Colorectal Website Review John R. Monson, M.D., Editor

Anal Fissure This section provides a monthly review of websites both from the specialist colorectal surgeon, colorectal nurse specialist, and the patient_s perspectives. A different topic will be addressed in every issue. If you have topic or website suggestions, please send them to [email protected]

Anal fissures (fissure-in-ano) are ulcers or tears occurring in the squamous epithelium of the anal canal usually precipitated by constipation or anal trauma. They are common and account for up to 15 percent of colorectal surgical clinic attendances. For the patient, anal fissures cause significant pain and in refractory cases can lead to deterioration in quality of life. Symptom duration and treatment responses of anal fissures are difficult to predict and surgery remains a last resort with risk of incontinence. The internet offers information on this condition, and the more popular sites are reviewed in this article. These sites only deal with primary anal fissures not associated with underlying disease conditions (e.g., carcinoma, Crohn_s, lymphoma, or infective diseases). Other complicated fissures require specialist medical advice depending on disease pathology. FOR THE PHYSICIAN AND SPECIALIST NURSE: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003431/frame.html The Cochrane Library is a collection of databases designed to evaluate independent evidence and aid healthcare decision-making. The review is written by Rick Nelson, M.D., late of Chicago, Illinois and now of Sheffield, U.K., and divided to surgical and nonsurgical therapies for anal fissure. This link leads to the article BNon-surgical therapy for anal fissure,^ which was published recently in October 2006. jjjj—Although this is a bulky document of 59 pages, the discussion element is short (5–6 pages) with sufficient content and succinctness to make easy reading for the average clinician. For the specialist wanting a more detailed view of the evidence, individual studies are summarized showing primary outcome and results. This is followed by tables comparing results of treatments in nonrandomised studies and concludes with meta-analysis of nonsurgical treatment vs. placebo/surgical intervention showing treatment success or incidence of adverse events. This review is recent, easy to read, and is structured so that both the specialist and nonspecialist are able to obtain as much or as little information required. However, it does not list final treatment recommendations for quick reading in a comprehensible way, and some sections require the reader to draw their own conclusions. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002199/frame.html BThe operative procedures for fissure-in-ano^ is the second section of the Cochrane Review and is written by the same author. The layout is the same as the first section on the nonsurgical management of anal fissures; however, this section is shorter (21 pages) as a result of the paucity and poor study quality of trials into surgical treatment. The metaDOI: 10.1007/s10350-007-0268-8 Published online: 14 June 2007

1280

Vol. 50, No. 8

COLORECTAL WEBSITE REVIEW analyses component compares only three of the operative techniques (anal stretch, open lateral internal sphincterotomy, and closed lateral internal sphincterotomy) because of the lack of comparative trials. Individual comparative reports are presented on lateral sphincterotomy vs. dermal skin flap, posterior sphincterotomy vs. lateral sphincterotomy and other techniques. This is a relatively recent report published in April 2005. jjjj—The relatively poor evidence of surgical treatments for anal fissure is highlighted, but nevertheless, the discussion is good and the recommendations are clear. Similar to the section on nonsurgical interventions, this provides easy access to information for the specialist and nonspecialist. http://www.clinicalevidence.com/ceweb/besttreatments/dsd/0407/0407_keymessages. jsp?btuk=1 BestTreatments is produced by the British Medical Journal (BMJ) Publishing Group Limited, which also provides recommendations based on review of recent literature. There is a separate Bpatient^ version and Bdoctors^ version. Most of the Bdoctors_ version^ is written by Rick Nelson and the recommendations are similar to the Cochrane Library. jjjj 1/2—The information on this site is similar to the Cochrane Review; however, whereas the Cochrane Review provides a more critical evaluation of the literature, including metholodological quality, this site provides the results of relevant trials but in a more readable way for those not wanting to explore the fine details of individual studies. The references provided are adequate for those wanting further reading. Details of trials comparing various treatments are shown and estimated treatment effects/adverse events incidence also are mentioned. This should be the first choice for most physicians. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=6506&nbr=4075 BPractice parameters for the management of anal fissures^ from The National Guidelines Clearing House was published in Diseases of the Colon & Rectum in 2004 and was written by the Standards Task Force of The American Society of Colon and Rectal Surgeons; among them is Richard Nelson, M.D. (who also wrote the Cochrane Review and BestTreatments as discussed previously). Eight recommendations are made for surgical and nonsurgical management of anal fissures. Each recommendation is followed by Level of Evidence (I–V) and Grade of Recommendation (A–D). jj—The eight recommendations are short, encompass all surgical and nonsurgical treatments, and will easily fit into white coat pockets as the briefest aide memoir for interns. However, the recommendations are made on expert consensus, and no discussion of the evidence is provided on the website. Discussion is available in the published version of Diseases of Colon & Rectum, although this is brief and seems to accept the face recommendations of individual studies without assessment of study quality. This website is a Bstarter kit^ for treatment of anal fissures, and readers would better benefit by obtaining the full version published in Diseases of the Colon & Rectum. http://www.surgeons.org/AM/presentations/DTrotter_1204.pdf This links to a 26-slide PowerPoint presentation by Dr. Dean Trotter, which has been embedded into a .pdf file (which is unfortunate). The presentation is well laid out; the slides are clear with sufficient information so as not to require a speaker. Each surgical and nonsurgical intervention is briefly described, also listing advantages and disadvantages and one trial to support the conclusions. Results of relevant comparative studies are shown toward the end. Basic surgical diagrams are used to depict surgical techniques. jjj—This is a good presentation but it has been severely hindered by conversion into a pdf file, which makes manoeuvring through the slides tedious. It is not meant to be an exhaustive critical evaluation but rather an overview of treatments with some supporting evidence—and succeeds in doing so. The information is suitable for most students and clinicians.

1281

1282

COLORECTAL WEBSITE REVIEW

Dis Colon Rectum, August 2007

INFORMATION FOR PATIENTS: http://www.besttreatments.co.uk/btuk/conditions/1000307477.html This site is the Bpatient version^ of BestTreatments, which was described earlier. The overall structure is the same as other patient-orientated sites, with pages on definition, symptoms, causes, and treatments. The treatment page is divided into Btreatments that work,^ Blikely to work,^ Bwork but whose harms may outweigh benefits,^ and Bneed further study^ with references. jjjj 1/2—This is probably the best site available for patients. The treatments are classified by how likely they are to work. Percentages from studies are quoted to provide a rough estimate of success and side-effects. Sufficient references are listed for the keen patient to look up. The layout is simple and fresh. Language is simple and medical terms are defined by clicking on them. Another novelty is that this seems to be the only site not inundated with distracting and annoying advertisements. It would benefit from one to two pictures to make it perfect, but overall, this is an excellent site. http://www.medicinenet.com/anal_fissure/article.htm MedicineNet.com (operated by WebMD) is an online, healthcare, media publishing company with information provided by physicians who also produced Webster_s New Worldi Medical Dictionary. The discussion is divided into separate web pages for definition, causes, symptoms, and treatment. This makes navigation more difficult, especially if using a slow computer. However, there is an option for a printer-friendly version, which combines all of the information in a continuous fashion, making a useful brochure. The language is simple and medical terms are defined by clicking on them. The treatments are well discussed with a good description of how each treatment is designed to work in relation to pathophysiology of anal fissures. Success rates from a few trials are quoted but not referenced. Key points are summarized at the end of the document in BAnal fissures at a glance.^ jjjj—This site is useful for patients with anal fissures. It is brief, concise, and provides information on pathophysiology of disease and also how treatments alter affect this. The estimated success rates are shown, although references for study results are not provided. However, this is not meant to be a critical evaluation for physician but rather additional information for the patient. It is one of the few sites that emphasizes the length of time that may be required for fissures to heal. Similar to many other websites for patients, this suffers from lack of pictures or tables, which would have simplified discussion. http://www.mayoclinic.com/health/anal-fissure/DS00762 Information on anal fissures provided by the Mayo Clinic website, last updated August 2006. jj —The format is similar to other websites in terms of diagnosis, risk factors, and treatment. It also visually highlights pertinent text points, making it much easier to follow. However, the explanation and content is inadequate, estimated success probabilities of treatments are not provided, and discussion is too brief. Overall, it is less inspiring than other websites. It may be useful as a leaflet to provide at initial diagnosis. http://www.webmd.com/hw/digestive_problems/uf4765.asp WebMD is another health information providing website, which is linked to the MedicineNet site. jj 1/2—This website is similar to the Mayo Clinic website but has slightly more factual content and medical terms are defined by clicking on them. The information is brief with all treatment options discussed in less than two half-pages. The reported success rates of individual

Vol. 50, No. 8

COLORECTAL WEBSITE REVIEW surgical and nonsurgical interventions are sporadic and based on approximately three references. The site is easy to read but contains minimal information on treatment and does not discuss surgical options. It may be useful as another leaflet to provide at initial diagnosis. http://www.boardsailor.com/jack/af/ This site is a unique self-help site started by a patient with anal fissure. There are 67 accounts from various patients from 1997 to present. Patients_ sagas are divided to those who underwent surgery, those with nonsurgical intervention, parents of children with fissures, and pregnant women with fissures. jj 1/2—The layout of this site is poor with endless reams of small text on a white background. There are 67 patient accounts and my vision blurred after the first 4. At the end of the site, a headache was induced by further changes in text size, font, and color. In terms of information content, it is difficult to find information on specific treatments, although an attempt is made to summarize each patient_s account in one sentence. These experiences are not an objective evaluation of treatment, and patients should be cautious about forming opinions based on the views expressed on this site. Beneficial treatments range from dietary advice, neomycin, and oil of oregano/wheat germ to antifungal foot cream to home dilatation using dildos from a sex shop. However, it does provide a forum/information freeshare about experiences of living with anal fissures, which may not be appreciated by the physician. The accounts on the postoperative recovery might give patients more realistic expectations than that provided by the medical team. MULTIMEDIA RESOURCES: http://www.proctosite.com/video_atlas/video_atlas_fissure.php This useful site by Proctosite is a free, open site dedicated to development of clinicians involved in colorectal disease. There are a series of video and still images of various surgical procedures and an overview of recent colorectal papers. jjj 1/2—There is a short video on anal fissure surgery, which shows a lateral internal sphincterotomy, and various other still images of similar procedures. This is an invaluable educational tool. However, it seems to be early in development and only limited topics are covered. This site is suitable for surgeons wanting to learn more about operative technique, bearing in mind that variations of the same surgical procedure are used by different surgeons. Only patients with the strongest constitution (or most inquisitive) are advised to watch this, especially if symptomatic with an anal fissure. OTHER: http://www.patient.co.uk/showdoc/23068676/ j 1/2—A single-page site that hardly contains any information of use. This is suitable for the passing nonmedical personnel who wants to know what an anal fissure is but has no vested interest. http://www.medic8.com/healthguide/articles/analfissure.html j 1/2—Another single-page site with insufficient information to guide treatment. http://www.nlm.nih.gov/medlineplus/ency/article/001130.htm# j —This is the only site with a pictorial depiction of an anal fissure, but information is even less than the others. One star, just for the pictures.

1283

COLORECTAL WEBSITE REVIEW

1284

Dis Colon Rectum, August 2007

SUMMARY: The website content on anal fissures is unsurprisingly not as extensive as other Bmore serious^ colorectal pathology, such as cancer or inflammatory bowel disease. Unfortunately, there is only one site that shows a picture of an anal fissure, which may alleviate patient anxiety, many who only know fissures as Ba tear^ but are unable to see it because of anatomical considerations. Overall best site for physician and nurse specialist: http://www.clinicalevidence.com/ceweb/besttreatments/dsd/0407/0407_keymessa ges.jsp?btuk=1 (jjjj 1/2) Best site for specialist wanting highly specific information on individual reports and critical evaluation of studies: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003431/frame.html (jjjj) Best patient site: http://www.besttreatments.co.uk/btuk/conditions/1000307477.html (jjjj 1/2)

Aravind Suppiah, M.R.C.S. East Yorkshire, United Kingdom Chris Macklin, M.D. West Yorkshire, United Kingdom