Conservative and surgical treatment of chronic anal fissure: prospective longer term results.
BACKGROUND
The aim of this prospective study was to assess the efficacy of different medical treatments and surgery in the treatment of chronic anal fissure (CAF).


METHODS
From January 2004 to March 2009, 311 patients with typical CAF completed the study. All patients were initially treated with 0.2% nitroglycerin ointment (GTN) or anal dilators (DIL) for 8 weeks. If no improvement was observed after 8 weeks, the patients were assigned to the other treatment or a combination of the two. Persisting symptoms after 12 weeks or recurrence were indications for either botulinum toxin injection into the internal sphincter and fissurectomy or lateral internal sphincterotomy (LIS). During the follow-up (29 +/- 16 months), healing rates, symptoms, incontinence scores, and therapy adverse effects were prospectively recorded.


RESULTS
Overall healing rates were 64.6% and 94% after GTN/DIL or BTX/LIS. Healing rate after GTN or DIL after 12 weeks course were 54.5% and 61.5%, respectively. Fifty-four patients (17.4%) responded to further medical therapy. One hundred two patients (32.8%) underwent BTX or LIS. Healing rate after BTX was 83.3% and overall healing after LIS group was 98.7% with no definitive incontinence.


CONCLUSIONS
In conclusion, although LIS is far more effective than medical treatments, BTX injection/fissurectomy as first line treatment may significantly increase the healing rate while avoiding any risk of incontinence.
Sileri
Pierpaolo
P
Department of Surgery, University of Rome Tor Vergata, Policlinico Tor Vergata, Chirurgia generale 6B Viale Oxford 81, 00133 Rome, Italy. piersileri@yahoo.com
Stolfi
Vito M
VM
Franceschilli
Luana
L
Grande
Michele
M
Di Giorgio
Alessandra
A
D'Ugo
Stefano
S
Attina'
Grazia
G
D'Eletto
Marco
M
Gaspari
Achille L
AL
D000287:Administration, Topical; D000328:Adult; D001905:Botulinum Toxins / Q000627:therapeutic use*; D002908:Chronic Disease; D015331:Cohort Studies; D004106:Dilatation / Q000379:methods; D005260:Female; D005401:Fissure in Ano / Q000175:diagnosis / Q000188:drug therapy* / Q000601:surgery*; D005500:Follow-Up Studies; D006801:Humans; D015552:Injections, Intralesional; D008297:Male; D008875:Middle Aged; D005996:Nitroglycerin / Q000627:therapeutic use*; D009824:Ointments / Q000627:therapeutic use; D011336:Probability; D011351:Proctoscopy / Q000379:methods; D011446:Prospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016896:Treatment Outcome
D009824:Ointments; D001905:Botulinum Toxins; D005996:Nitroglycerin