Are we following an algorithm for managing chronic anal fissure? A completed audit cycle

Abstract

BackgroundAnal fissure is one of the commonest proctological diseases with considerable national variation in sequential treatment. We aimed to audit our compliance of chronic anal fissure (CAF) management with national guidance provided by the Association of Coloproctology of Great Britain and Ireland (ACPGBI).MethodsWe retrospectively audited patients presenting to outpatient clinics with CAF over a 6-month period. Using electronic patient records, notes and clinic letters, we compared their management with ACPGBI algorithm. A prospective re-audit was then performed.ResultsForty-one patients were included in the analysis (59% male). Sixty-eight percent (n = 28/41) of patients were appropriately started on conservative dietary therapy, of whom only 7.1% (n = 2/28) had treatment success. Eighty-nine percent (n = 25/28) were then appropriately treated with either topical diltiazem 2% or GTN 0.4%. Overall, 43.9% (n = 18/41) of all patients' entire management strategy adhered to the ACPGBI guidelines. In total, 48.8% (n = 20/41) patients had surgical treatment (excluding Botox), of which only 15% (n = 3/20) had undergone ACPGBI-compliant management. After local dissemination of results and education, the re-audit of 20 patients showed significant improvement in adherence to the guidelines (43.9% vs. 95%; P = 0.0001).ConclusionsTopical creams were the most successful treatments (50%; n = 9/18) in ACPGBI-compliant strategies. Importantly, these data suggests that compliance with the ACPGBI algorithm leads to healing without surgery in 83.3% (n = 15/18) of patients, compared to 26.1% (n = 6/23) with non-compliant methods (P = 0.0004). This highlights the benefit of early conservative and medical management of CAF, before attempting surgery.

Treatment of anal fissure: a survey of surgical practice in Australia and New Zealand

“…Farkas et al . conducted an audit using the Association of Coloproctology of Great Britain and Ireland (ACPGBI) position statement as the standard and reported that 43.9% adhered to guidelines. Further, they demonstrated that compliance with the ACPGBI treatment algorithm was significantly correlated with success without surgery compared to using non‐compliant methods (83.3% vs 26.1%, Fisher's exact test, P = 0.00004).…”

Evaluation of outcomes in fissurectomy and V–Y advancement flap for the treatment of chronic anal fissure

“…According to British Coloproctology Protocol, if the medication therapy does not heal the wound after 6-8 weeks, botulinum injection is recommended. 11 If the wound does not heal after 2-3 months from injection, then lateral internal sphincterotomy will be performed for patient. These steps may take about 8-9 months.…”

Trends in Treatment for Hemorrhoids, Fistula, and Anal Fissure: Go Along the Current Trends

“…An anal fissure is a longitudinal, oval, ulcer-like tear in the anal canal that can extend from the dentate line to the anal verge [59][60][61][62][63]. In almost 90% of cases, the anal fissures are observed in the posterior midline and cause pain during defecation and/or bleeding due to hypertonia of the internal anal sphincter, which results in ischemia.…”

“…Topical or oral calcium channel blockers can be used as an alternative of topical nitrates. These are considered as first-line treatments for chronic anal fissures [59][60][61][62].…”