Surgery. 2022 Jul;172(1):41-52. doi: 10.1016/j.surg.2021.11.030. Epub 2022 Jan 5.

James Z Jin ¹, Sameer Bhat ², Brittany Park ², Molly-Olivia Hardy ², Hanson Unasa ², Melbourne Mauiliu-Wallis ², Andrew G Hill ²

Author information

¹Department of Surgery, South Auckland Clinical Campus, The University of Auckland, Middlemore Hospital, Auckland, New Zealand. Electronic address: James.jin@auckland.ac.nz.

²Department of Surgery, South Auckland Clinical Campus, The University of Auckland, Middlemore Hospital, Auckland, New Zealand.

Abstract

Background: There are multiple treatments for anal fissures. These range from medical treatment to surgical procedures, such as sphincterotomy. The aim of this study was to compare the relative clinical outcomes and effectiveness of interventional treatments for anal fissure.

Methods: Randomized controlled trials were identified by means of a PRISMA-compliant systematic review using the Medline, EMBASE, and CENTRAL databases. Inclusion criteria were randomized controlled trials comparing treatments for anal fissure. A Bayesian network meta-analysis was performed using BUGSnet package in R. Outcomes of interest were healing (6-8-, 10-16-, and >16-week follow-up), symptom recurrence, pain (measured on a visual analog scale), and fecal or flatus incontinence. PROPSERO Registration: CRD42021229615.

Results: Sixty-nine randomized controlled trials were included in the analysis. Lateral sphincterotomy remains the treatment with the highest odds of healing compared to botulinum toxin and medical therapy at all follow-up time points. There was no significant difference in healing between botulinum toxin and medical therapy at any time point. Advancement flap showed similar effectiveness compared to lateral sphincterotomy. Medical treatment and botulinum toxin had the highest pain scores at follow-up. Sphincterotomy had the highest odds of fecal and flatus incontinence.

Conclusion: Lateral sphincterotomy had the highest rates of healing and should be considered as the definitive treatment after failed initial therapy with botulinum toxin or medical treatment. Botulinum toxin was equally effective compared to medical treatment. Advancement flap shows similar effectiveness compared to lateral sphincterotomy, but more studies are needed to evaluate its efficacy.