CHEMICAL VERSUS SURGICAL SPHINCTEROTOMY IN TREATMENT OF FISSURE IN ANO

A parallel group , open label study

  • Sonam Yadav General Surgery Department, SBLS Civil Hospital, Jalandhar, Punjab, India
  • Satinderjit Singh Bajaj General Surgery Department, SBLS Civil Hospital, Jalandhar, Punjab, India
  • Jagminder Kaur Bajaj Punjab Institute of medical sciences
Keywords: lateral internal sphincterotomy, diltiazem gel

Abstract

Background: Fissure in ano affects morbidity and quality of life of patients. Lateral internal sphincterotomy is the standard treatment for this condition. Chemical sphincterotomy using 2 percent Diltiazem gel is reported to be effective. This study was conducted to compare the efficacy of 2% diltiazem gel in the treatment of chronic fissure in ano with lateral internal sphincterotomy. Methods: 60 patients with fissure in ano were randomly divided into two groups of 30 each. Group A received 2% diltiazem gel applied topically and group B was treated with lateral internal sphincterotomy. The treatment outcomes were compared based on time to pain relief and time to complete healing of fissure. Results: Patients in both groups were comparable in terms of age, sex, dietary habits, and duration of symptoms. All patients complained of pain; however, majority had no relation of pain with defecation. 90% patients of group A and 96.7% patients of group B had constipation. Only 20% patients of group A and 36.7% of group B had bleeding per rectum. Sentinel tag was present in 46.7% patients in group A and 66.7% patients in group B.  Pain was relieved earlier with LIS as compared to medical treatment with diltiazem. At 4th week all 30 (100%) patients undergoing LIS but only 33% patients in diltiazem group had complete pain relief. however, all patients in diltiazem group were also relieved of pain by 9th week of treatment. With surgical treatment 19 (63.3%) patients had completely healed fissures at 4 weeks, as compared to none in group A. Although all fissures healed in both the groups at 12 weeks, healing of fissures occurred late in diltiazem group. Conclusion: All patients in both groups had pain relief by 9th week and complete healing of fissures by 12th week though response was delayed in patients receiving conservative treatment.

References

[1] H. Gandomkar, A. Zeinoddini, R. Heidari, and H. A. Amoli, “Partial lateral internal sphincterotomy versus combined botulinum toxin a injection and topical diltiazem in the treatment of chronic anal fissure,” Diseases of the Colon & Rectum, vol. 58, no. 2, pp. 228–234, 2015.
[2] W. R. Schouten, J. W. Briel, J. J. Auwerda, and E. J. de Graaf, “Ischaemic nature of anal fissure,” British Journal of Surgery, vol. 83, no. 1, pp. 63–65, 1996.
[3] A. A. Ayantunde and S. A. Debrah, “Current concepts in anal fissures,” World Journal of Surgery, vol. 30, no. 12, pp. 2246–2260, 2006.
[4] S. Schlichtemeier and A. Engel, “Anal fissure,” Australian Prescriber, vol. 39, no. 1, pp. 14–17, 2016.
[5] S. L. Jensen, “Diet and other risk factors for fissure-in-ano,” Diseases of the Colon & Rectum, vol. 31, no. 10, pp. 770–773, 1988.
[6] G. Maria, D. Brisinda, M. P. Ruggieri, I. M. Civello, and G. Brisinda, “Identification of anti-endothelial cell antibodies in patients with chronic anal fissure,” Surgery, vol. 126, no. 3, pp. 535–540, 1999.
[7] D. W. Mapel, M. Schum, and A. Von Worley, “The epidemiology and treatment of anal fissures in a population-based cohort,” BMC Gastroenterology, vol. 14, no. 1, 2014.
[8] O. Lapid and S. Walfisch, “Perianal and gluteal burns as a complication of hot water bottle treatment for anal fissure,” Burns, vol. 25, no. 6, pp. 559–560, 1999.
[9] A. AL-Ubaide, S. Al-Rubaye, and R. M. Al-Ani, “Lateral internal anal sphincterotomy of chronic anal fissure: An experience of 165 cases,” Cureus, 2022.
[10] P. Garg, M. Garg, and G. R. Menon, “Long-term continence disturbance after lateral internal sphincterotomy for chronic anal fissure: A systematic review and meta-analysis,” Colorectal Disease, vol. 15, no. 3, 2013.
[11] M. J. Thornton, M. L. Kennedy, and D. W. King, “Manometric effect of topical glyceryl trinitrate and its impact on chronic anal fissure healing,” Diseases of the Colon & Rectum, vol. 48, no. 6, pp. 1207–1212, 2005.
[12] “2% topical diltiazem hydrochloride for chronic anal fissure.” [Online]. Available: https://www.nice.org.uk/advice/esuom3/resources/2-topical-diltiazem-hydrochloride-for-chronic-anal-fissure-pdf-17548582597. [Accessed: 20-Apr-2023].
[13] A. E. Berkel, C. Rosman, R. Koop, P. van Duijvendijk, J. van der Palen, and J. M. Klaase, “Isosorbide dinitrate ointmentvsbotulinum toxin A (dysport®) as the primary treatment for chronic anal fissure: A randomized multicentre study,” Colorectal Disease, vol. 16, no. 10, 2014.
[14] G. C.M, “A comparative study of lateral sphincterotomy and 2% Diltiazem gel local application in the treatment of chronic fissure in a no,” JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH, 2014.
[15] R. Vaithianathan and S. Panneerselvam, “Randomised prospective controlled trial of topical 2 % Diltiazem versus lateral internal sphincterotomy for the treatment of chronic fissure in ano,” Indian Journal of Surgery, vol. 77, no. S3, pp. 1484–1487, 2014.
[16] R. Mansoor Khan, “Prevalence of fissure-in-ano among the patients of anorectal complaints visiting Nium Hospital,” Journal of Community Medicine & Health Education, vol. 05, no. 02, 2015.
[17] R. Chaudhary and C. S. Dausage, “Prevalence of anal fissure in patients with anorectal disorders: A single-centre experience,” JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH, 2019.
[18] S. L. Jensen, “Treatment of first episodes of acute anal fissure: Prospective randomised study of lignocaine ointment versus hydrocortisone ointment or warm Sitz Baths Plus Bran.,” BMJ, vol. 292, no. 6529, pp. 1167–1169, 1986.
[19] H. Villalba, S. Villalba, and M. A. Abbas, “Anal fissure: A common cause of anal pain,” The Permanente Journal, vol. 11, no. 4, pp. 62–65, 2007.
[20] N. Hananel and P. H. Gordon, “Re-examination of clinical manifestations and response to therapy of fissure-in-ano,” Diseases of the Colon & Rectum, vol. 40, no. 2, pp. 229–233, 1997.
[21] J. Siddiqui, G. E. Fowler, A. Zahid, K. Brown, and C. J. Young, “Treatment of anal fissure: A survey of surgical practice in Australia and New Zealand,” Colorectal Disease, vol. 21, no. 2, pp. 226–233, 2018.
[22] R. L. Nelson, A. Chattopadhyay, W. Brooks, I. Platt, T. Paavana, and S. Earl, “Operative procedures for fissure in ano,” Cochrane Database of Systematic Reviews, 2011.
[23] P. Garg, “Recent advances in benign anorectal disorders,” GI Surgery Annual, pp. 51–94, 2022.
[24] H. Iswariah, J. Stephens, N. Rieger, D. Rodda, and P. Hewett, “Randomized prospective controlled trial of lateral internal sphincterotomy versus injection of botulinum toxin for the treatment of idiopathic fissure in ano,” ANZ Journal of Surgery, vol. 75, no. 7, pp. 553–555, 2005.
[25] E. A. Carapeti, M. A. Kamm, and R. K. Phillips, “Topical diltiazem and Bethanechol decrease anal sphincter pressure and heal anal fissures without side effects,” Diseases of the Colon & Rectum, vol. 43, no. 10, pp. 1359–1362, 2000.
Published
2023-05-17
How to Cite
[1]
S. Yadav, S. Bajaj, and J. Bajaj, “CHEMICAL VERSUS SURGICAL SPHINCTEROTOMY IN TREATMENT OF FISSURE IN ANO”, JSS, vol. 10, no. 1, May 2023.