Fahad Malik, MD1, Marina Kim, MD2, Jonathan M. Reyes, MD, MHA3, Bhavin Patel, MD1, Manuel O. Gonzalez, MD1, Simcha Weissman, DO4, Muhammad Aziz, MD5, Prasanna Wickremesinghe, MD1
1Richmond University Medical Center, Staten Island, NY; 2New York Methodist Hospital, Brooklyn, NY; 3Icahn School of Medicine at Mount Sinai (Elmhurst Hospital), Staten Island, NY; 4Hackensack University - Palisades Medical Center, Teaneck, NJ; 5University of Kansas Medical Center, Kansas CIty, KS
Introduction: Energy Therapy has been a well known non-surgical, minimally invasive treatment option for symptomatic grades I and II internal hemorrhoids. This treatment has not yet been studied in anal fissures refractory to medical therapy. Anal fissures, like hemorrhoids, can severely disrupt the quality of life for patients. Currently, only a few non-surgical treatments are available for anal fissures which involve conservative and supportive measures that include: increasing dietary fiber intake, stool softeners, sitz baths, topical analgesics or vasodilators. The gold standard for chronic anal fissures (CAF) refractory to medical therapy is treatment with internal sphincterotomy. Unfortunately with this treatment there is a chance of relapse and a risk of anal incontinence. We propose the use of hemorrhoid energy therapy (HET) with bipolar cautery as a safer, less invasive and effective therapy for recurrent anal fissures refractory to conservative management.
Case Description/Methods: 53 year old obese heterosexual man presented with bright red blood per rectum for two months managed outpatient for chronic constipation. Rectal examination revealed a large clot with anal tenderness and few internal hemorrhoids. Colonoscopy revealed 3 internal non-bleeding hemorrhoids and slow oozing bleeding anterior anorectal fissure. The anal fissure exhibited characteristics of chronicity with base exposing to the internal anal sphincter, hypertrophic anal papilla and sentinel pile. HET therapy with bipolar cautery was applied to the bleeding anal fissure. The tissue consisting of anal fissure in bowel wall was compressed in a parallel fashion and bipolar radiofrequency energy was delivered until the temperature reached 55C or 131F (5-20 seconds) for approximately 1.5 to 2 seconds.
Discussion: The delivery of energy to a targeted region with temperatures between 50 to 55C along with compression of the tissue can help obtain homeostasis for bleeding or CAF along with change of histology to mild scarring with fibrosis and occlusion of blood supply which would result in healing of the fissure. This intervention using bipolar cautery which could be an alternative treatment as a safer, less invasive and effective therapy for recurrent anal fissures refractory to conservative management prior to considering surgery. Our patient was followed up 2 years after the procedure with no recurrences of anal fissures or rectal bleeding, and reported improved quality of life with no complications from the procedure.
Citation: Fahad Malik, MD; Marina Kim, MD; Jonathan M. Reyes, MD, MHA; Bhavin Patel, MD; Manuel O. Gonzalez, MD; Simcha Weissman, DO; Muhammad Aziz, MD; Prasanna Wickremesinghe, MD. P0208 - ENERGY THERAPY - AN ALTERNATIVE TREATMENT OF ANAL FISSURES. Program No. P0208. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.