Chemical sphicterotomy versus surgical sphicterotomy in the management of chronic fissure in ANO: A prospective, randomized trial

Introduction: Fissure in ano is a common cause of severe anal pain. The hypertonia and spasm of the internal anal sphincter is believed to be the chief pathology in chronic fissures. The reduction of this hypertonia is most commonly achieved by surgical sphincterotomy, that results in fissure healing in more than 90% of the cases. However, the surgery carries a significant risk of incontinence. In this study, we explored chemical sphincterotomy by using topical 2% diltiazem as an effective and a safe alternative method to the surgical treatment for chronic fissure in ano. Materials and Methods: In this prospective trial, 200 patients with chronic anal fissures were randomly divided into group 1 and group 2, with 100 patients in each group. The group 1 cases received 2% topical diltiazem at the perianal skin twice daily for 6 weeks, while the group 2 subjects underwent lateral internal sphincterotomy. They were assessed biweekly during the treatment. The follow up was carried out for one year. Results: Complete fissure healing was found in 69.23% patients of group 1 (topical diltiazem) and in 95.87% patients of group 2 (surgical sphincterotomy). In the first group, the pain relief was fairly good, while in group 2, the response was quick and excellent. Mild headache was the main side effect in group1, while it was anal incontinence in group 2. 10.43% of the cases from the group 1 had recurrence, whereas none in the second group had it. Conclusion: We conclude that chemical sphincterotomy with the use of 2% topical diltiazem may be considered as first line treatment for chronic anal fissure. Surgical sphincterotomy should be reserved for patients who have failed to respond to chemical sphincterotomy.