A Systematic Review and Network Meta-Analysis Comparing Treatments for Anal Fissure

Authors List

Bhat, S., Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand Jin, J., Department of Surgery, South Auckland Clinical Campus, The University of Auckland, Middlemore Hospital, Auckland, New Zealand Hardy, M., Department of Surgery, South Auckland Clinical Campus, The University of Auckland, Middlemore Hospital, Auckland, New Zealand Unasa, H., Department of Surgery, South Auckland Clinical Campus, The University of Auckland, Middlemore Hospital, Auckland, New Zealand Mauiliu-Wallis, M., Department of Surgery, South Auckland Clinical Campus, The University of Auckland, Middlemore Hospital, Auckland, New Zealand Hill, A., 1. Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand; 2. Department of Surgery, South Auckland Clinical Campus, The University of Auckland, Middlemore Hospital, Auckland, New Zealand

Introduction: There are multiple treatments for anal fissures. These range from medical therapies to surgical procedures, such as sphincterotomy.

Aims: The objectives of this study were to compare the relative clinical outcomes and effectiveness of interventional treatments for anal fissure.

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

Results: A total of 6,239 patients with anal fissure from 69 RCTs were included in the present NMA. Lateral sphincterotomy was associated with the highest odds of healing compared to botulinum toxin and medical treatments at all follow-up time points. Advancement flap showing similar effectiveness compared to lateral sphincterotomy. There was no significant difference in rates of healing between botulinum toxin and medical therapy at any of the time points. However, medical treatments and botulinum toxin were associated with the lowest pain scores at follow-up. Sphincterotomy resulted in the highest odds of faecal and flatus incontinence.

Conclusions: 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 treatments. 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 relative efficacy.

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