Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 26041

AbstractMaterial and MethodsResultsDiscussionConclusionAcknowledgementReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2012 | Month : August | Volume : 6 | Issue : 6 | Page : 1018 - 1021

Chemical Sphicterotomy versus Surgical Sphicterotomy in the Management of Chronic Fissure in ANO: A Prospective, Randomized Trial

Rithin Suvarna, Panchami, Guruprasad Rai D.

1. Associate Professor, AJIMS, Mangalore, India. 2. Assistant Professor, FMMS, Mangalore, India. 3. Assistant Professor, AJIMS, Mangalore, India.

Correspondence Address :
Dr. Rithin Suvarna
Associate professor
AJIMS, Mangalore, India.
Phone: 9886203235
E-mail: dr.rithinsuvarna@gmail.com

Abstract

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.

Keywords

Fissure-in-ano, Sphincterotomy, Topical diltiazem

How to cite this article :

Rithin Suvarna, Panchami, Guruprasad Rai D.. CHEMICAL SPHICTEROTOMY VERSUS SURGICAL SPHICTEROTOMY IN THE MANAGEMENT OF CHRONIC FISSURE IN ANO: A PROSPECTIVE, RANDOMIZED TRIAL. Journal of Clinical and Diagnostic Research [serial online] 2012 August [cited: 2019 Oct 20 ]; 6:1018-1021. Available from
http://www.jcdr.net/back_issues.asp?issn=0973-709x&year=2012&month=August&volume=6&issue=6&page=1018-1021&id=2288

INTRODUCTION
Fissure in ano (AF) is a common proctologic condition in which there is a linear laceration in the lining of the distal anal canal, which is a common cause of severe anal pain (1). The pathogenesis of anal fissures is not well understood (2). Constipation and hard stools have been thought to be the important initiating factors (3). The chief pathology in chronic fissures appears to be persistent hypertonia and spasm of the internal anal sphincter (4),(5),(6). The reduction of this hypertonia improves the local blood supply and encourages the fissure healing. Chronic anal fissures, unlike acute fissures, don’t usually resolve with simple measures (7). They are most commonly treated by surgical sphincterotomy that heals the fissures in more than 90% of the cases (7),(8). However, the surgery carries a significant risk of incontinence (9)(10),(11). This limitation of the surgery has led to a search for alternative therapies such as topical diltiazem (chemical sphincterotomy), topical glyceryl trinitrate, etc. The aim of this prospective randomized trial was to compare the effectiveness and the side effects of chemical sphincterotomy (with the use of topical 2% diltiazem) versus surgical sphincterotomy in the treatment of chronic anal fissures.

Material and Methods

This prospective, comparative study was undertaken at the Vinaya Hospital and Research Centre, South Canara, from 2009 to 2012. Two hundred patients with a definite diagnosis of chronic anal fissure were enrolled in this study after obtaining an informed written consent from them. Ethical approval was obtained from the local ethical committee. The inclusion criteria included the patients who were aged between The first group was treated with a 2% diltiazem ointment (chemical sphincterotomy). The subjects were instructed to apply the ointment (about a size of a pea) to the anal margin by using their tip of the index finger, twice daily for 6 consecutive weeks. The cases from the second group underwent left lateral internal sphincterotomy under spinal/general anaesthesia. During the course of the treatment, both the groups were asked to eat a high fibre diet and to use warm sitz baths. They were reviewed in the Outpatients Department at the 2nd, 4th and 6th weekends during the course of the treatment and then, bimonthly for a year. At each visit, details on the fissure healing, pain relief and any side effects and recurrence were noted down. Also, specific questions were asked, particularly to the second group, regarding the leakage of flatus and faeces. The healing of the fissure was assessed visually and the intensity of the pain was assessed from a visual analogue score. Healing was defined as the complete disappearance of the fissure on examination. Every patient was supplied with a pain score chart. There were instructed to mark the level of the pain in it daily. These charts were graded from 0 to 10 and they were marked at one end- 0 (no pain) and at the other end -10 (worst pain). The disease was considered as recurrent if the fissure reappeared at the same site, 2 months after the surgery or 2 months after the 6 weeks course of the diltiazem application. The data was collected and analyzed statistically by using the SPSS version17 software. The p values were calculated by using the Chi-square test.

Results

The clinical details of the 200 cases which were studied have been shown in the (Table/Fig 1).In the first group, there was a slight female predominance, whereas a slight male predominance was observed in second group (Table/Fig 1). A majority of the cases in both the groups had anal pain and bleeding. A few cases had constipation as well. Diabetes mellitus and hypertension were noted in few patients. The commonest location was the posterior midline (Table/Fig 1). Most of the cases had sphincter spasms and an external skin tag (sentinel pile). The cases were evaluated at the 2nd, 4th and 6th weekends for fissure healing, pain alleviation, side effects and recurrences. 9 cases from group 1 and 3 cases from group 2 failed to complete the study due to cooperation problems. These subjects were not considered in the statistical analysis.Complete fissure healing was noted in 69.23% patients of group 1 (chemical sphincterotomy) and in 95.87% patients of group 2 (surgical sphincterotomy) within 6 weeks (Table/Fig 2).In the first group, the pain response was fairly good. The pain score (mean) fell steadily over 6 weeks (Table/Fig 3). But the pain alleviation in the second group was excellent and quick. In the second group, a steep drop in the pain score was noted in the first two weeks (Table/Fig 3).Mild headache was experienced by 5.49% patients of group 1, while none of the patients in group 2 had it. 9.27% of the cases from group 2 complained of flatus incontinence, whereas none of the cases in group 1 had it. However, the flatus incontinence improved over time, so that at the end of the 1year follow up, only 2 cases still had it. 5.15% cases in group 2 had a frank faecal incontinence in the first 6 weeks. Nevertheless, it also resolved completely over time (Table/Fig 4).5 of the 63 fissure healers from group 1 and 4 of the 93 healers from group 2 didn’t show up for follow up, while the rest of the patients completed the full 1 year’s follow up.10.43% of the cases from group 1 had recurrence, while none in group 2 had it (Table/Fig 5).

Discussion

Fissure in ano is a common proctologic disease in which there is a vertical tear in the lining of the distal anal canal (1). The posterior midline is the commonest location, followed by the anterior midline, especially in females (12). The pathogenesis of chronic AFs is poorly understood (2) (Table/Fig 6). Constipation and hard stools are often associated with fissures and they have been believed to initiate fissure formation (3). Inflammatory bowel disease and tuberculosis may be associated with fissures. In females, they often occur during pregnancy and following delivery (7). Chronic AFs are associated with internal anal sphincter hypertonia. The reduction of this hypertonia improves the local blood supply, thus encouraging the fissure healing. A sharp anal pain during defaecation, which is associated with the passage of bright red blood per rectum, is the classical feature of AFs (1) . The pain may be so severe, especially in acute fissures, that the patients may postpone the defaecation for days together until it becomes inevitable (7).This leads to hardening of the stools, which further worsens the condition. The fissures can be acute or chronic. Acute fissures have a shorter duration (less than a month) and they have fresh mucosal edges (1). They usually resolve with the use of simple measures like a high fibre diet, adequate water intake, and warm sitz baths (1). Chronic fissures are characterized by a sentinel pile, hypertophic anal papillae, anal spasms and/or fibrosis of the internal sphincter muscle (2). The internal sphincter fibres are usually exposed on the floor of the well developed fissure which goes into spasm due to irritation (7). The chronic AFs usually do not heal with simple conservative measures (7). They are most commonly treated surgically by lateral internal anal sphincterotomy, which lowers the resting anal pressure and heals them in more than 90% of the cases (7),(8). But, sphincterotomy carries a significant risk of incontinence (8),(9),(10)(11). This drawback of the surgical treatment has led to a search for alternative therapies. Chemical sphincterotomy has been tried by using a variety of agents which include topical glyceryl trinitrate (GTN), calcium channel blockers such as nifedipine or diltiazem and botulinum toxin. Some of these agents were found to be effective in healing chronic anal fissures with negligible side effects and these are now being considered as the first line treatment for chronic AFs (13). However, the medical treatment has two limitations: the moderate effectiveness (between 30% and 80%) and the need for a prolonged treatment (10). Topical GTN has been the most extensively studied and followed non-surgical treatment for chronic anal fissures (8). Although it is effective, headache and a high recurrence rate are its main drawbacks (1), (14),(15),(16),(17),(18). Diltiazem is a calcium channel blocker which acts by blocking the calcium channels in the smooth muscles, thus causing relaxation (1). Various studies have reported a 60% to 75% fissure healing rate with topical diltiazem (19),(20),(21),(22). Moreover, topical diltiazem causes less headache and a fewer side effects than the GTN ointment (19), (23).

Conclusion

We conclude that chemical sphincterotomy with the use of topical 2% diltiazem may be considered as the first line treatment for chronic anal fissures, in spite of the higher rate of recurrence and the temporary anal incontinence. Lateral internal sphincterotomy should be reserved for the patients who have failed to respond to the initial chemical sphincterotomy.

Acknowledgement

We would like to thank all the consultant surgeons at the Vinaya Hospital and Research Centre, south Canara, for allowing us to analyze their cases. We are very grateful to Dr Nanjesh and Dr Tantry for their help with the statistical analysis. The authors confirm that there are no known conflicts of interest which are associated with this publication and that there has been no financial support for this work that could have influenced its outcome.

References

1.
Leong APK. The pharmacological treatment of anal fissures – A future role in the primary care. Singapore Med J 2003; 44(3): 136-37.
2.
Uwe W. Pharmacological sphincterotomy for chronic anal fissures with the use of the botulinum toxin A. J Cutan Aesthet Surg. 2008 Jul-Dec; 1(2): 58-63.
3.
Jensen SL. Diet and other risk factors for fissure-in-ano. A prospective case control study. Dis Colon Rectum. 1988 Oct; 31(10):770-73.
4.
Utzig MJ, Kroesen AJ, Buhr HJ .Concepts in the pathogenesis and the treatment of chronic anal fissures—a review of the literature. The American Journal of Gastroenterology 2003; 98: 968-74.
5.
Hisham MA. A comparative study on oral and topical nifedipine in the treatment of chronic anal fissures. Sudanese Journal of Public Health 2012 (Oct); 5(4).
6.
Jonas M, Scholefield JH. Anal fissures. Gastroenterol Clin North Am 2001; 30(1):167-81.
7.
Gupta P J. The treatment of fissure in ano- revisited. Afr Health Sci. 2004 April; 4(1): 58-62.
8.
Golfam F, Golfam P, Khalaj A, Mortaz S S S. The effect of topical nifedipine in the treatment of chronic anal fissures. Acta Medica Iranica 2010; 48(5): 295-99.
9.
Jonathan NL, John HS. A randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in the treatment of anal fissures. The Lancet 1997; 349:11-14.
10.
Garcea G, Sutton C, Mansoori S, Lloyd T, Thomas M. The results following conservative lateral sphincteromy for the treatment of chronic anal fissures. Colorectal Disease 2003(July); 5( 4): 311-14.
11.
Dhawan S, Chopra S . Nonsurgical approaches for the treatment of anal fissures. The American Journal of Gastroenterology 2007; 102: 1312–21.
12.
Cook TA, Brading AF, Mortensen NJ. The contractile properties of the ano-rectal smooth muscle. Br J Surg 1999; 86:70-75.
13.
Haq Z, Rahman M, Chowdhury RA, Baten MA, Khatun M. Chemical sphincterotomy—the first line of treatment for chronic anal fissures. Mymensingh Med J. 2005 Jan; 14(1):88-90.
14.
Carapeti EA, Kamm MA, Mc Donald PJ. A randomised controlled trial that showed that glyceryl trinitrate heals anal fissures, that higher doses are not more effective, and that there is a high recurrence rate. GUT 1999; 44:727-30.
15.
Zuberi BF, Rajput MR, Abro H, Shaikh SA. A randomised trial of the glyceryl trinitrate ointment and the nitroglycerin patch in the healing of anal fissures. Int J Colorectal Dis 2000; 15:243-45.
16.
Carapeti EA, Kamm MA, Evans BK, Phillips RKS. Topical diltiazem and bethanechol decrease the anal sphincter pressure without side effects. Gut 1999; 45:719-22.
17.
Lund JN, Scholefield JH. A randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in the treatment of anal fissures. Lancet 1997; 349:11–14.
18.
Kennedy ML, Sowter S, Nguyen H, Lubowski DZ. Glyceryl trinitrate ointment for the treatment of chronic anal fissures: the results of a placebo-controlled trial and a long term follow-up. Dis Colon Rectum 1999; 42(8):1000-06.
19.
Knight JS, Birks M, Farouk R. The topical diltiazem ointment in the treatment of chronic anal fissures. Br J Surg. 2001; 88(4):553-56.
20.
Carapeti EA, Kamm MA, Phillips RKS. Topical diltiazem and bethanecol decrease the anal sphincter pressure and heal anal fissures without side effects. Dis Colon Rectum 2000; 43:1359-62.
21.
Antropoli C, Perrotti P, Rubino M, Martino A, De Stefano G, Migliore G, et al. Nifedipine for local use in the conservative treatment of anal fissures: the preliminary results of a multicentre study. Dis Colon Rectum 1999; 42(8):1011-15.
22.
Perrotti P, Bove A, Antropoli C, Molino D, Antropoli M, Balzano A, et al. Topical nifedipine with lidocaine ointment vs. active control for the treatment of chronic anal fissures: the results of a prospective, randomized, double-blind study. Dis Colon Rectum 2002; 45(11): 1468-75.
23.
Kocher HM, Steward M, Leather AJ, Cullen PT. A randomised clinical trial which assessed the side-effects of glyceryl trinitrate and diltiazem hydrochloride in the treatment of chronic anal fissures. Br J Surg 2002; 89:413-17.

DOI and Others

INANCIAL OR OTHER COMPETING INTERESTS:
None.

Date of Submission: Apr 09, 201 2
Date of Peer Review: May 09, 20 12
Date of Acceptance: Jun, 2012
Date of Online Ahead of Print: Jul 02, 2012

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com