Introduction Chronic anal fissures (CAF) are frequently encountered in coloproctology clinics. Chemical sphincterotomy with pharmacological agents is recommended as first-line therapy. Topical nitrates (TN) are effective at healing CAF but recurrences are common. An alternative treatment modality is injection of botulinum toxin (BT) into the anal sphincter. We aimed to perform a systematic review and meta-analysis to compare the effectiveness of BT and TN in the management of CAF.
Method The online published literature was searched for relevant articles from inception till January 2017. All published randomised trials (RCTs) that reported direct comparisons of BT and TN were included. Two independent reviewers performed methodological assessment and data extraction. Random effects models were used to calculate pooled effect size estimates.
Results Five RCTs describing 313 patients (154 in BT, 159 in TN) were included. There was significant heterogeneity among the trials. On random effects analysis, there were no significant differences in incomplete fissure healing (OR=0.47, 95% CI=0.13 to 1.67, p=0.24) or recurrence (OR=0.61, 95% CI=0.26 to 1.43, p=0.26) between BT and TN, respectively. BT was associated with a higher rate of transcient anal incontinence (pooled OR=2.53, 95% CI=0.98 to 6.57, p=0.06) but significantly fewer side effects (OR=0.09, 95% CI=0.01 to 0.72, p=0.02) and headache (OR=0.10, 95% CI=0.01 to 0.77, p=0.03)) compared to TN.
Conclusion BT is associated with fewer side effects when compared to TN but there is no difference in fissure healing. However, well-designed RCTs with adequate follow-up are needed to definitively answer this important clinical question.
Disclosure of Interest None Declared