Abstract
Background
Treatment of chronic anal fissure (CAF) by fissurectomy with botulinum toxin A (BTA) injection results in a healing rate of greater than 90%. BTA injection, however, can cause incontinence and perianal sepsis. The decrease in sphincter pressure following topical treatment with 2% diltiazem cream (DTC) is comparable to that following BTA injection but with potentially fewer complications and at less cost. We report the shortterm results of a pilot study comparing fissurectomy with BTA and fissurectomy followed by DTC for the treatment of CAF.
Methods
The recorded outcomes of CAF following treatment with the two methods were analysed retrospectively. Patients underwent either fissurectomy followed by injection of 40 U BTA into the internal sphincter (group A) or fissurectomy followed by the perianal application of DTC twice daily for 8 weeks (group B). Symptom resolution and treatment side effects at the initial follow-up were compared.
Results
Demographics, fissure characteristics and the number of multiparous women between the two groups were comparable. At a median follow-up of 12 weeks (range 8–20 weeks), the two groups had similar rates of complete symptom resolution (group A, 25/28, 89.3%; group B, 19/23, 82.6%; p=0.7739), with minor side effects.
Conclusions
In this small pilot study fissurectomy combined with chemical sphincterotomy resulted in high short-term fissure healing rates. The study also suggested that fissurectomy followed by 8 weeks of topical DTC may be as good as fissurectomy with BTA injection in the treatment of CAF. A prospective study, adequately powered to determine the significance of differences is needed.
Similar content being viewed by others
References
Nelson R (2005) Operative procedures for fissure in ano. Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD002199. DOI: 10.1002/14651858.CD002199.pub2
Nyam DC, Pemberton JH (1999) Long-term results of lateral internal sphincterotomy for chronic anal fissure with particular reference to incidence of faecal incontinence. Dis Colon Rectum 42:1306–1310
Khubchandani IT, Reed JF (1989) Sequelae of internal sphincterotomy for chronic fissure in ano. Br J Surg 76:431–434
Garcia-Aguilar J, Belmonte C, Wong WD et al (1996) Open vs. closed sphincterotomy for chronic anal fissure: long-term results. Dis Colon Rectum 39:440–443
Carapeti EA, Kamm MA, McDonald PJ et al (1999) Randomised control trial shows that glyceryl trinitrate heals anal fissures, higher doses are not more effective, and there is a high recurrence rate. Gut 44:727–730
Cook TA, Humphreys MM, McC Mortensen NJ (1999) Oral nifedipine reduces resting anal pressure and heals chronic anal fissure. Br J Surg 86:1269–1273
Carapeti EA, Kamm MA, Phillips RK (2000) Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects. Dis Colon Rectum 43:1359–1362
Jonas M, Neal KR, Abercrombie JF, Scholefield JH (2001) A randomised trial of oral vs. topical diltiazem for chronic anal fissures. Dis Colon Rectum 44:1074–1078
Maria G, Cassetta E, Gui D et al (1998) A comparison of botulinum toxin and saline for the treatment of chronic anal fissure. N Engl J Med 338:217–220
Brisinda G, Maria G, Bentivoglio AR et al (1999) A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure. N Engl J Med 341:65–69
Arroyo A, Perez F, Serrano P et al (2005) Long-term results of botulinum toxin for the treatment of chronic anal fissure: prospective clinical and manometric study. Int J Colorectal Dis 20:267–271
Lindsey I, Jones OM, Cunningham C et al (2003) Botulinum toxin as second-line therapy for chronic anal fissure failing 0.2% glyceryl trinitrate. Dis Colon Rectum 46:361–366
Sileri P, Mele A, Stolfi VM et al (2007) Medical and surgical treatment of chronic anal fissure: a prospective study. J Gastrointest Surg 11:1541–1548
Scholz T, Hetzer FH, Dindo D et al (2007) Long-term follow-up after combined fissurectomy and Botox injection for chronic anal fissures. Int J Colorectal Dis 22:1077–1081
Baraza W, Boereboom C, Shorthouse A, Brown S (2008) The long-term efficacy of fissurectomy and botulinum toxin injection for chronic anal fissure in females. Dis Colon Rectum 51:239–243
Engel AF, Eijsbouts QA, Balk AG (2002) Fissurectomy and isosorbide dinitrate not responding to conservative treatment. Br J Surg 89:79–83
Jost WH (1993) Use of botulinum toxin in anal fissure. Dis Colon Rectum 36:974
Smith M, Frizelle F(2004) Long term faecal incontinence following the use of botulinum toxin. Colorectal Dis 6:526–527
Jost WH, Schanne S, Mlitz H, Schimrigk K (1995) Perianal thrombosis following injection therapy into the external anal sphincter using botulinum toxin. Dis Colon Rectum 38:781
Klosterhalfen B, Vogel P, Rixen H, Mittermayer C (1989) Topography of the inferior rectal artery: a possible cause of chronic, primary anal fissure. Dis Colon Rectum 32:43–52
Schouten WR, Briel JW, Auwerda JJ (1994) Relationship between anal pressure and anodermal blood flow. The vascular pathogenesis of anal fissure. Dis Colon Rectum 37:664–669
Gibbons CP, Read NW (1986) Anal hypertonia in fissures: cause or effect. Br J Surg 73:443–445
Lambe GF, Driver CP, Morton S, Turnock RR (2000) Fissurectomy as a treatment for anal fissures in children. Ann R Coll Surg Engl 82:254–257
Bode WE, Culp CE, Spencer RJ, Beart RW Jr (1984) Fissurectomy with superficial midline sphincterotomy. A viable alternative for the surgical correction of chronic fissure/ulcer-inano. Dis Colon Rectum 27:93–95
Abcarian H, Lakshmanan S, Read DR, Roccaforte P (1982) The role of internal sphincter in chronic anal fissures. Dis Colon Rectum 25:525–528
Abcarian H (1980) Surgical correction of chronic anal fissure: results of lateral internal sphincterotomy vs. Fissurectomy — midline sphincterotomy. Dis Colon Rectum 23:31–36
Di Castro A, Biancari F, D’Andrea V, Caviglia A (1997) Fissurectomy with posterior midline sphincterotomy and anoplasty (FPSA) in the management of chronic anal fissures. Surg Today 27:975–978
Melange M, Colin JF, Van Wymersch T, Vanheuverzwyn R (1992) Anal fissure: correlation between symptoms and manometry before and after surgery. Int J Colorectal Dis 7:108–111
Lindsey I, Cunningham C, Jones OM et al (2004) Fissurectomy-botulinum toxin: a novel sphincter-sparing procedure for medically resistant chronic anal fissure. Dis Colon Rectum 47:1947–1952
Jonas M, Speake W, Scholefield JH (2002) Diltiazem heals glyceryl trinitrate-resistant chronic anal fissures: a prospective study. Dis Colon Rectum 45:1091–1095
Carapeti E, Kamm M, Evans B, Phillips R (1999) Topical diltiazem and bethanecol decrease anal sphincter pressure without side effects. Gut 45:719–722
Jonas M, Amin S, Wright J et al (2001) Topical 0.2 percent glyceryl trinitrate ointment has a short-lived effect on resting anal pressure. Dis Colon Rectum 44:1640–1643
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
References
Orsay C, Rakinic J, Perry WB et al (2004) Practice parameters for the management of anal fissures (revised). Dis Colon Rectum 47:2003–2007
Schouten WR, Briel JW, Auwerda JJ, De Graaf EJ (1996) Ischaemic nature of anal fissure. Br J Surg 83:63–65
Ayantunde AA, Debrah SA (2006) Current concepts in anal fissures. World J Surg 30:2246–2260
Lindsey I, Cunningham C, Jones OM et al (2004) Fissurectomy-botulinum toxin: a novel sphincter-sparing procedure for medically resistant chronic anal fissure. Dis Colon Rectum 47:1947–1952
Scholz T, Hetzer FH, Dindo D et al (2007) Long-term follow-up after combined fissurectomy and Botox injection for chronic anal fissures. Int J Colorectal Dis 22:1077–1081
Author information
Authors and Affiliations
Corresponding authors
Rights and permissions
About this article
Cite this article
Arthur, J.D., Makin, C.A., El-Sayed, T.Y. et al. A pilot comparative study of fissurectomy/diltiazem and fissurectomy/botulinum toxin in the treatment of chronic anal fissure. Tech Coloproctol 12, 331–336 (2008). https://doi.org/10.1007/s10151-008-0444-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10151-008-0444-4