Top

Published in:

01-06-2017 | Review

Operative and medical treatment of chronic anal fissures-a review and network meta-analysis of randomized controlled trials

Authors: Sabrina Maria Ebinger, Julia Hardt, René Warschkow, Bruno Martin Schmied, Alexander Herold, Stefan Post, Lukas Marti

Published in: Journal of Gastroenterology | Issue 6/2017

Abstract

Anal fissures are a common problem and have a cumulative lifetime incidence of 11%. Previous reviews on anal fissures show inconsistent results regarding post-interventional healing and incontinence rates. In this review our aim was to compare the treatments for chronic anal fissures by incorporating indirect comparisons using network meta-analysis. The PubMed database was searched for randomized controlled trials (RCTs) published between 1975 and 2015. The primary outcome measures were healing and incontinence rates after lateral internal sphincterotomy (LIS), anal dilatation (DILA), anoplasty and/or fissurectomy (FIAP), botulinum toxin (BT) and noninvasive treatment (NIT). Random effects network meta-analyses were complemented by fixed effects and Bayesian models. The present analysis included 44 RCTs and 3268 patients. After a median follow-up of 2 months, the healing rates for LIS, DILA, FIAP, BT and NIT were 93.1, 84.4, 79.8, 62.6, and 58.6% and the incontinence rates were 9.4, 18.2, 4.9, 4.1, and 3.0%, respectively. Compared with NIT, the odds ratio (OR) [95% confidence interval (CI)] for healing after LIS, DILA, FIAP and BT was 9.9 (5.4−18.1), 8.6 (3.1−24.0), 3.5 (1.0−12.7) and 1.9 (1.1−3.5), respectively, on network meta-analysis. The OR (95% CI) for incontinence after LIS, DILA, FIAP and BT was 6.8 (3.1−15.1), 16.9 (6.0−47.8), 3.9 (1.0−15.1) and 1.6 (0.7−3.7), respectively. Ranking of treatments, fixed effects and Bayesian models confirmed these findings. In conclusion, based on our meta-analysis LIS is the most efficacious treatment but is compromised by a high rate of postoperative incontinence. Given the trade-offs between the risks and benefits, FIAP and BT might be good alternatives for the treatment of chronic anal fissures.

Available only for authorised users

Pascual M, Pera M, Courtier R, et al. Endosonographic and manometric evaluation of internal anal sphincter in patients with chronic anal fissure and its correlation with clinical outcome after topical glyceryl trinitrate therapy. Int J Colorectal Dis. 2007;22:963–7.CrossRefPubMed

Herzig DO, Lu KC. Anal fissure. Surg Clin North Am. 2010;90:33–44.CrossRefPubMed

Ayantunde AA, Debrah SA. Current concepts in anal fissures. World J Surg. 2006;30:2246–60.CrossRefPubMed

Schouten WR, Briel JW, Auwerda JJ, et al. Ischaemic nature of anal fissure. Br J Surg. 1996;83:63–5.CrossRefPubMed

Cross KL, Massey EJ, Fowler AL, et al. The management of anal fissure: ACPGBI position statement. Colorectal Dis. 2008;10[Suppl 3]:1–7.CrossRefPubMed

Griffin N, Acheson AG, Tung P, et al. Quality of life in patients with chronic anal fissure. Colorectal Dis. 2004;6:39–44.CrossRefPubMed

Ortiz H, Marzo J, Armendariz P, et al. Quality of life assessment in patients with chronic anal fissure after lateral internal sphincterotomy. Br J Surg. 2005;92:881–5.CrossRefPubMed

Perry WB, Dykes SL, Buie WD, et al. Practice parameters for the management of anal fissures (3rd revision). Dis Colon Rectum. 2010;53:1110–5.CrossRefPubMed

Garg P, Garg M, Menon GR. Long-term continence disturbance after lateral internal sphincterotomy for chronic anal fissure: a systematic review and meta-analysis. Colorectal Dis. 2013;15:e104–17.CrossRefPubMed

10.

Nelson RL, Thomas K, Morgan J, et al. Non surgical therapy for anal fissure. Cochrane Database Syst Rev. 2012;15(2):CD003431.

11.

Nelson RL, Chattopadhyay A, Brooks W, et al. Operative procedures for fissure in ano. Cochrane Database Syst Rev. 2011:CD002199.

12.

Jansen JP, Naci H. Is network meta-analysis as valid as standard pairwise meta-analysis? It all depends on the distribution of effect modifiers. BMC Med. 2013;11:159.CrossRefPubMedPubMedCentral

13.

Mills EJ, Thorlund K, Ioannidis JP. Demystifying trial networks and network meta-analysis. BMJ. 2013;346:f2914.CrossRefPubMed

14.

Hutton B, Salanti G, Caldwell DM, et al. The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med. 2015;162:777–84.CrossRefPubMed

15.

Rucker G, Schwarzer G. Automated drawing of network plots in network meta-analysis. Res Synth Methods. 2016;7:94–107.CrossRefPubMed

16.

Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996;17:1–12.CrossRefPubMed

17.

Berger VW, Alperson SY. A general framework for the evaluation of clinical trial quality. Rev Recent Clin Trials. 2009;4:79–88.CrossRefPubMedPubMedCentral

18.

Iswariah H, Stephens J, Rieger N, et al. Randomized prospective controlled trial of lateral internal sphincterotomy versus injection of botulinum toxin for the treatment of idiopathic fissure in ano. ANZ J Surg. 2005;75:553–5.CrossRefPubMed

19.

Marby M, Alexander-Williams J, Buchmann P, et al. A randomized controlled trial to compare anal dilatation with lateral subcutaneous sphincterotomy for anal fissure. Dis Colon Rectum. 1979;22:308–11.CrossRefPubMed

20.

Parellada C. Randomized, prospective trial comparing 0.2 percent isosorbide dinitrate ointment with sphincterotomy in treatment of chronic anal fissure: a two-year follow-up. Dis Colon Rectum. 2004;47:437–43.CrossRefPubMed

21.

Mousavi SR, Sharifi M, Mehdikhah Z. A comparison between the results of fissurectomy and lateral internal sphincterotomy in the surgical management of chronic anal fissure. J Gastrointest Surg. 2009;13:1279–82.CrossRefPubMed

22.

Leong AF, Seow-Choen F. Lateral sphincterotomy compared with anal advancement flap for chronic anal fissure. Dis Colon Rectum. 1995;38:69–71.CrossRefPubMed

23.

Jensen SL, Lund F, Nielsen OV, et al. Lateral subcutaneous sphincterotomy versus anal dilatation in the treatment of fissure in ano in outpatients: a prospective randomised study. Br Med J (Clin Res Ed). 1984;289:528–30.CrossRef

24.

Hiltunen KM, Matikainen M. Anal manometric evaluation in anal fissure. Effect of anal dilation and lateral subcutaneous sphincterotomy. Acta Chir Scand. 1986;152:65–8.PubMed

25.

Oettle GJ. Glyceryl trinitrate vs. sphincterotomy for treatment of chronic fissure-in-ano: a randomized, controlled trial. Dis Colon Rectum. 1997;40:1318–20.CrossRefPubMed

26.

Libertiny G, Knight JS, Farouk R. Randomised trial of topical 0.2% glyceryl trinitrate and lateral internal sphincterotomy for the treatment of patients with chronic anal fissure: long-term follow-up. Eur J Surg. 2002;168:418–21.CrossRefPubMed

27.

Katsinelos P, Papaziogas B, Koutelidakis I, et al. Topical 0.5% nifedipine vs. lateral internal sphincterotomy for the treatment of chronic anal fissure: long-term follow-up. Int J Colorectal Dis. 2006;21:179–83.CrossRefPubMed

28.

Siddique MI, Murshed KM, Majid MA. 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. 2008;34:12–5.CrossRefPubMed

29.

Giridhar CM, Babu P, Rao KS. A comparative study of lateral sphincterotomy and 2% diltiazem gel local application in the treatment of chronic fissure in ANO. J Clin Diagn Res. 2014;8:NC01–2.

30.

Maria G, Cassetta E, Gui D, et al. A comparison of botulinum toxin and saline for the treatment of chronic anal fissure. N Engl J Med. 1998;338:217–20.CrossRefPubMed

31.

Abd Elhady HM, Othman IH, Hablus MA, et al. Long-term prospective randomised clinical and manometric comparison between surgical and chemical sphincterotomy for treatment of chronic anal fissure. S Afr J Surg. 2009;47:112–4.PubMed

32.

Festen S, Gisbertz SS, van Schaagen F, et al. Blinded randomized clinical trial of botulinum toxin versus isosorbide dinitrate ointment for treatment of anal fissure. Br J Surg. 2009;96:1393–9.CrossRefPubMed

33.

Brisinda G, Maria G, Bentivoglio AR, et al. A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure. N Engl J Med. 1999;341:65–9.CrossRefPubMed

34.

Magdy A, El Nakeeb A, el Fouda Y, et al. Comparative study of conventional lateral internal sphincterotomy, V-Y anoplasty, and tailored lateral internal sphincterotomy with V-Y anoplasty in the treatment of chronic anal fissure. J Gastrointest Surg. 2012;16:1955–62.CrossRefPubMed

35.

Fischer M. Hamelmann H. Dilatation or sphincterotomy as the treatment of primary-chronic fissure in ano. Results of a random, clinical study after 2–3 years. Chirurg. 1978;49:215–8.PubMed

36.

Wang ZY, Sun JH, Chen XJ. Prospective randomized trial of optimum anal canal release treatment for chronic anal fissure. Zhong Xi Yi Jie He Xue Bao. 2005;3(190):206.

37.

Berkel AE, Rosman C, Koop R, et al. Isosorbide dinitrate ointment vs botulinum toxin A (Dysport) as the primary treatment for chronic anal fissure: a randomized multicentre study. Colorectal Dis. 2014;16:O360–6.CrossRefPubMed

38.

Weaver RM, Ambrose NS, Alexander-Williams J, et al. Manual dilatation of the anus vs. lateral subcutaneous sphincterotomy in the treatment of chronic fissure-in-ano. Results of a prospective, randomized, clinical trial. Dis Colon Rectum. 1987;30:420–3.CrossRefPubMed

39.

Ram E, Vishne T, Lerner I, et al. Anal dilatation versus left lateral sphincterotomy for chronic anal fissure: a prospective randomized study. Tech Coloproctol. 2007. doi:10.1007/s10151-007-0373-7

40.

Renzi A, Izzo D, Di Sarno G, et al. Clinical, manometric, and ultrasonographic results of pneumatic balloon dilatation vs. lateral internal sphincterotomy for chronic anal fissure: a prospective, randomized, controlled trial. Dis Colon Rectum. 2008;51:121–7.CrossRefPubMed

41.

Boschetto S, Giovannone M, Tosoni M, et al. Hydropneumatic anal dilation in conservative treatment of chronic anal fissure: clinical outcomes and randomized comparison with topical nitroglycerin. Tech Coloproctol. 2004;8:89–92 (discussion 92–3).CrossRefPubMed

42.

Saad AM, Omer A. Surgical treatment of chronic fissure-in-ano: a prospective randomised study. East Afr Med J. 1992;69:613–5.PubMed

43.

Hancke E, Schwaner S. Chronic anal fissure-operativ treatement with analdialtation, fissurektomy vs. lateral sphinterotomy. Coloproctology. 2003;25:95–105.CrossRef

44.

Hasse C, Brune M, Bachmann S, et al. Lateral, partial sphincter myotomy as therapy of chronic anal fissue. Long-term outcome of an epidemiological cohort study. Chirurg. 2004;75:160–7.CrossRefPubMed

45.

Jost WH. One hundred cases of anal fissure treated with botulin toxin: early and long-term results. Dis Colon Rectum. 1997;40:1029–32.CrossRefPubMed

46.

Lindsey I, Cunningham C, Jones OM, et al. Fissurectomy-botulinum toxin: a novel sphincter-sparing procedure for medically resistant chronic anal fissure. Dis Colon Rectum. 2004;47:1947–52.CrossRefPubMed

47.

Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21:1539–58.CrossRefPubMed

48.

Higgins JPT GSe. Cochrane handbook for systematic reviews of interventions version 5.1.0. The Cochrane Collaboration. Available from http://www.cochrane-handbook.org. 2011 (updated March 2011).

49.

Olsen J, Mortensen PE, Krogh Petersen I, et al. Anal sphincter function after treatment of fissure-in-ano by lateral subcutaneous sphincterotomy versus anal dilatation. A randomized study. Int J Colorectal Dis. 1987;2:155–7.CrossRefPubMed

50.

Richard CS, Gregoire R, Plewes EA, et al. Internal sphincterotomy is superior to topical nitroglycerin in the treatment of chronic anal fissure: results of a randomized, controlled trial by the Canadian Colorectal Surgical Trials Group. Dis Colon Rectum. 2000;43:1048–57 (discussion 1057–8).CrossRefPubMed

51.

Evans J, Luck A, Hewett P. Glyceryl trinitrate vs. lateral sphincterotomy for chronic anal fissure: prospective, randomized trial. Dis Colon Rectum. 2001;44:93–7.CrossRefPubMed

52.

Colak T, Ipek T, Kanik A, et al. A randomized trial of botulinum toxin vs lidocain pomade for chronic anal fissure. Acta Gastroenterol Belg. 2002;65:187–90.PubMed

53.

Mentes BB, Irkorucu O, Akin M, et al. Comparison of botulinum toxin injection and lateral internal sphincterotomy for the treatment of chronic anal fissure. Dis Colon Rectum. 2003;46:232–7.CrossRefPubMed

54.

Siproudhis L, Sebille V, Pigot F, et al. Lack of effficacy of botulinum toxin in chronic anal fissure. Aliment Pharmacol Ther. 2003;18:515–24.CrossRefPubMed

55.

Arroyo A, Perez F, Serrano P, et al. Surgical versus chemical (botulinum toxin) sphincterotomy for chronic anal fissure: long-term results of a prospective randomized clinical and manometric study. Am J Surg. 2005;189:429–34.CrossRefPubMed

56.

Ho KS, Ho YH. Randomized clinical trial comparing oral nifedipine with lateral anal sphincterotomy and tailored sphincterotomy in the treatment of chronic anal fissure. Br J Surg. 2005;92:403–8.CrossRefPubMed

57.

Mishra R, Thomas S, Maan MS, et al. Topical nitroglycerin versus lateral internal sphincterotomy for chronic anal fissure: prospective, randomized trial. ANZ J Surg. 2005;75:1032–5.CrossRefPubMed

58.

De Nardi P, Ortolano E, Radaelli G, et al. Comparison of glycerine trinitrate and botulinum toxin-a for the treatment of chronic anal fissure: long-term results. Dis Colon Rectum. 2006;49:427–32.CrossRefPubMed

59.

Fruehauf H, Fried M, Wegmueller B, et al. Efficacy and safety of botulinum toxin a injection compared with topical nitroglycerin ointment for the treatment of chronic anal fissure: a prospective randomized study. Am J Gastroenterol. 2006;101:2107–12.CrossRefPubMed

60.

Brisinda G, Cadeddu F, Brandara F, et al. Randomized clinical trial comparing botulinum toxin injections with 0.2 per cent nitroglycerin ointment for chronic anal fissure. Br J Surg. 2007;94:162–7.CrossRefPubMed

61.

Suknaic S, Patrlj L, Steresinic M, et al. Surgical or biologic sphincterotomy in the treatment of chronic anal fissure. Acta Med Croatica. 2008;62:73–80.PubMed

62.

Nasr M, Ezzat H, Elsebae M. Botulinum toxin injection versus lateral internal sphincterotomy in the treatment of chronic anal fissure: a randomized controlled trial. World J Surg. 2010;34:2730–4.CrossRefPubMed

63.

Samim M, Twigt B, Stoker L, et al. Topical diltiazem cream versus botulinum toxin a for the treatment of chronic anal fissure: a double-blind randomized clinical trial. Ann Surg. 2012;255:18–22.CrossRefPubMed

64.

Valizadeh N, Jalaly NY, Hassanzadeh M, et al. Botulinum toxin injection versus lateral internal sphincterotomy for the treatment of chronic anal fissure: randomized prospective controlled trial. Langenbecks Arch Surg. 2012;397:1093–8.CrossRefPubMed

65.

Arslan K, Erenoglu B, Dogru O, et al. Lateral internal sphincterotomy versus 0.25% isosorbide dinitrate ointment for chronic anal fissures: a prospective randomized controlled trial. Surg Today. 2013;43:500–5.CrossRefPubMed

66.

Aslam MI, Pervaiz A, Figueiredo R. Internal sphincterotomy versus topical nitroglycerin ointment for chronic anal fissure. Asian J Surg. 2014;37:15–9.CrossRefPubMed

Title: Operative and medical treatment of chronic anal fissures-a review and network meta-analysis of randomized controlled trials
Authors: Sabrina Maria Ebinger
Julia Hardt
René Warschkow
Bruno Martin Schmied
Alexander Herold
Stefan Post
Lukas Marti
Publication date: 01-06-2017
Publisher: Springer Japan
Published in: Journal of Gastroenterology / Issue 6/2017
Print ISSN: 0944-1174
Electronic ISSN: 1435-5922
DOI: https://doi.org/10.1007/s00535-017-1335-0

ACC 2024 Congress Coverage

Heart Failure Video

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Operative and medical treatment of chronic anal fissures-a review and network meta-analysis of randomized controlled trials

Abstract

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 6/2017

ITPA polymorphism effects on decrease of hemoglobin during sofosbuvir and ribavirin combination treatment for chronic hepatitis C

Serum metabolomics analysis for early detection of colorectal cancer

Strain elastography for assessment of liver fibrosis and prognosis in patients with chronic liver diseases

Oral branched-chain amino acid granules improve structure and function of human serum albumin in cirrhotic patients

Procalcitonin is a useful biomarker to predict severe acute cholangitis: a single-center prospective study

Influence of previous abdominal surgery on surgical outcomes between laparoscopic and open surgery in elderly patients with colorectal cancer: subanalysis of a large multicenter study in Japan

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page