Purpose:
Evidence-based medicine suggests that in the management of chronic anal fissure (CAF), lateral internal sphincterotomy (LIS) is far more effective than medical treatment in lowering the anal sphincter tone and curing the fissure. In the current study, we developed a treatment algorithm from topical nitroglycerine (NTG) to Botox (BTX) to LIS and analyzed its cost benefit by calculating the effective and potential costs based on the treatment success and the rate of avoided surgeries.

Methods:
Patients presenting between 11/2003-12/2004 with CAF and symptoms for >3months were prospectively treated according to a treatment algorithm which started with (1) topical NTG, in case of failure (2) injection of BTX, thus limiting (3) surgery to those who failed both non-surgical options or at any point chose the surgical approach. Based on the primary end points of fissure healing or surgery, we calculated the true cost (algorithm) and the potential incremental cost (BTX+surgery or surgery in all patients, respectively).

Results:
67 patients with CAF (m/f 25/42, median duration of symptoms 16 weeks) were treated according to the algorithm. NTG alone was successful in fissure healing in 31 out of 67 patients (46.2%). 2 developed a recurrent fissure and then received BTX as part of the protocol. Of the 36 patients who failed NTG trial, 3 requested surgery; the others were treated with BTX, which was successful in 84.8%. 5 patients (15.2%) failed BTX and subsequently required surgery. The overall surgery rate in the whole study group was 11.9%, whereas CAF healed in 88.1% of our patients with medical treatment alone. Cost for NTG is $10, for 100U BTX $268, and for outpatient surgery $513 (not including the hospital costs). The total cost for these 67 patients therefore was $16,378 (290 for NTG, 10,564 for NTG+BTX, 1569 for NTG+Surg, and 3955 for NTG+BTX+surgery). If all patients had received BTX with a 15% failure rate, the total cost would have been $23,180 (41% cost increase). If all patients had undergone surgery as initial treatment, the total cost would have been $34,371 (109% cost increase). Additional hospital costs for the surgery cases would account for an even more dramatic cost discrepancy.

Conclusion:
Our treatment algorithm for CAF with stepwise escalation can avoid surgery in 88% of the patients. It is highly cost-efficient and resulted in savings of >29% (compared to BTX+Surgery) and >53% (compared to surgery in all patients),respectively.