**11.7 Iontophoresis**

Iontophoresis using a zinc or copper electrode and applying a positive current will help to facilitate healing by hardening the underlying fissure, decreasing bleeding and affording pain relief.

#### **11.8 Nd:YAG or CO2 laser**

Contact Nd:YAG laser therapy appears to be efficient and safe in the treatment of anorectal lesions, including anal fissures (Sankar & Joffe, 1988; Walfisch et al., 1994). With the advent of the CO2 laser, a laser sphincterotomy and fissurectomy have proved to be very effective, with good results, prompt rehabilitation, reduced amount of complications and fewer recurrences (Ali, 1988; Skobelkin et al., 1989). It involves laser vaporization of the fissure locally. Patient acceptance is remarkable, and the treatment can be carried out at a fraction of the cost of hospital surgical treatment. There are no reports of laser treatment for anal fissures in children.

### **11.9 Wonder remedies**

60 Complementary Pediatrics

hyperhidrosis, achalasia and chronic anal fissure (Jankovic & Brin, 1991). Botulinum toxin (Botox) is associated with a similar rate of healing of anal fissure as GTN, but is more expensive. The technique, dose and site of injection do not affect the rate of healing. The experience in children is very small. Jost & Schimrig (1993) first reported the use of botulin toxin (BT) for anal fissure in 1933. The commercially available agent prevents neural transmission by preventing acetylcholine release from presynaptic nerve terminals. BT exerts its effects on the acetylcholine releasing parasympathetic peripheral nerve endings as well as the ganglionic nerve endings, leading to flaccid paralysis of the internal anal sphincter (IAS). This effect stays for about 3 months, a period sufficient for most noncomplicated anal fissures to heal. Jost (1997) subsequently reported on a series of 100 patients treated with BT injection. In all, 78 patients became pain-free within 3 days, and healing rates at 3 and 6 months were 82% and 79%. BT injection was compared with topical GTN (0.2% twice daily) in a randomized trial of 50 chronic anal fissure patients (Brisinda et al., 1999). Resting anal pressure decreased in both groups, but did so to a greater extent in the BT group (29% with BT vs. 14% with GTN at 2 months). Healing rates were 96% in the

BT group and 60% in the GTN group. No adverse effects were seen in the BT group.

operation or in whom surgery has failed (Cundall et al., 2003).

panthenol, calendula, goldenseal and Emu oil , can be used (Kruzel, 2006).

Hyperbaric oxygen therapy provides a significant increase in tissue oxygenation in hypoperfused wounds. This increase in oxygen tension induces positive changes in the wound repair process by enhancing fibroblast replication, collagen synthesis and neovascularization. Cundall et al. (2003) reported a small series of adult patients with chronic anal fissure treated by hyperbaric oxygen. They found the procedure safe and appropriate in patients who have failed medical treatment, in those at risk of fecal incontinence, and in patients who are unfit for

Homeopathic medicines are excellent to alleviate the pain and spasm. Some of the more often indicated medicines are Chamomilla, Graphites, Nitric acid, Ratanhia, Sepia, Silicea and Thuja. Aesculus and Paeonia may be indicated if keynote symptoms are present. Homeopathic medicines often work faster and provide greater pain relief than analgesics and narcotics. In order to facilitate healing of the fissure, a topical cream consisting of Vitamins A and E,

Iontophoresis using a zinc or copper electrode and applying a positive current will help to facilitate healing by hardening the underlying fissure, decreasing bleeding and affording

Contact Nd:YAG laser therapy appears to be efficient and safe in the treatment of anorectal lesions, including anal fissures (Sankar & Joffe, 1988; Walfisch et al., 1994). With the advent of the CO2 laser, a laser sphincterotomy and fissurectomy have proved to be very effective, with good results, prompt rehabilitation, reduced amount of complications and fewer

**11.5 Hyperbaric oxygen** 

**11.6 Naturopathic treatment** 

**11.7 Iontophoresis** 

**11.8 Nd:YAG or CO2 laser** 

pain relief.

Fig. 3a. Anal Fissures DX: a unique formula with anti-inflammatory properties, providing immediate soothing relief.

Fig. 3b. H-Fissures: healing natural oil with anti-inflammatory properties, specially formulated to provide instant relief from the pain and discomfort of fissures, reducing the swelling without skin irritation.

Fig. 3c. Fissure Control: a breakthrough topical homeopathic treatment made of a blend of herbs (Chamomile, Lavandula Angustifolia, Helichrysum, and Hamamelis Virginiana).

Nifedipine Gel with Lidocaine in the Treatment

disease and profound immunosupression.

**12. Surgical treatment** 

**12.1 Anal dilatation** 

**12.2 Fissurectomy** 

**12.3 Internal anal sphincterotomy** 

of Anal Fissure in Children: A Pilot Study and Review of the Literature 63

Surgical treatment is rarely needed for infants and children. Open or closed lateral internal sphincterotomy (healing rates of 93% to 100%, recurrence rates of 0% to 25%), internal sphincterotomy (for chronic anal fissures), and posterior midline sphincterotomy are all part of the surgical arsenal. The open lateral sphincterotomy is the procedure of choice for children. Relative contraindications to operative treatment include inflammatory bowel

First described in 1829 by Recamier and popularized by Lord in the treatment of hemorrhoids, anal stretching has been used in the past based on the concept of loosening the sphincter muscle and increasing the blood flow to the anoderm. Anal dilatation was reintroduced for anal fissure therapy in 1964, with success rates of 87% to 100% (Watts et al., 1964), but are not recommended in children because of the very high rate of recurrence (10%

Fissurectomy as a treatment for anal fissures in children was found successful only when combined with postoperative laxative therapy (Lambe et al., 2000a). An important part of their technique was the use of stay sutures to avoid the need for an anal retractor, thereby preventing stretching of the internal anal sphincter. A triangular part of the anoderm is excised along with the fissure itself. A good and reliable operation, but leaves behind a large and uncomfortable external wound, which takes a long time to heal. Application of a split

Internal anal sphincterotomy (IAS) was popularized for the treatment of anal fissure during the 1950s by Eisenhammer (1951). Lateral internal sphincterotomy (LIS) has been found to be the preferred operation. LIS can be performed using either the open or closed technique , the method of Notaras, dividing the IAS via a small stab wound (Notaras, 1971). Equal success has been reported with open or closed lateral sphincterotomy for acute and chronic anal fissures in children. A systematic review on the treatment of anal fissure was published by Steele & Madoff in 2006. Current concepts in anal fissures were reported by Ayantude et

Chronic anal fissures tend to be refractory and are usually reluctant to heal with conservative treatment. Chronicity is defined by chronology (6-8 weeks) and morphologic features (visible transverse internal anal sphincter fibers, chronic granulation tissue, indurated edge, a sentinel pile, and a hypertrophic anal papilla). A very large series of adult patients was published by Lysy et al. in 2006. Prolonged periods of treatment were necessary and 384 patients were healed (84.4%) by the end of four months. Older age and longer time interval between symptom appearance and treatment negatively affected fissure healing. The explanation for the latter was that longer time exposure of the fissure area to


thickness graft to the wound has been advocated, in order to improve healing.

al. (2006) in the same year, involving a literature search from 1970 to 2004.

Fig. 3d. Paeonia-Heel: a homeopathic medicine containing Paeonia officinalis (Peony), Graphites (graphite), Nux vomica (vomit nut), Sulfur (sulphur), Acidum nitricum (nitric acid), and Hamamelis (witch-hazel).

Fig. 3e. Dr Wheatgrass's cream: enriched with highly bioactive wheatgrass-derived antioxidants, containing vitamins A,C and E, phytosterols, aminoacids and minerals. The Figure shows Dr Wheatgrass's antioxidant skin recovery cream.

Fig. 3f. Nature's Wonderland Stone Root Herbal Supplement: Collinsonia Canadensis, sour and spicy in taste, and warming in action. It relaxes constriction and clears venous congestion and inflammation. The Figure shows the Collinsonia Canadensis flowers.
