title: Comparison of surgical vs chemical sphincterotomy using botulinum toxin for the treatment of chronic anal fissure: a meta-analysis.
abstract: OBJECTIVE
  To analyse systematically prospective randomized controlled trials dealing with the effectiveness of surgical sphincterotomy (SS) vs chemical sphincterotomy (CS) using botulinum toxin for the management of chronic anal fissure (CAF).
  
  
  METHODS
  A systematic review of the literature was undertaken. Prospective randomized controlled trials on the effectiveness of SS vs CS using botulinum toxin were selected and analysed to generate the summative outcome.
  
  
  RESULTS
  Four prospective randomized controlled trials dealing with SS vs CS using botulinum injection, which included 279 CAF patients, were analysed. Based on the random effects model, there was a higher complication rate [Risk ratio (RR) 14.54 (-9.84, -38.9) 95% CI, df = 2, P < 0.0163] and a higher risk of transient faecal incontinence [RR 6.39 (-2.37, -15.1) 95% CI, df = 3, P < 0.0001] in the SS group than in the CS group. However, there was significant heterogeneity among the trials (Q = 8 408 891, P < 0.0001), indicating a wide confidence interval range; thus, the inferiority of SS could not be shown. SS had a significantly higher healing rate [RR 1.63, (1.34-1.91) 95% CI, df = 3, P < 0.0110] and a significantly lower recurrence rate [RR 0.35 (0.33-0.38) 95% CI, df = 3, P < 0.0221] than CS.
  
  
  CONCLUSIONS
  Both CS and SS are comparable in the management of CAF. There are no differences in the complication rates and incontinence rates between the two procedures. SS has a higher healing rate and a lower recurrence rate than CS. As long as the patient is willing to accept a negligible risk of transient faecal incontinence, SS should be the first-line treatment for CAF.
authors.affiliation: Department of Colorectal Surgery, Worthing Hospital, Worthing, West Sussex, UK. surgeon1wrh@hotmail.com
authors.forename: M S
authors.initials: MS
authors.lastname: Sajid
authors.forename: S
authors.initials: S
authors.lastname: Hunte
authors.forename: S
authors.initials: S
authors.lastname: Hippolyte
authors.forename: V A
authors.initials: VA
authors.lastname: Kiri
authors.forename: C
authors.initials: C
authors.lastname: Maringe
authors.forename: M K
authors.initials: MK
authors.lastname: Baig
mesh_terms: D001003:Anal Canal / Q000187:drug effects / Q000601:surgery; D001905:Botulinum Toxins / Q000627:therapeutic use*; D002908:Chronic Disease; D005242:Fecal Incontinence / Q000209:etiology; D005401:Fissure in Ano / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D006801:Humans; D011183:Postoperative Complications; D011446:Prospective Studies; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D016896:Treatment Outcome
chemical_list: D001905:Botulinum Toxins