence.
Therefore,as a noninvasive alternative treatment, we aimed to stimulate similar nerves such as the Posterior Tibial Nerve (PTN) by Transcutaneous Electrical Nerve Stimulation (TENS).
In our technique, we used a combined motor response (evidenced by the flexion of the big toe) and a sensory response (evidenced by a tingling sensation felt on the foot) as the stimulation parameters. However, further studies are needed to standardize the stimulation parameters for TENS procedure in anal fissure treatment.
The results of our study do not offer any insight in the physiological mechanism of this technique. However, the beneficial effect of this technique on chronic anal fissure might be due to the parasympathetic activation leading to internal anal sphincter relaxation with positive effect on the spasm subsequently improving ischemia. Another mechanism of action of TENS might be the increase in rectal mucosal blood flow leading to improvement in ischemia.
The study was conducted on twenty patients (fifteen females, five males) with a mean age of 34.75 ± 11.42 (range 19 –years with chronic anal fissure.
The mean BMI was 26.15 ± 2.83 (range 21 – 30), and disease duration was 4.45 ± 2.80 (range 1–12) months. All the patients completed the procedure by coming to the outpatient clinic for 30 days.
The improvement of the symptoms after the fifth session was 50% (Ten out of twenty), and after the tenth session was 80% (sixteen out of
twenty), and in the last follow-up day was 85% (seventeen out of twentyFissure healing after the fifth session was 40% (eight out of twenty), and after tenth session was 70% (fourteen out of twenty), and after the last day follow up was 75% (fifteen out of twenty).
The decrease in the ratio of symptoms and the healing of the fissure was statistically significant (p=0.029and p=0.048, respectively). On the last follow up day of the TENS procedure, seventeen patients reported total improvement of perineal pain and bleeding.
The VAS score at the beginning of procedure for all patients (twenty patients) was above 5, after the fifth session was above 5 for one patient, from 1-5 for sixteen patients and was 0 for three patients, and after the tenth session VAS score was from 1-5 for four patients and 0 for sixteen patients.
VAS score for pain decreased significantly from the fifth session to the tenth session (p=0.000). Wexner’s constipation score also decreased significantly after the tenth session (p=0.000).
Fissure healing was seen in eight patients after the fifth session, in fourteen patients after the tenth session, and in fifteen patients at the last follow-up day.
The six patients who had non-healing fissure at the end of the tenth session, the procedure was repeated again in two of them. The fissure
healing was seen only in one of them after the second procedure.
In two out of the fifth patients - who had not fissure healing at the end of the last follow up day - undergone lateral sphinctertomy because of non-healing fissure.
Treatment compliance was good in all cases, and all patients completed the study procedure. No significant side effects were seen, Pain and bleeding resolved in seventeen patients in the last follow up day after the treatment, and fissure healing which was defined as mucosal healing was observed in fifteen patients in the last follow up day after the treatment.
All patients had secondary features such as sentinel piles, and all patients had indurated margins. Indurated margins resolved in all patients who showed mucosal healing though sentinel piles did not change with treatment.