Skip to main content

Advertisement

SpringerLink
Log in

Randomised Prospective Controlled Trial of Topical 2 % Diltiazem Versus Lateral Internal Sphincterotomy for the Treatment of Chronic Fissure in Ano

  • Published:
Indian Journal of Surgery Aims and scope Submit manuscript

Abstract

Fissure in ano is a very common disorder of the anorectal region. Internal sphincter hypertonia with decreased relaxation coupled with mucosal ischemia of posterior anal canal are the major pathologies in chronic anal fissure (CAF). Though lateral internal sphincterotomy (LIS) remains the gold standard of treatment for the disease, it is accompanied by the potential complication of incontinence to both flatus and faecal matter. The aim of our study was to explore the role of topical diltiazem as an effective and a safe alternative to sphincterotomy for chronic anal fissure. Ninety patients with CAF were randomly assigned to group A and group B, with 45 patients each. Group A patients received 2 % diltiazem topical application, twice daily, and group B patients underwent LIS. All the patients were reviewed at first, fourth and sixth week after initiation of treatment. Visual analogue scores for pain and healing of fissure by visual inspection were recorded and compared. In group A, 71 % had complete healing of fissure at 6 weeks, with fair amount of pain relief (mean VAS—3.38), and in group B, 96 % showed healing of fissure, with excellent pain relief (mean VAS—1.87). Headache and flushing were noted in two patients in group A while no patients in group B developed incontinence. We conclude that LIS is more effective than topical diltiazem in the treatment of CAF. Topical diltiazem may be employed as an initial conservative treatment option before considering the surgical alternative.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Uwe W (2008) Pharmacological sphincterotomy for chronic anal fissures with the use of the botulinum toxin A. J Cutan Aesthet Surg 1:58–63

    Article  Google Scholar 

  2. Jensen SL (1988) Diet and other risk factors for fissure-in-ano. A prospective case control study. Dis Colon Rectum 31:770–773

    Article  CAS  PubMed  Google Scholar 

  3. Rankinic J (2007) Anal fissure. Clin Colon Rectal Surg 20:133–138

    Article  Google Scholar 

  4. Perry WB, Dykes SL, Buie WD, Rafferty JF (2010) Standards practice task force of the American Society of Colon and Rectal Surgeons Practice parameters for the management of anal fissures (3rd. revision). Dis Colon Rectum 53:1110–1115

    Article  PubMed  Google Scholar 

  5. Nelson RL, Chattopadhyay A, Brooks W, Platt I, Paavana T, Earl S (2011) Operative procedures for fissure in ano. Cochrane Database Syst Rev (11):Art. No.: CD002199. doi:10.1002/14651858.CD002199.pub4

  6. Publications.nice.org.uk. 2013. ESUOM3: Chronic anal fissure: 2% topical diltiazem hydrochloride key… ESUOM3. [online] Available at: http://publications.nice.org.uk/esuom3-chronic-anal-fissure-2-topical-diltiazem-hydrochloride-esuom3. Accessed 13 Dec 2013

  7. Schouten WR, Briel JW, Auwerda JJ (1994) Relationship between anal pressure and anodermal blood flow. Dis Colon Rectum 37:664–669

    Article  CAS  PubMed  Google Scholar 

  8. Schouten WR, Briel JW, Auwerda JJ, De Graaf EJ (1996) Ischaemic nature of anal fissure. Br J Surg 83:63–65

    Article  CAS  PubMed  Google Scholar 

  9. Nelson R (2009) Non surgical therapy for anal fissure. In: The cochrane library, issue 3. Wiley, Chichester

  10. Cross KL, Massey EJDA, Fowler AL, Monson JRT (2008) The management of anal fissure: ACPGBI position statement. Colorectal Dis 10(Suppl 3):1–7

    Article  PubMed  Google Scholar 

  11. Nelson RL, Thomas K, Morgan J, Jones A (2012) Non surgical therapy for anal fissure. Cochrane Database Syst Rev (2):Art. No.:CD003431. doi:10.1002/14651858.CD003431.pub3

  12. Nelson R (2010) Anal fissure (chronic). Clinical evidence; 03:407 BMJ Publishing Group Ltd

  13. Yiannakopoulou E (2012) Botulinum toxin and anal fissure: efficacy and safety systematic review. Int J Color Dis 27:1–9

    Article  Google Scholar 

  14. Brown CJ, Dubreuil D, Santoro L, Liu M, O’Connor BI, McLeod RS (2007) Lateral internal sphincterotomy is superior to topical nitroglycerin for healing chronic anal fissure and does not compromise long-term faecal continence: six-year follow up of a multicenter, randomized, controlled trial. Dis Colon Rectum 50:442–448

    Article  PubMed  Google Scholar 

  15. Karamanlis E, Michalopoulos A, Papadopoulos V et al (2010) Prospective clinical trial comparing sphincterotomy, nitroglycerin ointment and xylocaine/lactulose combination for the treatment of anal fissure. Tech Coloproctol 14:S21–S23

    Article  PubMed  Google Scholar 

  16. Perry WB, Dykes SL, Buie WD, Rafferty JF (2010) Practice parameters for the management of anal fissures (3rd revision). Dis Colon Rectum 53:1110–1115

    Article  PubMed  Google Scholar 

  17. Griffin N, Acheson AG, Jonas M, Scholefield JH (2002) The role of topical diltiazem in the treatment of chronic anal fissures that have failed glyceryl trinitrate therapy. Colorectal Dis 4:430–435

    Article  CAS  PubMed  Google Scholar 

  18. Shrivastava UK, Jain BK, Kumar P, Saifee Y (2007) A comparison of the effects of diltiazem and glyceryl trinitrate ointment in the treatment of chronic anal fissure: a randomized clinical trial. Surg Today 37:482–485

    Article  CAS  PubMed  Google Scholar 

  19. Jawaid M, Masood Z, Salim M (2009) Topical diltiazem hydrochloride and glyceryl trinitrate in the treatment of chronic anal fissure. J Coll Phys Surg Pak 19:614–617

    Google Scholar 

  20. Abd Elhady HM, Othman IH, Hablus MA et al (2009) Long-term prospective randomised clinical and manometric comparison between surgical and chemical sphincterotomy for treatment of chronic anal fissure. S Afr J Surg 47(1):12–14

    Google Scholar 

  21. Sanei B, Mahmoodieh M, Masoudpour H (2009) Comparison of topical glyceryl trinitrate with diltiazem ointment for the treatment of chronic anal fissure: a randomized clinical trial. Acta Chir Belg 109:727–730

    CAS  PubMed  Google Scholar 

  22. Sajid MS, Rimple J, Cheek E, Baig MK (2008) The efficacy of diltiazem and GTN for the medical management of chronic anal fissure: a meta-analysis. Int J Colorectal Dis 23:1–6

    Article  CAS  PubMed  Google Scholar 

  23. Siddique MI, Murshed KM, Majid MA (2008) Comparative study of lateral internal sphincterotomy versus local 0.2% glyceryl trinitrate ointment for the treatment of chronic anal fissure. Bangladesh Med Res Counc Bull 34:12–15

    Article  PubMed  Google Scholar 

  24. Liratzopoulos N, Efremidou EI, Papageorgiou MS, Kouklakis G, Moschos J et al (2006) Lateral subcutaneous internal sphincterotomy in the treatment of chronic anal fissure: our experience. J Gastrointest Liver Dis 15:143–147

    Google Scholar 

Download references

Acknowledgments

The authors thank the Postgraduate Dean Academics, Prof. N. Ananthakrishnan and Vice Chancellor of Mahatma Gandhi Medical College & Research Institute for their support and all the residents and staff in the Department of Surgery.

Conflict of Interest

None.

Author information

Authors and Affiliations

  1. Department of General Surgery, Mahatma Gandhi Medical College & Research Institute, Puducherry, 607402, India

    Rajan Vaithianathan

  2. Department of General Surgery, Chennai Medical College Hospital & Research Centre, Trichy, 621105, India

    Senthil Panneerselvam

Authors
  1. Rajan Vaithianathan
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Senthil Panneerselvam
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Rajan Vaithianathan.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Vaithianathan, R., Panneerselvam, S. Randomised Prospective Controlled Trial of Topical 2 % Diltiazem Versus Lateral Internal Sphincterotomy for the Treatment of Chronic Fissure in Ano. Indian J Surg 77 (Suppl 3), 1484–1487 (2015). https://doi.org/10.1007/s12262-014-1080-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12262-014-1080-z

Keywords

Search

Navigation