title: Efficacy of management algorithm for reducing need for sphincterotomy in chronic anal fissures.
abstract: BACKGROUND
  Lateral internal sphincterotomy is the most effective treatment for chronic anal fissure (CAF), but carries a risk of faecal incontinence. We aimed to analyse efficacy and acceptance of a treatment algorithm in reducing the rate of necessary sphincterotomies.
  
  
  METHODS
  Patients with CAF seen from 2001 to 2010 were retrospectively analysed. All patients were offered all steps of the algorithm nitroglycerine (NTG) → Botox (BTX) → surgery, unless symptoms or patient preference demanded a more aggressive treatment. Patients were followed up in clinic, and treatment was advanced if a step either failed or caused intolerable side effects.
  
  
  RESULTS
  Two hundred and nine patients were included in the analysis. Mean duration of symptoms was 25.6 months and mean follow up 16 months. One hundred and 41 patients started on NTG, 36 on BTX, and 31 went straight to surgery. One patient opted for no treatment. Symptoms persisted in 58 (41.1%) of 141 NTG patients. Forty-five (31.9% of NTG subset) were advanced to BTX and 13 (9.2% of subset) to surgery. Of the 81 (36 primary + 45 secondary) BTX patients (38.8% of the total), only 11 (13.6% of subset) required surgery. A total of 55 (31 primary + 24 secondary; 26.3%) patients needed surgery: two (3.6%) fissures did not heal, one patient developed an abscess, 14 (25.5%) had prolonged wound healing and two (3.6%) developed a recurrent fissure after the sphincterotomy had healed.
  
  
  CONCLUSIONS
  Our algorithm is effective in CAF and the majority of patients respond to conservative management. Only 26.3% of all patients require surgery, which is effective but also carries some temporary morbidity.
authors.affiliation: Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA.
authors.forename: R
authors.initials: R
authors.lastname: Sinha
authors.forename: A M
authors.initials: AM
authors.lastname: Kaiser
mesh_terms: D000465:Algorithms; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use; D002908:Chronic Disease; D005260:Female; D005401:Fissure in Ano / Q000188:drug therapy* / Q000601:surgery*; D006801:Humans; D008297:Male; D009465:Neuromuscular Agents / Q000627:therapeutic use; D005996:Nitroglycerin / Q000627:therapeutic use; D012189:Retrospective Studies; D014665:Vasodilator Agents / Q000627:therapeutic use
chemical_list: D009465:Neuromuscular Agents; D014665:Vasodilator Agents; D019274:Botulinum Toxins, Type A; D005996:Nitroglycerin