A pilot comparative study of fissurectomy/diltiazem and fissurectomy/botulinum toxin in the treatment of chronic anal fissure

Abstract

Treatment of chronic anal fissure (CAF) by fissurectomy with botulinum toxin A (BTA) injection results in a healing rate of greater than 90%. BTA injection, however, can cause incontinence and perianal sepsis. The decrease in sphincter pressure following topical treatment with 2% diltiazem cream (DTC) is comparable to that following BTA injection but with potentially fewer complications and at less cost. We report the shortterm results of a pilot study comparing fissurectomy with BTA and fissurectomy followed by DTC for the treatment of CAF. The recorded outcomes of CAF following treatment with the two methods were analysed retrospectively. Patients underwent either fissurectomy followed by injection of 40 U BTA into the internal sphincter (group A) or fissurectomy followed by the perianal application of DTC twice daily for 8 weeks (group B). Symptom resolution and treatment side effects at the initial follow-up were compared. Demographics, fissure characteristics and the number of multiparous women between the two groups were comparable. At a median follow-up of 12 weeks (range 8-20 weeks), the two groups had similar rates of complete symptom resolution (group A, 25/28, 89.3%; group B, 19/23, 82.6%; p=0.7739), with minor side effects. In this small pilot study fissurectomy combined with chemical sphincterotomy resulted in high short-term fissure healing rates. The study also suggested that fissurectomy followed by 8 weeks of topical DTC may be as good as fissurectomy with BTA injection in the treatment of CAF. A prospective study, adequately powered to determine the significance of differences is needed.