Innovations in chronic anal fissure treatment: A systematic review

Table 3 Studies comparing healing rates of different surgical therapies

S/N	Ref.	Study details	Results	Remarks
1	Garcea et al[30] 2002 Single arm, retrospective, non-randomized	Conservative lateral sphincterotomy for chronic anal fissures 65 patients	97% healing rate	98% of patients had prior failure of healing with GTN Maximum of 5 mm of internal sphincter divided
2	Tocchi et al[31] 2004 Single arm, prospective, non-randomized	Lateral subcutaneous internal sphincterotomy for non-responders to 0.2% GTN 164 patients	100% healing rate within 6 wk
3	Liratzopoulos et al[32] 2006 Single arm, prospective, non-randomized	Lateral subcutaneous sphincterotomy for chronic anal fissures 246 patients	Overall healing rate-97.5% at 3 mo
4	Wiley et al[33] 2004 Dual arm, prospective, randomized	Open vs closed lateral sphincterotomy 79 patients	Open technique-95% healing rates Closed technique-97% healing rates	Closed technique: Blind division of internal sphincter guided by finger Open technique: Division under direct vision
5	Jensen et al[34] 1984 Double arm, prospective, randomized	Lateral sphincterotomy vs simple anal dilatation	Sphincterotomy-100% healing rate Anal dilatation-96.4% Recurrences-3.3% (sphincterotomy) vs 28.6% (anal dilatation)
6	Renzi et al[13] 2007 Double arm, prospective, randomized	Pneumatic balloon dilatation vs lateral sphincterotomy 53 patients	Balloon dilatation-83.3% healing rate Sphincterotomy-92%	Balloon dilated to 20 PSI and maintained for 6 min Division of half of internal sphincter
7	Richard et al[35] 2000 Double arm, prospective, randomized	Internal sphincterotomy vs 0.25% GTN 90 patients	Internal sphincterotomy-92.1% healing rate at 6 wk GTN-27.2% healing rate at 6 wk 5.5% of GTN group had an eventual sphincterotomy Recurrences-0 (sphincterotomy) vs 5/44 (11.4%) (GTN)
8	Evans et al[36] 2001 Dual arm, prospective, randomized	0.2% GTN vs lateral sphincterotomy for chronic anal fissures 65 patients	Sphincterotomy-97% healing rate after 8 wk GTN-60.6% healing rate after 8 wk 12/13 (92%) of patients not healed by GTN healed after sphincterotomy Recurrence-50% (GTN) vs 15.4% (sphincterotomy) 11/13 (85%) of GTN failures not compliant with treatment-7/13 (54%) (lack of effect) and 4/13 (31%) (headaches)
9	Brown et al[37] 2007 Double arm, prospective, randomized, multi-centric	2% GTN vs lateral internal sphincterotomy at 6 yr post-treatment 82 patients	GTN-11/27 (40.7%) patients had recurrence Sphincterotomy-no recurrence Patient satisfaction-100% (sphincterotomy) vs 56% (GTN)	60% of GTN patients underwent subsequent sphincterotomy
10	Menteş et al[29] 2003 Double arm, prospective, randomized	Botulinum toxin 0.3 units/kg vs internal sphincterotomy 111 patients	Sphincterotomy healing rates-82% (1 mo)-98% (2 mo)-94% (6 mo)-94% ( 12 mo) Botulinum toxin healing rates-62.3% (1 mo)-73.8% (2 mo)-86.9% (6 mo, with a second injection given at end of 2nd month for non-healers)-75.4% (12 mo, with 7 patients having recurrences)
11	Schiano di Visconte et al[14] 2009 Double arm, prospective, randomized	0.25% GTN and anal cryothermal dilators BD vs 0.4% GTN 60 patients	Dilators and 0.25% GTN-86.6% healing rate 0.4% GTN-73.3% healing rate Recurrence after 1 year-3.3% (GTN and dilators) vs 13.3% (GTN only)	Dilators soaked for 15 min in 40 degrees water
12	Yucel et al[15] 2009 Double arm, prospective, randomized	Controlled intermittent anal dilatation (CIAD) vs lateral sphincterotomy 40 patients	Dilatation-90% healing rate at 2 mo Sphincterotomy-85% healing rate at 2 mo	Adjustable anal speculum dilated to 4.8 cm followed by relaxation for 15 times over 5 min
13	Singh et al[9] 2005 Single arm, prospective, non-randomised	Rotational flap for treatment of chronic anal fissures 21 patients	Complete healing in 17/21 (81.0%) patients
14	Giordano et al[10] 2009 Single arm, prospective, non-randomised	Cutaneous advancement flap anoplasty for chronic anal fissures 51 patients	98% healing rate No recurrences at median 6 mo follow-up 3/51 developed new fissures at new locations
15	Pelta et al[11] 2007 Double arm, prospective, randomized	Subcutaneous fissurotomy for chronic anal fissures 109 patients	98.2% healing rate	Opening up of subcutaneous tract beneath fissure and excision of sentinel tag
16	Soll et al[12] 2004 Single arm, prospective, non-randomized	Fissurectomy and botulinum toxin 20-25 units for chronic anal fissures not responsive to medical therapy 31 patients	93% healing rate by 16 wk with 7% having symptomatic relief despite non-healing fissures
17	Gupta[16] 2008 Single arm, prospective, non-randomized	Closed anal sphincter manipulation (sphincterolysis) for chronic anal fissures 312 patients	96.5% healing rate within 8 wk No recurrence	Finger fracture of internal sphincter fibres over left lateral side without breaching anal mucosa
18	Tan et al[7] 2009 Single arm, prospective, non-randomized	Effect of posterior perineal support on chronic anal fissure healing	Moderate (or more) improvement in: Pain-50% (2 wk) and 97.5% (3 mo) Bleeding-46.9% (2 wk) and 65.6% (3 mo) Constipation-40.6% (2 wk) and 84.4% (3 mo) Need for laxatives-15.6% (2 wk) and 40.6% (3 mo) Abdominal discomfort-31.3% (2 wk) and 68.8% (3 mo) Decrease in pain score from 5 (before treatment) to 0 (after 3 mo)

GTN: Glyceryl trinitrate.