Anal Fissure Disease
(The Cranford Technique)
Dr. Steven G. Cranford
An anal fissure is a linear ulcer usually extending from just below the ano-rectal line to the margin of the anus. The pain associated with fissure disease is disportionate to the size of the lesion with post-defecatory pain (intense burning) lasting anywhere from minutes to hours. Location is usually in the posterior midline (90%), which according to Schouten, may be explained by relative ischemia in that area because of the sphincter spasm or increased resting pressure of the surrounding sphincteric musculature (internal/external). Anterior fissures are more common in women than men accounting for only 10% of all fissures in the former, while accounting for only 1% in the later. Lateral fissure disease, which may or may not be painful, may be suggestive of serious local or systemic pathology (HIV, Crohn’s disease, ulcerative colitis, TB, syphilis, leukemia and anal carcinoma)
There is pathology that is consistent with the fissure disease and chronicity usually dictates its extent. It is not uncommon to see hypertrophied anal papilla (can be multiple), sentinel pile of Brodie (fibrous inflamed tissue located at the base of the ulcer), internal sphincter spasm (may lead to anal stenosis and develop an “overshoot” or increased resting potential of the surrounding musculature) and very small amounts of suppuration (see illustration). The etiology of the fissure disease is usually passage of a large stool or prolonged straining over a period of time (chronic constipation). The clinician usually finds a patient with a fiber-depleted diet, which may be more susceptible to this condition. The typical set of symptoms for anal fissure disease is post-defecatory pain, frank bleeding, sentinel pile, constipation/obstipation and even dysuria. When you examine this patient you must be quite careful, as there will be predictable apprehension because of the pain. It is important to use topical anesthetics (lidocaine 5%) prior to such examination and in some cases perianal infiltration (posterior midline) of 1-2 cc’s of bupivacaine may be required. Digital exam will quickly allow the physician to determine the extent of sphincter spasm/ anal stenosis, which along with the other clinical findings, is vital to dictating an appropriate treatment protocol.
Treatment of acute/subacute anal fissure disease is completely dictated by signs, symptoms and clinical findings. Absence of associated pathology (hypertrophied anal papilla, sentinel pile, and anal stenosis) allow the clinician to prescribe conservative non-surgical treatment. If surrounding pathology is present, especially anal stenosis, then the only solution may be outpatient surgery (anal dilation, fissurectomy/ fissurotomy-“Cranford Technique”).
The treatment plan at The Sandy Blvd. Rectal Clinic-Portland for anal fissure disease is as follows:
Appropriate dietary changes, which usually consist of excluding dairy products, coffee, alcohol, hot spicy foods, chocolate, tomatoes, strawberries, citrus fruits/ juices and using stool softeners, topical anti-inflammatory cream/ ointments (steroids), topical lidocaine 5% ointment and suppositories.
The same as above but including either nitroglycerine (0.2% glyceryl trinitate ointment) applied to the perianus tid or diltiazem 2% gel applied tid. I prefer the diltiazem as the nitroglycerine can cause severe headache.
Cranford Technique-this procedure consists of anal dilation (manual), fissurotomy/ fissurectomy (surgical excision of the diseased ulcerated tissue) and surgical excision or fulguration of the sentinel pile and/ or all hypertrophied anal papilla. The patient then follows up 3-4 days post-operatively with perianal applications of diltiazem 2% gel tid for 30 days, topical anesthetics and a suitable stool softener.
The advantage of the Cranford Technique is to maintain the integrity of the internal sphincter muscle. I sometimes joke with my patient that I am a “sphincter saver”, as the medical management of acute anal fissure disease is a lateral internal sphincterotomy. The internal sphincter muscle is resected in its entirety, thus reducing the resting potential of said muscle, allowing increased vascularity to the diseased tissue which facilitates healing. The obvious side effect from this procedure is a condition called “wet anus syndrome” or anal leakage. This is a very annoying condition, which could and should be avoided. Dr. Steven G. Cranford has performed between 1200-1500 outpatient “fissure repairs” under local anesthesia at the Sandy Blvd. Rectal Clinic-Portland.
The Cranford Technique
Prior to the procedure I go through the typical PARQ- (Procedure, Alternatives, Risks, Questions).
I may prescribe diazepam (5mg), 1/2 tablet of hydrocodone or 50mg of tramadol to help with patient anxiety.
Patient is placed in a modified left lateral Sims position.
Suitable topical disinfectant is applied to the perianal tissue along with a topical anesthetic (lidocaine 5% or tetracaine 2%). I recommend that one slowly massage the anesthetic into the anus/ perianal skin to help achieve some degree of anesthesia.
I then inject, with a diabetic syringe, ½ cc of bupivacaine into the anal verge of all four quadrants. This helps create a “wheel” (pocket of anesthesia) to allow one to less painfully inject further anesthetics. I have found that diabetic syringes are far less painful than the typical 26 or 30 gauge needles. I then continue to inject about 15-20 cc’s of bupivacaine (5cc syringe with 30 gauge needle) which provides excellent long-term anesthesia (60-600 min.). It is important not to use anesthetic w/epinephrine (1:100,00) because when you perform anorectal surgery you always want to see your bleeders, which can then be sutured or fulgurated.
I then digitally dilate the anal canal. I insert one, two and then three fingers and I slowly go back and fourth (pronate/ supinate) with the intention of stretching the anal canal and its surrounding musculature. If you try to do this too quickly you may avulse or tear muscle instead of stretching it. After you complete the anal dilation you can check to see if the canal is adequately dilated by inserting a Young’s #3 or #4 dilator.
The surgery consists of the use of high frequency surgical diathermy. The tip of the instruments “blends” tissue to open up the fissure and extend it approximately 1-2 centimeters. You must then surgically remove any overhanging edges of the wound being careful to cauterize any bleeding. What you are left with is a wound that is usually 1cm wide and 2cm in length. The wound is left open and subsequently packed with sterile gauze to allow for proper drainage.
I then check for any hypertrophied anal papilla and fulgurate with surgical diathermy (spark setting) or if quite large surgically extirpate and fulgurate the base. When treating fissure disease one must remove/ fulgurate all hypertrophied anal papilla or your outcome may be compromised.
Post-operative follow-up consists of the application of ice directly to the anus, topical disinfectants, topical anesthetics, suitable pain medications (hydrocodone, oxycodone) and sometimes low dose (prophylactic) antibiotics (cephalexin 250 mg 1 bid for 10 days).
After 3-4 days patient then applies to the perianus topical diltiazem 2% gel tid for 30 days. This compounded medication is a calcium channel blocker which helps to relax the internal sphincter muscle, improving blood flow to the area, thus resulting in healing. Appropriate stool softeners (psyllium, flax seed) are also prescribed.
I hope this information has been helpful to the clinician. It is important to know that there is an alternative to the typical “lateral internal sphincterotomy” and its attendant probability of some loss of proper anal sphincter function (wet anus syndrome).
Dr. Cranford has been doing this procedure for nearly 40 years at The Sandy Blvd. Rectal Clinic-Portland. You may contact Dr Cranford toll free at 1-888-750-1432 or 503-232-7609 or his cell phone at 503-702-4200 and he will answer any questions you may have. You may also visit his website at www.sandyclinic.com