AMBULATORY TREATMENT FOR ANAL FISSURE DAVID WEISS, M.D.

NEW

T HE treatment of fissure in ano has usuaIIy been one of operation or paIIiation. The purpose of this paper

is to instiI1 a greater interest in a method of ambuIatory therapy.

Anal fissure is a common condition to which the human being is susceptibIe. It is not rare to find severa members of the same famiIy afllicted with this minor but annoying aiIment. The pain and discomfort are intense and are due to the exposure of the nerve fibriIs in the open wound. The pain is very often brought on with the commencement of the act of defecation and remains at its termination, Iasting for an hour or even Ionger. With the initiation of this subjective sensation, the sphincter is thrown into spasm and thus interferes with the heaIing process of the uIcer at the ana orifice.

The patient suffering with a fissure in ano is invariabIy constipated. Not aIone that, but he develops a fear of bowe1 movements and, therefore, restrains him- seIf in order to avoid the discomfort that is associated with defecation. Thus, a vicious cycIe is estabIished wherein constipation becomes persistent.

The usua1 site, though not the onIy one, for the fissure is at the posterior commissure. The fissure is trianguIar with the apex pointing inward from the anai orifice and is about I to 2 cm. Iong. A fissure is often protected and hidden by a so-caIIed “watchman,” which is a projection of skin in front of it, known as a sentine1 piIe.

The basis of a11 forms of therapy is to rest the sphincter in order to permit the process of repair to progress unimpeded. One may excise the fissure bed or curette it; or leave it aIone and instead stretch the sphincter or even cut the external fibers thus paraIyz-

YORK

ing it temporariIy and obtaining the neces- sary rest for heaIing.

However, many individuaIs are reticent about submitting to an operation or to anything that sounds like one for the reIief of this condition. Again, many others can- not find the opportunity or the time to have themseIves attended to. Rather than the above, they reIy on the use of various combinations of drugs, either in supposi- tory or ointment form, which prove to be 0nIy temporizing measures. Patients are more apt to aIIow themseIves to be treated, therefore, if they are toId that by means of injections, which wiI1 not incapacitate them, aIIeviation of ana fissure can be accompIished.

The method is simpIe and entaiIs the use of a soIution of an anesthetic drug in an oiIy base, which wiI1 cause a sIow absorp- tion of the substance. This wiI1 extend the period of anesthesia and ease the spasm of the ana sphicter over a sufficient time to aIIow heaIing.

In 1935 Steinberg1 reported the treatment of a series of 60 cases with various soIu- tions; 30 of the patients being treated with a soIution of nupercaine in oi1, and 30 with a solution containing benaco1. He compares the immediate discomfort attending the use of both materiaIs, stressing the favora- biIity of the former. FrankfeIdt2 in 1934, cited the use of GabrieI’s solution in cases of ana fissure and uIcer and in recta1 neuroses. I have used two preparations, both of which have shown themseIves to be capable of producing a IocaI anesthetic effect Iasting for a Iong period of time; one injection causing a cessation of pain and

1 STEINBERG, N. The use of Gab&I’s modified solu- tion in the treatment of fissure in ano. New England Jour. Med., 2~3: 162-164 (July 25) 1935.

2 FRANKFELDT, F. M. The use of Gabriel’s formuIa in proctoIogy. Internat. Jour. Med. and Surg., 47: 213

(ApriI) 1934.

88

Case

, Solu- I tion Duration of

Number

Used Symptoms of In-

jections

I. s. w., 2. J. M.. 3. M. P.. 4. M.K... 5. J. L. 6. H. II.... 7. E. K.... 8. M. B.... 9. S.F

IO. H. N.. II. R. S.,

12. R.Il.... 13. s. P.. 14. H. R. _. 14. R.P.... 16.B.S.. 17. F. K.. . 18. C. B.. 19. S.G.... 20. L. hl.... 21. M. F.... 22. R. hl. ,’ 23. H. C.. 24. N.F.... 25. E.S.... 26. J. H. 27. A.O.... 28. M. F. 29. P. B. 30. L.F....

‘5 I2

9 20

:

:

12

6 I2

6 5 4

IO

4 4 5

; 4 5

I 4 years 3 0 No recurrence I 2 years 3 No recurrence I 2 years 3 Sentinel p:Ie * No recurrence I 4 years 4 *SIough and IistuIa SIight itching I I year 2 0 No recurrence I 8 months 2 0 No recurrence I r year 2 0 No recurrence I I year 2 0 No recurrence I 4 years 4 SentineI piIe No recurrence I 5 months 2 0 No recurrence I 3 years 4 Pruritis ani No recurrence; pruritis

same I 2% years 5 SentineI piIe No recurrence I 4 months 2 0 No recurrence I 7 years 5 SentineI piIe OccasionaI itching I 6 months 2 0 No recurrence I 8 months 3 0 No recurrence

3 0 No recurrence 5 0 Occasional itching 3 Sentinel piIe No recurrence 3 0 No recurrence 3 0 No recurrence 5 *SIight sIough No recurrence 2 0 Slight itching 2 0 No recurrence 2 0 No recurrence 4 0 No recurrence 3 0 No recurrence 2 0 No recurrence 4 SentineI piIe No recurrence 2

II

II

II

II

II

II

II

II

II

I year 3 years 2 years

14 months 1 year 2M years 4 months 7 months 3 months 1% years

14 months 9 months 2 years 6 months

‘5 6

‘5 6 9

IO

‘4 9 9 9

20 6 6 6

I2

9

6 12

6

I

I

-

8 3 7 3 4 6 9 5

: II 4 4 4 6 5

: 4 1 No recurrence

Total Lmount ,f Solu-

tion in C.c.

NEW SERIES VOL. XXXVII, No. I Weiss-AnaI Fissure American JournaI of Surgery 89

spasm often for as Iong as four weeks. The situated at the posterior commissure, the soIutions empIoyed are : patient is pIaced either in the Iithotomy or

I. Nupercaine, base. 0.5 per cent Sims’ position. A I fi inch, 22 gauge needIe PhenoI. 1 0 per cent BenzyI aIcoho1.. 10.0 per cent Oil of sweet almond. q.s.

is inserted through the norma skin (Fig. I)

Nupercaine is a-butyloxycinchoninic

about 0.3 to I cm. dista1 to the fissure edge, and I minim of the soIution is injected

acid diethyt-ethyIenediamide. II. Eucupin, base.. . 0.2 per cent

Ethylaminobenzoate. 3. o per cent

immediateIy. This wiI1 aIIow the introduc- tion of the Ieft index finger through the ana

BenzyI aIcoho1. 5 o per cent orifice and thus enable one to fee1 the OiI of sweet atmond. g.s. Eucupin is isoamylhydrocupreine, an aIkaIoid synthetized from quinine.

needIe, guiding it as it is advanced in the subcutaneous tissue to a pIace just beyond the apex of the fissure, but at no time to

PROCEDURE penetrate the fissure bed or mucous mem- A few words wiI1 s&Ice to describe the brane. One-haIf to one cubic centimeter of

procedure. Assuming that the fissure is the seIected solution, depending on the size

TABLE I THIRTY CASES TREATED WITH THE NUMBER OF INJECTIONS RANGING FROM TWO TO FIVE, AND

THE PERIOD FOR REPAIR FROM THREE TO ELEVEN WEEKS, AND WITH TWO COMPLICATIONS

IeaIing Complications Be- ‘ime in fore or as a ResuIt FoIIow-up 6 Months After Weeks of Treatments

* Complication developing as a resuIt of treatment.

90 American Journal of Surgery Weiss-Anal Fissure JULY. 1937

FIG. I. Showing the various positions of the needte injecting beneath the fissure and the sphincter on either side of the fissure. s, sphincter muscle; F, fissure.

FIG. 2. Showing the fistuIous tracts in the shape of an inverted “Y.” A, anus; F, fistula; M, mu&e.

NEW SERIES VOL. XXXVII, No. I Weiss-AnaI Fissure American Journal of Surgery 9’

of the Iesion, is then injected beginning at mucous membrane; another said she had the point beneath the fissure apex and itching onIy when she permitted herseIf to continuing as the needIe is being drawn become constipated, however here, too, out. The needIe is then partiaIIy with- there was no recurrence of the fissure. One drawn, and with the index finger stiI1 in of the first cases (Table I, Case IV) was an the anus, it is redirected, guiding it into ana fissure of four years duration situated the sphincter muscIe, first on one side at the posterior commissure and with a adjoining the fissure and depositing I c.c., large sentine1 piIe. This patient received and then on the other side adjoining the 5 c.c. injections; the sentine1 pile was fissure. Too much soIution should not be removed after the second treatment. After injected; nor shouId the soIution be the fourth injection, a sIough was noted, pIaced intracutaneous or superficia1 be- folIowed by the deveIopment of a fistuIous cause it wiI1 resuIt in sIoughing. It is tract, having the shape of an inverted far better to use smaIIer quantities and “Y.” UndoubtedIy, this was caused by the repeat the injections in seven to ten days. Iarge amount of material used at each It may take from one to four or five treat- sitting. Without any additiona anesthetic, ments unti1 compIete repair of the fissure the tracts were Iaid bare (Fig. 2). From is accompIished. The important fact is that then on, heaIing took pIace without any foIIowing the first treatment the patient further diffIcuIty. has immediate reIief, gains confidence, and bowe1 movements are characterized by the CONCLUSION

absence of ensuing pain, smarting or I beIieve that the treatment of fissure in soreness. ano is feasibIe by injections of IocaI anes-

If a sentine1 piIe is present, its remova is thetics in oil, and can be accompIished in essentia1 for cure. This may be done after the ambuIatory patient. This method is not the first injection or at a date in the near complicated, and appeaIs to the patient future; no additiona infiItration of a IocaI because it is non-incapacitating and, there- anesthetic is required for its ablation. fore, economical. Furthermore, it is impor-

In the series of 30 cases treated with tant to remember that constipation and these formuIas, there were 2 cases which ana fissure are compIementary, that is, deveIoped sIoughs (TabIe I). This com- synergistic etioIogica1 and maintaining pIication proIonged the period necessary factors for each other and both conditions for repair but the terminal resuIt was good. must be treated at the same time. FinaIIy, Three of the patients seen after six months Iarge doses produce sIoughs, and therefore, compIained of an occasiona itching sensa- it is advisabIe to use smaIIer quantities tion which was slight and not constant, which can be repeated unti1 the ultimate examination reveaIed no break in the repair of the ana fissure.