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Langenbeck's Archives of Surgery Feb 2005Chronic anal fissure is a common benign disorder that causes severe, sharp anal pain during defaecation. Fissures are generally associated with raised resting anal... (Review)
Review
BACKGROUND
Chronic anal fissure is a common benign disorder that causes severe, sharp anal pain during defaecation. Fissures are generally associated with raised resting anal pressures, and treatments are aimed at reduction of these pressures. Surgical sphincterotomy is very successful at healing fissures but is associated with significant morbidity. Much work has gone into the development of new pharmacological agents that can promote healing of chronic anal fissures by production of a reversible chemical sphincterotomy, with the aim of avoiding long-term problems of incontinence.
METHODS
We review these recent innovations that have largely replaced surgery as first line treatment for chronic anal fissure.
CONCLUSIONS
Despite there being initial success with many of these pharmacological agents in the treatment of patients with chronic anal fissures, there are still some concerns about their use. In particular, the occurrence of side effects limits their use, and, unfortunately, they are not always effective at healing fissures. However, despite these drawbacks they remain excellent first-line options in the treatment of chronic anal fissures, and surgery should be offered only to patients who fail these therapies.
Topics: Algorithms; Anal Canal; Botulinum Toxins; Calcium Channel Blockers; Fissure in Ano; Humans; Nitroglycerin; Pressure
PubMed: 14624292
DOI: 10.1007/s00423-003-0430-2 -
Acta Chirurgica Belgica 2006The physiopathology of anal fissures is still not completely elucidated. Most probably, chronic anal fissures are ischaemic ulcers, continuously enhanced by sphincter... (Review)
Review
The physiopathology of anal fissures is still not completely elucidated. Most probably, chronic anal fissures are ischaemic ulcers, continuously enhanced by sphincter hypertonia. The dorsal location of most fissures is attributed to the scarcity of arteriolar anastomoses dorsally. The healing process is obstructed by fibrosis, provoked by repeated mechanical injuries and chronic inflammation.
Topics: Chronic Disease; Fissure in Ano; Humans
PubMed: 17168260
DOI: 10.1080/00015458.2006.11679942 -
The Surgical Clinics of North America Jun 1978
Review
Topics: Adult; Anus Diseases; Constriction, Pathologic; Crohn Disease; Diagnosis, Differential; Female; Fissure in Ano; Humans; Male; Ulcer
PubMed: 354052
DOI: 10.1016/s0039-6109(16)41531-8 -
The Cochrane Database of Systematic... Oct 2006Because of the disability associated with surgery for anal fissure and the risk of incontinence, medical alternatives for surgery have been sought. Most recently,... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Because of the disability associated with surgery for anal fissure and the risk of incontinence, medical alternatives for surgery have been sought. Most recently, pharmacologic methods that relax the anal smooth muscle, to accomplish reversibly what occurs in surgery, have been used to obtain fissure healing.
OBJECTIVES
To assess the efficacy and morbidity of various medical therapies for anal fissure.
SEARCH STRATEGY
Search terms include "anal fissure randomized". Timing from 1966 to May 2006. Further details of the search below.
SELECTION CRITERIA
Studies in which participants were randomized to a non-surgical therapy for anal fissure. Comparison groups may include an operative procedure, an alternate medical therapy or placebo. Chronic fissure, acute fissure and fissure in children are included in the review. Atypical fissures associated with inflammatory bowel disease or cancer or anal infection are excluded.
DATA COLLECTION AND ANALYSIS
Data were abstracted from published reports and meeting abstracts, assessing method of randomization, blinding, "intention to treat" and drop-outs, therapies, supportive measures (applied to both groups), dosing and frequency and cross-overs. Dichotomous outcome measures included Non-healing of the fissure (a combination of persistence and recurrence), and Adverse events (including incontinence, headache, infection, anaphylaxis). Continuous outcome measures included measures of pain relief and anorectal manometry.
MAIN RESULTS
48 different comparisons of the ability of medical therapies to heal anal fissure have been reported in 53 RCTs. Eleven agents were used (nitroglycerin ointment (GTN), isosorbide dinitrate, Botulinum toxin (Botox), diltiazem, nifedipine (Calcium channel blockers or CCBs), hydrocortisone, lignocaine, bran, minoxidil, indoramin, and placebo) as well as anal dilators and surgical sphincterotomy.GTN was found to be marginally but significantly better than placebo in healing anal fissure (48.6% vs. 37%, p < 0.004), but late recurrence of fissure was common, in the range of 50% of those initially cured. Botox and CCBs were equivalent to GTN in efficacy with fewer adverse events. No medical therapy came close to the efficacy of surgical sphincterotomy, though none in these RCTs was associated with the risk of incontinence.
AUTHORS' CONCLUSIONS
Medical therapy for chronic anal fissure, acute fissure and fissure in children may be applied with a chance of cure that is marginally better than placebo, and, for chronic fissure in adults, far less effective than surgery.
Topics: Fissure in Ano; Humans; Randomized Controlled Trials as Topic
PubMed: 17054170
DOI: 10.1002/14651858.CD003431.pub2 -
The Cochrane Database of Systematic... 2003Because of the disability associated with surgery for anal fissure and the risk of incontinence, medical alternatives for surgery have been sought. Most recently,... (Review)
Review
BACKGROUND
Because of the disability associated with surgery for anal fissure and the risk of incontinence, medical alternatives for surgery have been sought. Most recently, pharmacologic methods that relax the anal smooth muscle, to accomplish reversibly what occurs in surgery, have been used to obtain fissure healing.
OBJECTIVES
To assess the efficacy and morbidity of various medical therapies for anal fissure.
SEARCH STRATEGY
Search terms include "anal fissure randomized".
SELECTION CRITERIA
Studies in which participants were randomized to a non-surgical therapy for anal fissure. Comparison groups may include an operative procedure, an alternate medical therapy or placebo. Chronic fissure, acute fissure and fissure in children are included in the review. Atypical fissures associated with inflammatory bowel disease or cancer or anal infection are excluded.
DATA COLLECTION AND ANALYSIS
Data were abstracted from published reports and meeting abstracts, assessing method of randomization, blinding, "intention to treat" and drop-outs, therapies, supportive measures (applied to both groups), dosing and frequency and cross-overs. Dichotomous outcome measures included Non-healing of the fissure (a combination of persistence and recurrence), and Adverse events (including incontinence, headache, infection, anaphylaxis). Continuous outcome measures included measures of pain relief and anorectal manometry.
MAIN RESULTS
21 different comparisons of the ability of medical therapies to heal anal fissure have been reported in 31 RCTs. Nine agents were used (nitroglycerin ointment (GTN), isosorbide dinitrate, Botulinum toxin (Botox), diltiazem, nifedipine (Calcium channel blockers or Cachablos), hydrocortisone, lignocaine, bran, placebo) as well as anal dilators and surgical sphincterotomy. When two studies are excluded from analysis due to quality concerns, the significance disappears in the three main analyses: GTN vs. placebo group (0.78; 0.56-1.08), in children (0.96; 0.48-1.92) and adults (0.73; 0.50-1.07). That is, GTN was, in this modified analysis, not significantly better than placebo in curing anal fissure. Cachablos were not tested against placebo, but in a comparison to GTN, Cachablo was equivalent in its ability to cure fissure (odds ratio 0.66; 0.22-2.01). Botox, in a meta-analysis of two studies compared to placebo, showed no significant advantage in efficacy (0.75; 0.32-1.77), and in a comparison to GTN analyzing two studies, was also not significantly better than GTN (0.48; 0.21-1.10).
REVIEWER'S CONCLUSIONS
Medical therapy for chronic anal fissure, acute fissure and fissure in children may be applied with a chance of cure that is only marginally better than placebo, and, for chronic fissure in adults, far less effective than surgery.
Topics: Fissure in Ano; Humans; Randomized Controlled Trials as Topic
PubMed: 14583976
DOI: 10.1002/14651858.CD003431 -
CMAJ : Canadian Medical Association... Jul 2019
Review
Topics: Administration, Topical; Calcium Channel Blockers; Conservative Treatment; Fissure in Ano; Humans
PubMed: 31266788
DOI: 10.1503/cmaj.190074 -
Diseases of the Colon and Rectum Apr 2004This is a meta-analysis of randomized, controlled trials to assess the efficacy and morbidity of medical therapies for anal fissure. (Meta-Analysis)
Meta-Analysis Review
PURPOSE
This is a meta-analysis of randomized, controlled trials to assess the efficacy and morbidity of medical therapies for anal fissure.
METHODS
Medline and the Cochrane Controlled Trials Register and the Cochrane Colorectal Cancer Review Groups Controlled Trials Register were searched using the terms "anal fissure randomized" from 1966 to 2002. Studies in which participants were randomized to a nonsurgical therapy for anal fissure were the focus of this review. Comparison groups included an operative procedure, an alternate medical therapy, or placebo. Chronic fissure, acute fissure, and fissure in children were included in the review, however, atypical fissure associated with inflammatory bowel disease, cancer, or anal infection were excluded. Data were abstracted from published reports and meeting abstracts, assessing method of randomization, blinding, "intention to treat" and dropouts, therapies, supportive measures, dosing and frequency, and crossovers. Outcome measures included nonhealing of the fissure and adverse events.
RESULTS
Twenty one different comparisons of medical therapies to heal anal fissure have been reported in 31 trials, including 9 agents-glyceryl trinitrate, isosorbide dinitrate, botulinum toxin, diltiazem, nifedipine, hydrocortisone, lidocaine, bran, placebo-as well as anal dilators and surgical sphincterotomy. Glyceryl trinitrate was favored in the analysis over placebo (odds ratio = 0.55, 95 percent confidence interval, 0.41-0.74). After excluding two studies from analysis because of placebo response rates >2 standard deviations below the mean for all studies, the advantage of glyceryl trinitrate over placebo was no longer statistically significant (odds ratio = 0.78; 95 percent confidence interval, 0.56-1.08). Nifedipine and diltiazem did not differ from glyceryl trinitrate in their ability to cure fissure (0.66; 0.22-2.01). Botulinum toxin compared with placebo showed no significant efficacy (0.75; 0.32-1.77), and was also no better than glyceryl trinitrate (0.48; 0.21-1.10). Surgery was more effective than medical therapy in curing fissure (0.12; 0.07-0.22).
CONCLUSIONS
Medical therapy for chronic anal fissure, acute fissure, and fissure in children may be applied with a chance of cure that is only marginally better than placebo, and for chronic fissure, far less effective than surgery.
Topics: Adult; Botulinum Toxins, Type A; Child; Fissure in Ano; Humans; Neuromuscular Agents; Nifedipine; Nitroglycerin; Placebos; Prognosis; Randomized Controlled Trials as Topic; Treatment Outcome; Vasodilator Agents
PubMed: 14994109
DOI: 10.1007/s10350-003-0079-5 -
Current Problems in Dermatology 2002
Review
Topics: Administration, Topical; Botulinum Toxins, Type A; Fissure in Ano; Humans; Nitroglycerin
PubMed: 12471714
DOI: 10.1159/000060670 -
The British Journal of General Practice... Aug 2019
Topics: Administration, Topical; Botulinum Toxins, Type A; Conservative Treatment; Dietary Fiber; Fissure in Ano; Humans; Nitroglycerin; Ointments; Pain; Physical Examination; Practice Guidelines as Topic; Primary Health Care; Referral and Consultation
PubMed: 31345824
DOI: 10.3399/bjgp19X704957 -
Alimentary Pharmacology & Therapeutics Jul 2006Anal fissure is one of the most common anorectal conditions encountered in clinical practice. Most patients experience anal pain with defecation and minor bright red... (Review)
Review
BACKGROUND
Anal fissure is one of the most common anorectal conditions encountered in clinical practice. Most patients experience anal pain with defecation and minor bright red rectal bleeding, allowing a focused history to direct the evaluation.
METHODS
A systematic medical literature search of NIH, Pubmed, and MEDLINE using the search terms anal fissure, sphincterotomy, anal surgery and anal fissure medical therapy. English language was not a restriction. Cited references were used to find additional studies.
RESULTS
No single treatment is the best choice for all patients. Because pharmacological therapy is not associated with permanent alterations in continence, a trial of either a topical sphincter relaxant or botulin toxin injection, along with adequate fluid and fibre intake, is a reasonable option. However, because pharmacological therapy has lower healing and higher relapse rates, surgery can be offered in the first instance to patients without incontinence risk factors who have severe, unrelenting pain and are willing to accept a small risk of incontinence, for the highest likelihood of prompt healing and the lowest risk of recurrence.
CONCLUSIONS
Both non-operative and operative approaches currently exist for the management of anal fissure. Improved non-surgical therapies may continue to lessen the role of sphincter-dividing surgery in future.
Topics: Administration, Oral; Administration, Topical; Botulinum Toxins, Type A; Diet; Dilatation; Fissure in Ano; Gastrointestinal Agents; Humans; Injections, Intralesional
PubMed: 16842451
DOI: 10.1111/j.1365-2036.2006.02990.x