Diltiazem Gel Research Articles

A Prospective Study To Evaluate Medical Management Vs Surgical Intervention In Pain Relief And Healing Of Anal Fissure

Introduction: Anal fissure is a commonly encountered problem for surgeons. It is a longitudinal tear in distal anal canal with or without an ulcer. It causes significant changes in quality of life. This study was done to compare the efficacy of medical management and surgical intervention in cases of anal fissures. Methods: 50 patients were divided into two groups of 25 each. Group A patients were treated with topical application of 2% diltiazem gel and Group B patients were treated with Lateral sphincterotomy. Both groups were examined weekly for 4 weeks for pain using VAS score and at 12 weeks for healing. Results: 21(84%) patients were pain free after 4 weeks under Group A, 24 (96%) patients were pain free after 4 weeks under Group B. 22(88%) patients were completely healed at 12 weeks under Group A, 25(100%) patients were completely healed at 12 weeks under Group B. Conclusion: Lateral sphincterotomy can be advocated as treatment of choice for anal fissures. It has better pain relief and healing rates compared to topical application of 2% diltiazem gel. Medical Management can be used in patients refusing surgery or unfit for surgery

Management of chronic fissure in ano-lateral internal sphincterotomy versus 2% diltiazem gel local application: a prospective comparative study

Background: Fissure-in-ano is one of the most common benign anorectal disorders often encountered in surgical outpatient department. Various pharmacological agents and surgical interventions have been tried in the management of fissure in ano. In this study we have compared medical management by topical diltiazem gel with established surgical procedure of lateral internal sphincterotomy (LIS) in the management of chronic anal fissure. Methods: A total of 50 patients with chronic fissure in ano involved in this prospective comparative study, between December 2020 to May 2022, at Rajarajeswari Medical College and Hospital, Bengaluru. Selected patients were put under two groups of 25 participants each, A (2% diltiazem group) and B (lateral internal sphincterotomy - LIS group) using simple randomization technique and were to receive treatment accordingly. Fissure healing and pain relief were recorded on presentation and during follow up visits. Results: The results were compared weekly for 4 weeks and monthly for 2 consecutive months. Fissure healing and pain relief were recorded. Conclusions: Both 2% diltiazem group and LIS group are equally effective and did not show any difference in pain relief or fissure healing with p value not significant (>0.05).

Efficacy of Laryngeal Mask Airway Impregnation with Diltiazem Gel on Hemodynamic Changes in Patients with Hypertension Undergoing Phacoemulsification Surgery: A Randomized Clinical Trial

Background: Airway control problems are among the most prevalent causes of anesthesia-related mortality and morbidity. Some devices provide patients with adequate oxygen supply and ventilation during surgery by creating a safe airway in anesthetized patients. One of these devices is the laryngeal mask airway (LMA). The compression and painful stimuli following the LMA cuff inflation can lead to hemodynamic changes. Diltiazem gel is used in the control and treatment of hypertension (HTN) and heart arrhythmia and is absorbed through the tracheal mucosa. Objectives: By assuming that diltiazem gel is superior to other drugs used to prevent arrhythmias and hemodynamic changes during surgery, this study aimed to evaluate the effect of LMA impregnation with diltiazem gel, compared to lubricant gel. Methods: This study was conducted as a double-blind, randomized clinical trial on 80 participants with HTN who were candidates for phacoemulsification (phaco) surgery in Imam Khomeini Hospital, Kermanshah, Iran. The participants were assigned to an intervention (LMA impregnated with diltiazem gel) and a control group (LMA impregnated with lubricant gel) through the block random method in the form of 40 blocks of 2 using a random-numbers table. Hemodynamic changes (systolic and diastolic blood pressure and heart rate) were measured before, immediately after, 5 min, and 15 min after intubation, during surgery every 15 min, upon entering the recovery unit, and 15 and 30 min after entering the recovery unit. Results: The mean systolic and diastolic blood pressure in the intervention group showed a significant decrease, compared to that in the control group. A significant difference was also observed in the mean heart rate difference between the two study groups, but only at the beginning of the study (P<0.05). Additionally, according to the results of repeated measures analysis of variance, the mean of the measured variables showed a significant difference at different measurement times in the intervention group (P<0.05). Conclusion: The findings supported the effectiveness of diltiazem gel in reducing blood pressure, especially in the final stages of surgery, decreasing the number of premature ventricular contractions, and controlling normal breathing. Therefore, specialists and surgeons can use diltiazem gel to control the hemodynamic status of patients.

Evaluation of the Efficacy of Topical Hydrocortisone in the Treatment of Anal Fissure in Patients Undergoing Pharmacological Treatment

Background and Objective: Anal fissure can be associated with trauma caused by passing hard stools or prolonged diarrhea. The present study aimed to determine the effectiveness of topical hydrocortisone in the treatment of anal fissures in patients under medical treatment referred to Fatemi Hospital and Kausar Clinic of Ardabil Medical Sciences, Ardabil, Iran, in 2019. Materials and Methods: In this clinical trial study, 200 patients with anal fissures were randomly divided into two groups. The intervention group was treated with diltiazem gel, psyllium powder, lactulose syrup, and hydrocortisone topical ointment. Hydrocortisone ointment was not used in the control group. Results: The mean scores of initial pain were 8.06±0.7 and 7.79±1.02 in the intervention and control groups, respectively. The mean pain at the end of the first week was 2.5±1.06 in the intervention group and 3.34±0.89 in the control group. Pain reduction was significantly higher in the intervention group than in the control group in the first week of treatment. Two weeks later, the pain was 1.46±0.7 in the intervention group and 1.86±0.74 in the control group. There was a significant difference between the two groups in the first and second weeks of treatment. Conclusion: The therapeutic combination of a topical corticosteroid with a calcium channel blocker at the beginning of treatment for chronic fissures during the first week of treatment led to a faster response in the form of pain reduction

A COMPARATIVE STUDY OF LATERAL SPHINCTEROTOMY AND 2% DILTIAZEM GEL LOCAL APPLICATION IN THE TREATMENT OF FISSURE IN ANO

troduction: Anal ssure is a non-healing linear tear in the distal anal mucosa below the dentate line and is a painful entity.Fissure in ano is a common proctologic disease affecting both men and womenparticularly young.They require surgery like manual anal dilation or lateral internal sphincterotomy which heal the ssure in more than 90% cases but with a signicant risk of impaired anal continence. Newer non surgical therapies such as topical 2% diltiazem gel, have shown good efcacy without impairing anal continence. The aim of the study is to compare the AIMefcacy of outcome of Lateral Sphincterotomy Versus 2% Diltiazem gel in the treatment of chronic ssure in ano. 70 Material and Methods: patients diagnosed with ssure in ano were randomly divided into 2 %Diltiazem and lateral sphincterotomy groups. Patient were followed up at regular interval for symptomatic relief and healing of ssure. Less 89.4% patients Result: in diltiazem group and 100% of patients in lateral internal sphicterotomy group ssure healed completely between 4-8 weeks. In the diltiazem group pain relief was fairly good. 42 patients (89.4%) had pain relief at the end of 14 weeks. But the pain relief in lateral internal sphincterotomy group was excellent with 100% patients having complete pain relief by 8 weeks. Mild headache was experienced with diltiazem patients.1 patient complained of atus incontinence with lateral internal sphincterotomy. We conclude that lateral sphincterotomy is the gold standard t Conclusion: reatment for the ssure in ano but chemical sphincterotomy using 2% topical diltiazem gel can be considered a good second line treatment option in those unt for surgery or for those not willing for surgery

A randomised controlled clinical study to evaluate the role of Nirvapana Upakrama with Durva ointment in the management of Pittaja Dushta Vrana with special reference to fissure-in-ano

Introduction: Fissure-in-ano is an ulcer in the longitudinal axis of lower anal canal. It is having prevalence of about 17.91%. By seeing the signs and symptoms we can consider it as one among the six varieties of Dushta Vrana i.e., Pittaja Dustavrana. Due to busy life schedules people don’t prefer hospitalization and other operative procedures. So, there is a need to find out a new and simpler medicament which enables easy and better storage, preservation and mode of application. Here an attempt was made to study the effect of Nirvapana Upakrama in the management of fissure in ano is taken. This Upakrama is used for the treatment of Vrana accompanied with Daha, Paka, Jwara and having Pitta Kopa and Raktena Abhibhuta. Since fissure is having the similar symptoms this treatment can be adopted for the management of the same. Methodology: A randomized controlled clinical study was conducted over 30 subjects in two groups. Fifteen subjects were advised to apply Diltiazem gel and 15 subjects were advised to apply Durva ointment twice daily for a period of 14 days. Results: Rapid reduction in pain, burning sensation and length of ulcer was observed in the subjects who were given Durva ointment. Discussion: Durva ointment having Madura Rasa, Snigdha Guna and Sheeta Virya does Vatapitta Shamana and pacifies vitiated Rakta. Kashaya rasa of Durva does Vrana Ropana and Rakta Sthambana which amplifies in ulcer healing and relaxation of the sphincter.

A comparison of lateral internal sphincterotomy versus subcutaneous fissurectomy under local anaesthesia with 2% diltiazem gel in the management of chronic fissure in ano: prospective study

Background: Anal fissure is one of the most common benign anorectal condition that is caused by an ulcer or breach in the anoderm of the anal canal. It causes very severe pain and discomfort and directly affects the quality of life. From the past, various surgical treatment modalities have been practised to bring complete cure and relief but have always been associated with secondary complications. The aim of the study was to compare efficacy of outcome of lateral internal sphincterotomy and subcutaneous fissurectomy with topical 2% diltiazem gel in the treatment of chronic fissure in ano.Methods: 60 patients who were diagnosed with chronic anal fissure between 2019-2021 at MGM Medical College were undertaken in this study. Patients were selected randomly on alternate basis. Group A patients were subjected to subcutaneous fissurectomy under local anaesthesia with post-operative application of 2% diltiazem gel. Group B patients were subjected to LIS. Surgical wound infection, absenteeism from work, symptomatic relief were assessed and compared between the groups.Results: There was no significant difference among both the study population in terms of age and gender. There was a statistically significant association between post-operative wound infection (p=0.011), number of work days lost (p=0.008) and satisfaction level (p=0.020).Conclusions: LIS is still a better surgical choice for treating chronic anal fissures than subcutaneous fissurectomy with 2% diltazem gel, due to less complications, faster pain alleviation, and fewer missed work days.

Comparing the Efficacy of 2% Diltiazem Gel with 0.2% Glyceryl Trinitrate in Anal Fissure

Objective: To compare the efficacy of 2% diltiazem gel with 0.2% glyceryl trinitrate in patients presenting with chronic anal fissure at Tertiary Care Hospital, Larkana.
 Methodology: This prospective comparative Study was conducted at department of Surgery ward-II Chandka Medical Hospital, Larkana from 14-01-19 to 14-07-19. A total of 130 patients who were treated as OPD cases were included in this study. Each patient detailed history & clinical examination, details of symptomatology was recorded in a epically diagnosed proforma. These patients were randomly divided in two equal groups i-e group A 65 patients and group B 65 patients. Group A patients were treated with 02% glyceryl trinitrate and group B patients were treated with diltiazem gel 02%. All the patients of group A & B were followed up to 02 months after start of leadema as a OPD cases.
 Results: A total of 130 patients (65 each in 2% diltiazem gel with 0.2% glyceryl trinitrate group) were included. Mean age in both groups was 42.56±3.91 and 41.71±4.01. 46 (70.8%) and 19 (29.2%) were male and female in Group A and 39 (60%) and 26 (40%) were male and female in Group B. Efficacy of 2% diltiazem gel with 0.2% glyceryl trinitrate in patients presenting with chronic anal fissure was 76.9% and 50.8% respectively.
 Conclusion: DTZ (2%) and GTN (0.2%) are equally effective in healing anal fissures. DTZ is better than GTN as it causes less side effects, low recurrence rate, healing rate and therefore better compliance.

Comparison of the Effects of Diltiazem Gel with Lidocaine Gel on Reducing Pain and Discomfort in Patients Undergoing Rectosigmoidoscopy: A Randomized Double-blinded Clinical Trial

Background: Flexible rectosigmoidoscopy is an easy and accessible exam to diagnose distal colon diseases, although many patients refuse to undergo it due to pain and discomfort during the procedure. Studies show that the application of local lidocaine, as an analgesic has no effect on pain relief in patients undergoing rectosigmoidoscopy. The current study aims at comparing the effects of diltiazem gel, an antispasmoic drug with local pain-reducing effects, with lidocaine gel in patients undergoing flexible rectosigmoidoscopy. Materials and Methods: The current double-blinded, randomized, clinical trial was performed to compare the effect of two topical drugs, lidocaine and diltiazem, on pain relief in patients undergoing rectosigmoidoscopy. A total of 80 patients who were potential candidates for rectosigmoidoscopy were enrolled in the study after obtaining the informed consent and then randomly assigned to one of the lidocaine gel (2 mL) or diltiazem gel (2 mL) group, 10 minutes prior to rectosigmoidoscopy. The level of pain in the patients during the procedure was measured using the visual analogue scale (VAS) and the results were recorded. The data were analyzed using paired samples ttest and independent t-test as well as analysis of covariance (ANOVA) with SPSS version 18. P-value <0.05 was considered the level of significance. Results: Of 80 patients, 35 (43.75%) were male and 45 (56.25%) female. The mean age and body mass index (BMI) of the patients were 51.45 ± 15.21 years and 25.95 ± 7.47 kg/m2, respectively, and there was no significant difference between the groups. The most frequent indications for rectosigmoidoscopy were abdominal pain (46.3%) and rectorrhagia (31.3%). The mean VAS score for pain reported by the patients in the lidocaine and diltiazem groups was 3.97 ± 2.89 and 2.60 ± 2.36, respectively. The VAS score for pain in the diltiazem group was significantly lower than lidocaine group (P = 0.023). Conclusion: The application of local diltiazem gel around the anus, in spite of no side effects, can effectively reduce the pain and discomfort in patients during rectosigmoidoscopy. Iranian Registry of Clinical Trials (Reg. No 31055).

A prospective clinical study of fissure in ano and analysis of various treatment modalities

Background: Fissure-in-ano is a very common problem across the world. The rationale of treating this condition is to reduce the internal anal sphincter tone, thereby relieving the spasm and improving the circulation. This study aims to analyse the various modalities of treatment given for fissure in ano and observe the presentations and tailor the treatment needs of the patient. Methods: This study was done prospectively on 165 patients with fissure in ano in Apollo BGS hospitals Mysore, and patients were treated with Diltiazem gel and Left lateral sphincterotomy when and as needed. Results: 165 patients were prospectively studied, treated with conservative management with Diltiazem gel and left lateral sphincterotomy when and as needed. 134 patients (81.2%) improved and fissure healed and 31 patients (18.8%), whose fissure was not healed were subjected to Left lateral sphincterotomy. Mean time taken for fissure to heal with conservative management was 5.26 weeks and with surgery was 3.41 weeks. Conclusion: Topical Diltiazem gel therapy should be advocated as the first line of treatment and surgery should be reserved for patients with relapse and therapeutic failure of prior pharmacological treatment.

Comparative study of unilateral subcutaneous internal anal sphincterotomy and 02% diltiazem local application in acute fissure in ano: a study of 40 patients over 01 year

Background: Two most demoralizing things in life are physical pain and bad body odour. A counted few body pains are as terrible, as oppressive and as tormenting, almost on daily basis as the pain of fresh acute fissure in ano. It pins your whole being, your awareness of life and focus of living on to your painful anus. Anal fissures are commonly encountered in routine colorectal practice. Fissure has traditionally been treated surgically. Developments in the pharmacological understanding of the internal anal sphincter have resulted in more conservative approaches towards treatment.Methods: 40 patients with acute fissure in ano were divided into 02% diltiazem gel and unilateral subcutaneous internal anal sphincterotomy (USIAS) groups. Patients in the two groups were followed up subsequently.Results: Anal fissures were found completely healed in 14 (70%) out of 20 patients treated with 02% diltiazem gel between 4-8 weeks. Healing was 100% with “USIAS” group. The mean healing duration of fissure was 04.45 weeks in diltiazem gel group and 03.45 weeks in “USIAS” group. 65% patients were free from pain after treatment with diltiazem gel whereas 95% patients were free from pain after treatment with “USIAS”.Conclusions: This prospective study, demonstrates that “USIAS” is superior to pharmacological treatment of anal fissure with good symptomatic relief, high rate of healing with very low rate of complication. Patients who are not willing to undergo surgery may be managed by 02% diltiazem as pharmacological line of management for fissure in ano.

A comparative study of chemical sphincterotomy (using 2% diltiazem) and lateral internal sphincterotomy for chronic anal fissure

Background: Anal fissure is the most common painful condition of anal region characterised by vertical ulcers affecting distal end of anal canal. The main aim of this study is comparing 2 % diltiazem and lateral internal sphincterotomy in the treatment of chronic anal fissure.Materials and Methods: The Study was conducted as a clinical trial in Sree Mookambika institute of medical sciences, Kulasekharam from May 2020 to November 2020.100 patients diagnosed with chronic fissure in ano on the basis of history of painful defecation with or without per rectal bleeding for more than 6 weeks and per rectal examination were enrolled in the study after obtaining an informed written consent from them. Results has been detailed in both descripted and statistical point of view and simplified in understandable format.Results: In 89.36% of patients in diltiazem group and 100% of patients in lateral internal sphincterotomy group fissure healed completely between 4-8 weeks. In the diltiazem group pain relief was good. 42 patients (89.4%) had pain relief at the end of 14 weeks. 5 patients (10.6%) had no pain relief. But pain relief in lateral internal sphincterotomy group was excellent with 100% patients having complete pain relief by 8 weeks’ time. Mild headache was experienced with diltiazem by 3(6.4%) patients.1 patient (2.1%) complained of flatus incontinence with lateral internal sphincterotomy.Conclusion: We conclude that lateral internal sphincterotomy is the gold standard treatment of chronic fissure in ano but chemical sphincterotomy using 2% diltiazem gel can be considered as a good second line treatment option in those unfit for surgery or for those not willing for surgery.

Stability and Analgesic Efficacy Study for a Mixture of Diltiazem, Lidocaine and Diclofenac Gel Formulations in Post Hemorrhoidectomy Pain Reduction in Iraqi Patients

Stability and Analgesic Efficacy Study for a Mixture of Diltiazem, Lidocaine and Diclofenac Gel Formulations in Post Hemorrhoidectomy Pain Reduction in Iraqi Patients

Treatment of fissure in Ano-conservative treatment with diltiazem and surgical treatment with lateral sphincterotomy: Two faces of same coin

Background: Fissure in Ano is a most troubling and painful condition that affects a great majority of population world over. It is one of the common reason of bleeding per anus. Though the nature and anatomy of fissure in Ano is quite clear still the method of treating them with optimal clinical results and least pain and inconvenience to the patient is still open to debate. Hence this study is intended to know conservative treatment method and to offer the patient the same, who are not willing for operative procedure. In the present era of evidence based medicine, in order to reduce the need for anesthesia and surgery this study is intended. Methods: The present study was conducted in 100 patients at Department of Surgery who have been clinically diagnosed as chronic fissure in Ano and also who are admitted in surgery ward for surgical treatment. Group – A: 50 patients who are subjected to chemical sphincterotomy with 2% Diltiazem gel used topically. Group – B: 50 patients who underwent Lateral sphincterotomy.Results: In present study 42/50 patients treated with conservative treatment got relief from pain and cured of fissure compared to that with surgical treatment. Hence 84% of patients were not exposed to surgical risk and were cured effectively with conservative treatment.Conclusions: Conclusion drawn from our study is that conservative treatment with Diltiazem very effective in the treatment of chronic fissure in Ano. This method can, not only be offered to the patient who are not willing for operative procedure but also it significantly reduces the need for anesthesia and surgery in many patients.

Prospective comparative study between lateral sphincterotomy and subcutaneous fissurectomy with topical 2% diltiazem gel in the treatment of chronic fissure in ano

Background: Anal fissure is defined as an ulcer in the anoderm usually in the posterior midline, less frequently in the anterior midline and rarely in the lateral position of the anal canal. Different treatment modalities include non-invasive pharmacological therapies, lateral internal sphincterotomy (LIS) which is the gold standard for treatment and new therapies that include perineal support devices, Gonyautoxin injection, fissurectomy, fissurotomy, sphincterolysis, and flap procedures. Thus, aim of the study was to compare the efficacy of outcome of lateral internal sphincterotomy and subcutaneous fissurectomy with topical 2% Diltiazem gel in the treatment of chronic fissure in ano.Methods: 50 patients with chronic fissure in ano attending OPD of Department of General Surgery, KVGMCH, Sullia were randomly selected and divided into Group A (n=25): Lateral internal sphincterotomy (control group) and Group B (n=25): Subcutaneous fissurectomy + topical 2% Diltiazem Gel (test group).Results: Patients of Group B showed much less mean duration of absenteeism (2.88 weeks) compared to Group A. Comparison between Group B and Group A showed statistically significant differences in pain relief (P<0.0001), complications (p=0.03), mean duration of sitz baths (p<0.0001), absenteeism (p<0.0001) respectively.Conclusion: Hence Subcutaneous fissurectomy with topical 2% Diltiazem gel is a better surgical option for chronic fissure in ano than conventional Lateral internal sphincterotomy.

Diltiazem Gel Versus Nitroglycerin Ointment in Healing Process of Scleroderma Digital Ulcers: A Blind Randomized Controlled Trial.

Aim: Assessing the effect of Diltiazem gel on scleroderma digital ulcers compared to Nitroglycerin ointment and placebo. Methods: A single blind randomized controlled trial was done on 90 scleroderma patients, randomly divided to three groups: one receiving Diltazem gel 2%, the other receiving Nitroglycerin ointment 2% and control one receiving Vaseline as placebo for 2 times per day for 8 weeks. The patients' demographic information and disease characteristics were summarized. The longest diameter of the ulcers was measured in 3 groups at the beginning and at the end of the study. The site of the ulcers and the number of new ones were, also, determined for each patient Results: The effect size of the ulcers, in each three groups, was significantly lower at the end of the survey (Diltiazem P

Comparative Study of Chemical Sphincterotomy and Lateral Internal Sphincterotomy for Chronic Anal Fissure

Introduction Fissure-in-ano is a very common problem which causes considerable morbidity and affects the patient's quality of life to a great extent. This warrants prompt treatment of the condition with appropriate methods. In this study, we assess and compare the efficacy and adverse effects of topical application of 2% Diltiazem gel with that of Lateral internal sphincterotomy. Method 100 patients with chronic fissure in ano were divided into Diltiazem gel and Lateral internal sphincterotomy groups and followed up at regular intervals for symptomatic relief and healing. Results Fissure was completely healed in 42 (89.36%) out of 47 patients by 8 weeks in the Diltiazem group, 3 patients experienced mild headache, 2 local irritation, 13 patients were pain-free at the end of 4 weeks, 26 patients were 8 weeks and 3 patients by 14 weeks. 5 patients were not relieved of pain at the end of 14 weeks. Completely healed in 48 (100%) out of 48 patients by 4 weeks in the Lateral Internal Sphincterotomy group.21 patients experienced post-operative pain and incontinence for flatus in 1 patient. 32 patients were pain-free by 4 weeks and all the patients were free of pain by 8 weeks. Conclusion The current study shows results in favour of lateral internal sphincterotomy with a healing rate of 100% with a faster pain-relief and minimal complications if performed by the experienced surgeon. However topical 2% diltiazem gel is an effective agent can be safely prescribed for patients having contraindications for surgery. With a healing rate close to 90%, topical 2% Diltiazem therapy can be advised as the first line of treatment for the treatment of chronic anal fissure.

A Prospective, Randomised Comparative Study of Lateral Sphincterotomy and Local Application of 2% Diltiazem Gel in Treatment of Chronic Anal Fissure

A Prospective, Randomised Comparative Study of Lateral Sphincterotomy and Local Application of 2% Diltiazem Gel in Treatment of Chronic Anal Fissure

Comparative study of topical diltiazem with lateral internal sphincterotomy in management of chronic anal fissure

Introduction: Chronic anal fissure is persistent or recurrent painful linear ulcer situated in anal canal just below the dentate line to the anal verge and fails to heal within 6-8 weeks. For these fissures, partial lateral sphincterotomy is done which diminishes internal anal sphincter hypertonia and anal canal pressure but can lead to long term disturbances of sphincter function. In the present study we have compared medical management by topical diltiazem ointment with established surgical procedure of lateral internal sphincterotomy in the management of chronic anal fissure. Material and Methods: This was a prospective comparative randomised study, carried out on 100 patients of chronic anal fissure at S.M.S. Medical College, Jaipur. Intensity of pain was recorded on 0-10 Numeric Rating Scale and Wong-Baker Faces Pain Rating Scale (Visual analogue scale) on presentation and during follow up visits. Selected patients were put under two groups of 50 participants each, A (study group, diltiazem group) and B (control group, partial lateral sphincterotomy group) using simple randomization technique and were to receive treatment accordingly. Results: 26% patients of study group and 42% patients of control group reported no pain at 1st week of treatment. 72 % patients of study group and 94 % patients of control group reported no pain at 8th week of treatment. Conclusion: Topical diltiazem gel has shown to have several advantages and can be considered first line topical treatment but Partial lateral internal sphincterotomies still gold standard procedure for chronic anal fissure.

Local and Oral Antibiotics with Avoidance of Constipation (LOABAC) Treatment for Anal Fissure: a New Concept in Conservative Management.

Anal fissure is one of the most common presenting complaints in the outpatient departments of colorectal and general surgery. In spite of newer advances (nitroglycerin or diltiazem gels and botulinum injection locally) in the conservative management of this disease, up to 40 % of patients would still require surgical intervention. In surgical options, lateral internal sphincterotomy (LIS) is considered as a gold standard by many surgeons because it is believed to be safe, has low morbidity, and is easy to perform. However, recent meta-analysis shows that LIS is associated with up to 14 % incontinence rates. Therefore, the need for conservative management cannot be overemphasized. As of today, chronic fissure-in-ano is considered a noninfective pathology and antibiotics have no role in its management. However, during the last decade, evidence is emerging to the contrary. In 2007, Pelta et al. found subcutaneous tract at the base of the fissure in almost all the patients and hypothesized sub-clinical infection as the reason for causing symptoms in chronic fissure-in-ano. In 2010, local application of povidine-iodine solution showed to improve symptoms in chronic fissure [1]. In 2012, it was demonstrated that a short course (5 days) of oral antibiotics (ciprofloxacin 500 mg plus ornidazole 500 mg) gave significant symptomatic relief in up to 90 % patients [2]. However, this relief was not sustained if constipation was not strictly avoided. Subsequently, in 2014, it was shown that local application of antibiotics cream (ornidazole with or without povidine-iodine) for 3 months in addition to the above regimen (a short course of oral antibiotics plus avoidance of constipation, local application of Diltiazem gel was recommended if anal sphincter spasm was present) sustained the symptomatic benefits achieved and helped to cure the fissure in up to 90 % of patients [3]. These findings are significant for two reasons. First, they highlight that infection can have an important role in etiopathogenesis of chronic fissure-in-ano. Secondly, high success rate of conservative management is encouraging, especially against the background of high complications of standard surgical treatment (LIS). Therefore, local and oral antibiotics with avoidance of constipation (LOABAC) treatment shows a new direction in the management of chronic anal fissure. Prospective controlled preferably randomized studies would be needed to substantiate these results.