**14. Special situations**

64 Complementary Pediatrics

inflammation and ischemia and subsequent fibrosis may compromise the healing process. After recurrence, patient education for self and prompt retreatment was found to improve outcome. Chronic anal fissures are caused by internal sphincter hypertonia, which leads to reduced blood flow and tissue hypoxia, with consequent healing failure. A cautious surgical approach is required to treat those who do not respond to medical treatment, and should include excision of the fissure along with its sentinel tag and internal sphincterotomy at the base of the ulcer (Cohen & Dehn, 1995; Lambe et al., 2000b). The wound is left open and should heal in 7-14 days without scarring. Local reconstruction with advancement flaps is a relatively new and effective adjunct to chronic fissure excision. Practice parameters for the management of anal fissures from the American Society of Colon and Rectal Surgeons were reported by Orsay et al. (2004) and a very extensive review on the diagnosis and care of patients with anal fissure was reported by the American Gastroenterological Association

Seventy children suffering from acute and chronic anal fissures treated by us between 2004 and 2010 comprised the study population. They were all treated topically with nifedipine gel 0.2% with lidocaine for 4 weeks and followed up for as long as possible in our outpatient

Because anal fissure has such a distinctive appearance, its healing is the most objective measure of treatment efficacy available that can be standardized. Combining all analyses in which a placebo was used as the comparison group, the healing rate in the placebo group is 35.5 percent, a level of response that is fairly uniform across studies (standard deviation, 11.8 percent). For these reasons we did not find necessary to use a control group in the

There were 28 males and 42 females. Their clinical presentation consisted of constipation, rectal bleeding, anal and abdominal pain, perianal itching and rectal prolapse (58, 50, 33, 6, 4, and 1 cases, respectively). Posterior, anterior, multiple, both posterior and anterior, and both posterior and lateral fissures were the main physical findings (44, 16, 5, 4, and 1 cases, respectively). Fifty eight patients completed the 4-week treatment course, with another 7 patients requiring a second 4-week treatment course in order to achieve complete remission, indicated by resolution of symptoms and complete healing of the fissure (65 patients altogether). The remaining 5 patients had recurrence of symptoms in 2, 4, 11, 18 and 19 months, respectively, treated successfully by an additional 4-week course of nifedipine. The recurrence rate observed was very low (7.14%). All the 70 patients had a mean follow-up of 1.88 years, ranging from 6 months to 5.2 years. Problems with compliance were not observed, one of the main reasons for treatment failure in adults. No side effects of

(Madoff & Fleshman, 2003).

clinic (a maximum of 5 years).

**13.1 Subjects** 

**13.2 Methods** 

present pilot study.

nifedipine were observed.

**13.3 Results** 

**13. Our experience: Nifedipine gel 0.2% with lidocaine** 

