Can topical applicatıons be an alternative to surgery in the treatment of chronic anal fissures?

Abstract

Introduction: Anal fissure, characterized by a painful ulcer in the anal canal, presents a significant medical challenge. While surgical approaches like lateral internal sphincterotomy (LIS) have been the gold standard for chronic anal fissures, they come with potential complications such as incontinence and abscess formation. In contrast, medical treatments, including topical glyceryl trinitrate and diltiazem, have emerged as alternatives, offering non-invasive options with potentially fewer complications. Method: In this retrospective study, we evaluated 136 patients treated for chronic anal fissures between June 2019 and December 2022 at Balikesir University Hospital, comparing surgical and medical interventions. The study encompassed demographic analysis, treatment modalities, complete recovery, recurrence rates, and side effects/complications. Statistical analyses, including logistic regression, were performed to assess the efficacy and risks associated with different treatments. Results: Our findings indicated a higher rate of complete recovery with surgical treatment (86.1%) compared to medical treatments (glyceryl trinitrate: 64.8%, diltiazem: 69.6%). However, no significant difference was observed in recurrence rates between treatment groups. Surgical intervention exhibited a higher incidence of complications such as incontinence and abscess formation, while medical treatments were associated with side effects like headache and gastrointestinal disturbances. Notably, diltiazem therapy showed outcomes comparable to other modalities, indicating its potential as an effective and safer alternative. Conclusion: Despite the favorable outcomes of surgical treatment, considerations of potential complications underscore the importance of tailored approaches. Prospective, randomized controlled trials with larger cohorts are warranted to further elucidate the efficacy and safety profiles of medical treatments in chronic anal fissures, facilitating informed decision-making in clinical practice.

Keywords

• Lateral internal sphincterotomy
• Fissure in ano
• Nitroglycerin
• Diltiazem

References

1. 1.Cross KLR, Brown SR, Kleijnen J, et al. TheAssociation of Coloproctology of Great Britain andIreland guideline on the management of anal fissure. Color Dis. 2023;25(12):2423–57.
2. 2.Higuero T. Update on the management of analfissure. J Visc Surg. 2015;152(2):S37–43.
3. 3.Vaithianathan R, Panneerselvam S. Randomisedprospective controlled trial of topical 2% diltiazemversus lateral internal sphincterotomy for thetreatment of chronic fissure in ano. Indian J Surg.2015;77:1484–7.
4. 4.Al-Ubaide AF, Al-Rubaye SM, Al-Ani RM, Amer AU,Al-Rubaye S. Lateral internal anal sphincterotomy of chronic anal fissure: an experience of 165 cases.Cureus. 2022;14(10).
5. 5.Hananel N, Gordon PH. Re-examination of clinicalmanifestations and response to therapy of fissure-in-ano. Dis colon rectum. 1997;40(2):229–33.
6. 6.Asefa Z, Awedew AF. Comparing closed versusopen lateral internal sphincterotomy formanagement of chronic anal fissure: systematicreview and meta-analysis of randomised controltrials. Sci Rep. 2023;13(1):20957.
7. 7.Stewart Sr DB, Gaertner W, Glasgow S, Migaly J,Feingold D, Steele SR. Clinical practice guideline forthe management of anal fissures. Dis Colon Rectum.2017;60(1):7–14.
8. 8.Garg P, Garg M, Menon GR. Long-term continencedisturbance after lateral internal sphincterotomyfor chronic anal fissure: a systematic review andmeta-analysis. Color Dis. 2013;15(3):e104–17.

9. 9.Ala S, Saeedi M, Hadianamrei R, Ghorbanian A.Topical diltiazem vs. topical glyceril trinitrate in thetreatment of chronic anal fissure: a prospective, randomized, double-blind trial. Acta Gastroenterol Belg. 2012;75(4):438–42.
10. 10.Kocher HM, Steward M, Leather AJM, Cullen PT.Randomized clinical trial assessing the side-effectsof glyceryl trinitrate and diltiazem hydrochloride inthe treatment of chronic anal fissure. Wiley OnlineLibrary; 2002.
11. 11.Davids JS, Hawkins AT, Bhama AR, et al. TheAmerican Society of Colon and Rectal SurgeonsClinical Practice Guidelines for the Management ofAnal Fissures. Dis Colon Rectum. 2023;66(2):190–9.
12. 12.Arroyo A, Montes E, Calderón T, et al. Treatmentalgorithm for anal fissure. Consensus document ofthe Spanish Association of Coloproctology and theColoproctology Division of the Spanish Associationof Surgeons. Cirugía Española (English Ed.2018;96(5):260–7.
13. 13.Salati SA. Anal fissure–an extensive update.Polish J Surg. 2021;93(4):46–56.
14. 14.Brown CJ, Dubreuil D, Santoro L, Liu M, O’ConnorBI, McLeod RS. Lateral internal sphincterotomy issuperior to topical nitroglycerin for healing chronicanal fissure and does not compromise long-termfecal continence: six-year follow-up of a multicenter,randomized, controlled trial. Dis colon rectum.2007;50:442–8.
15. 15.Nevins EJ, Kanakala V. Topical diltiazem andglyceryl-trinitrate for chronic anal fissure: A meta-analysis of randomised controlled trials. Turkish JSurg. 2020;36(4):347.
16. 16.Patel HS, Chavda J, Parikh J, Naik N. Study ofoperated patients of lateral internal analsphincterotomy for chronic anal fissure. J Clindiagnostic Res JCDR. 2013;7(12):2863.
17. 17.Acar T, Acar N, Güngör F, et al. Comparativeefficacy of medical treatment versus surgicalsphincterotomy in the treatment of chronic analfissure. Niger J Clin Pract. 2020;23(4):539–44.
18. 18.Bara BK, Mohanty SK, Behera SN, et al.Fissurectomy versus lateral internal sphincterotomy in the treatment of chronic anal fissure: A randomized control trial. Cureus. 2021;13(9).
19. 19.Magdy A, El Nakeeb A, Youssef M, Farid M.Comparative study of conventional lateral internalsphincterotomy, VY anoplasty, and tailored lateralinternal sphincterotomy with VY anoplasty in thetreatment of chronic anal fissure. J Gastrointest Surg. 2012;16(10):1955–62.
20. 20.Abdelhady H, Othman I, Hablus M, Ismail T,Aboryia M, Selim M. Long-term prospectiverandomised clinical and manometric comparisonbetween surgical and chemical sphincterotomy fortreatment of chronic anal fissure. South African JSurg. 2009;47(4).
21. 21.Newman M, Collie M. Anal fissure: diagnosis,management, and referral in primary care. Br J GenPract. 2019;69(685):409.
22. 22.Shrivastava UK, Jain BK, Kumar P, Saifee Y. Acomparison of the effects of diltiazem and glyceryltrinitrate ointment in the treatment of chronic analfissure: a randomized clinical trial. Surg Today.2007;37:482–5.
23. 23.Bansal AR, Kumar Yadav P, Godara R, Pal N,Tripura R, Jaikaran. Comparative evaluation of 0.2%glyceryl trinitrate vs. 2% diltiazem ointment intreatment of chronic anal fissure treatment-arandomized trial. Hell J Surg. 2016;88:25–30.