Background: chemical sphincterotomy promotes chronic anal fissure (CAF) healing without the risk of developing fecal incontinence associated with lateral internal sphincterotomy (LIS). However, its effects are transient and the risk of recurrence is reported as high as 50%. The aim of this prospective study is to asses the efficacy of different medical treatments and LIS to lower anal sphincter tone and healing CAF. We also propose a treatment algorithm.Patients and
Methods: from 1/04 to 09/06, 156 patients with CAF completed the study. Atypical CAF associated with III/IV degree hemorrhoids, inflammatory bowel disease, cancer or anal infection were excluded. All patients were initially treated with 0.2% nitroglycerin ointment (GTN) or anal dilators (DIL) for 8 weeks. If no improvement was observed after 4 weeks, the patient was assigned to the other treatment or a combination of the two. Persisting symptoms after 12 weeks or recurrence were indications for either botulinum toxin A (BTX) injection (25 units) into the internal anal sphincter associated to fissurectomy or LIS. Patients with unhealed or recurrent CAF who refused surgery were offered a further medical treatment. Prior to surgery all patients underwent anorectal manometry. Patients were seen after 1, 2, 3 and 12 months and if required. Healing rates, symptoms, incontinence scores and therapy adverse effects were recorded. Data were prospectically entered in a database and statistically analyzed.
Results: Median follow up was 19+/-8 months ranging from 3 to 33 months. Overall healing rates were 65.3% and 96.3% respectively for GTN/DIL and BTX/LIS group. Sixty-six patients (42.3%) healed and had no recurrence after GTN (37/93 pts) or DIL (29/63 pts) without significant differences between the two groups (39.8% vs 46%). Thirty-six patients (23.1%) who experienced CAF recurrence/unhealing responded to further medical therapy. Twenty (12.8%) patients required combined GTN/dilators therapy and fourteen (70%) responded. Mild side effects occurred in 13% of GTN group. Fifty-four patients (34.6%) underwent BTX (22 pts) or LIS (32 pts). Of the BTX, eighteen patients (81.8%) healed One patient experienced transitory flatus incontinence. Two out of 4 subsequently required LIS for recurrence (1 pt) or unhealing (1 pt). LIS group showed a 100% healing rate with no morbidity and postoperative incontinence.
Conclusions: medical therapy cures conveniently most CAF with few mild adverse effects. Although LIS is far more effective than medical treatment to cure CAF, BTX injection/fissurectomy as first line treatment may significantly increase the healing rate while avoiding any risk of incontinence.