{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T22:23:53Z","timestamp":1787955833552,"version":"build-2784847793"},"reference-count":33,"publisher":"Wiley","issue":"1","license":[{"start":{"date-parts":[[2018,1,3]],"date-time":"2018-01-03T00:00:00Z","timestamp":1514937600000},"content-version":"vor","delay-in-days":2,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Colorectal Disease"],"published-print":{"date-parts":[[2018,1]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Aim<\/jats:title><jats:p>Chronic anal fissures (<jats:styled-content style=\"fixed-case\">CAF<\/jats:styled-content>s) are frequently encountered in coloproctology clinics. Chemical sphincterotomy with pharmacological agents is recommended as first\u2010line therapy. Topical nitrates (<jats:styled-content style=\"fixed-case\">TN<\/jats:styled-content>) heal <jats:styled-content style=\"fixed-case\">CAF<\/jats:styled-content> effectively but recurrences are common. An alternative treatment modality is injection of botulinum toxin (<jats:styled-content style=\"fixed-case\">BT<\/jats:styled-content>) into the anal sphincter. We aimed to perform an updated systematic review and meta\u2010analysis to compare the effectiveness of <jats:styled-content style=\"fixed-case\">BT<\/jats:styled-content> and <jats:styled-content style=\"fixed-case\">TN<\/jats:styled-content> in the management of <jats:styled-content style=\"fixed-case\">CAF<\/jats:styled-content>.<\/jats:p><\/jats:sec><jats:sec><jats:title>Method<\/jats:title><jats:p>PubMed, <jats:styled-content style=\"fixed-case\">EMBASE<\/jats:styled-content> and Cochrane databases were searched for relevant articles from inception until March 2017. All randomized controlled trials (<jats:styled-content style=\"fixed-case\">RCT<\/jats:styled-content>s) that reported direct comparisons of <jats:styled-content style=\"fixed-case\">BT<\/jats:styled-content> and <jats:styled-content style=\"fixed-case\">TN<\/jats:styled-content> were included. Two independent reviewers performed methodological assessment and data extraction. Random effects models were used to calculate pooled effect size estimates.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Six <jats:styled-content style=\"fixed-case\">RCT<\/jats:styled-content>s describing 393 patients (194 <jats:styled-content style=\"fixed-case\">BT<\/jats:styled-content>, 199 <jats:styled-content style=\"fixed-case\">TN<\/jats:styled-content>) were included. There was significant heterogeneity among the trials. On random effects analysis there were no significant differences in incomplete fissure healing (<jats:styled-content style=\"fixed-case\">OR<\/jats:styled-content>\u00a0=\u00a00.47, 95% <jats:styled-content style=\"fixed-case\">CI<\/jats:styled-content> 0.13\u20131.68, <jats:italic>P\u00a0<\/jats:italic>=<jats:italic>\u00a0<\/jats:italic>0.24) or recurrence (<jats:styled-content style=\"fixed-case\">OR<\/jats:styled-content>\u00a0=\u00a00.70, 95% <jats:styled-content style=\"fixed-case\">CI<\/jats:styled-content> 0.39\u20131.25, <jats:italic>P\u00a0<\/jats:italic>=<jats:italic>\u00a0<\/jats:italic>0.22) between <jats:styled-content style=\"fixed-case\">BT<\/jats:styled-content> and <jats:styled-content style=\"fixed-case\">TN<\/jats:styled-content>, respectively. <jats:styled-content style=\"fixed-case\">BT<\/jats:styled-content> was associated with a higher rate of transient anal incontinence (<jats:styled-content style=\"fixed-case\">OR<\/jats:styled-content>\u00a0=\u00a02.53, 95% <jats:styled-content style=\"fixed-case\">CI<\/jats:styled-content> 0.98\u20136.57, <jats:italic>P\u00a0<\/jats:italic>=<jats:italic>\u00a0<\/jats:italic>0.06) but significantly fewer total side effects (<jats:styled-content style=\"fixed-case\">OR<\/jats:styled-content>\u00a0=\u00a00.12, 95% <jats:styled-content style=\"fixed-case\">CI<\/jats:styled-content> 0.02\u20130.63, <jats:italic>P\u00a0<\/jats:italic>=<jats:italic>\u00a0<\/jats:italic>0.01) and headache (<jats:styled-content style=\"fixed-case\">OR<\/jats:styled-content>\u00a0=\u00a00.10, 95% <jats:styled-content style=\"fixed-case\">CI<\/jats:styled-content> 0.02\u20130.60, <jats:italic>P\u00a0<\/jats:italic>=<jats:italic>\u00a0<\/jats:italic>0.01) compared with <jats:styled-content style=\"fixed-case\">TN<\/jats:styled-content>.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p><jats:styled-content style=\"fixed-case\">BT<\/jats:styled-content> is associated with fewer side effects than <jats:styled-content style=\"fixed-case\">TN<\/jats:styled-content> but there is no difference in fissure healing or recurrence. Patients need to be warned regarding the risk of transient anal incontinence associated with <jats:styled-content style=\"fixed-case\">BT<\/jats:styled-content>.<\/jats:p><\/jats:sec>","DOI":"10.1111\/codi.13969","type":"journal-article","created":{"date-parts":[[2017,11,22]],"date-time":"2017-11-22T17:52:41Z","timestamp":1511373161000},"page":"6-15","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":40,"title":["Botulinum toxin injection <i>vs<\/i> topical nitrates for chronic anal fissure: an updated systematic review and meta\u2010analysis of randomized controlled trials"],"prefix":"10.1111","volume":"20","author":[{"given":"S. M.","family":"Sahebally","sequence":"first","affiliation":[{"name":"Department of Surgery Lambe Institute National University of Ireland Galway Ireland"},{"name":"Department of Colorectal Surgery University Hospital Galway Galway Ireland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"B.","family":"Meshkat","sequence":"additional","affiliation":[{"name":"Department of Colorectal Surgery University Hospital Galway Galway Ireland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"S. R.","family":"Walsh","sequence":"additional","affiliation":[{"name":"Department of Surgery Lambe Institute National University of Ireland Galway Ireland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"D.","family":"Beddy","sequence":"additional","affiliation":[{"name":"Department of Colorectal Surgery Connolly Hospital Blanchardstown Ireland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2018,1,3]]},"reference":[{"key":"e_1_2_8_2_1","first-page":"0407","article-title":"Anal fissure (chronic)","volume":"2014","author":"Nelson RL","year":"2014","journal-title":"BMJ Clin Evid"},{"key":"e_1_2_8_3_1","doi-asserted-by":"publisher","DOI":"10.1186\/1471-230X-14-129"},{"key":"e_1_2_8_4_1","doi-asserted-by":"publisher","DOI":"10.1055\/s-0035-1570390"},{"key":"e_1_2_8_5_1","doi-asserted-by":"publisher","DOI":"10.1097\/DCR.0000000000000735"},{"key":"e_1_2_8_6_1","doi-asserted-by":"publisher","DOI":"10.1007\/BF02234828"},{"key":"e_1_2_8_7_1","doi-asserted-by":"publisher","DOI":"10.1007\/BF02236977"},{"key":"e_1_2_8_8_1","doi-asserted-by":"publisher","DOI":"10.1007\/s10350-004-6392-9"},{"key":"e_1_2_8_9_1","first-page":"CD003431","article-title":"Non surgical therapy for anal fissure","author":"Nelson RL","year":"2012","journal-title":"Cochrane Database Syst Rev"},{"key":"e_1_2_8_10_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1463-1318.2007.01387.x"},{"key":"e_1_2_8_11_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.b2700"},{"key":"e_1_2_8_12_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.cct.2015.09.002"},{"key":"e_1_2_8_13_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1572-0241.2006.00722.x"},{"key":"e_1_2_8_14_1","doi-asserted-by":"publisher","DOI":"10.1111\/codi.12615"},{"key":"e_1_2_8_15_1","doi-asserted-by":"publisher","DOI":"10.1002\/bjs.6747"},{"key":"e_1_2_8_16_1","doi-asserted-by":"publisher","DOI":"10.1002\/bjs.5514"},{"key":"e_1_2_8_17_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM199907083410201"},{"key":"e_1_2_8_18_1","first-page":"112","article-title":"Long\u2010term prospective randomised clinical and manometric comparison between surgical and chemical sphincterotomy for treatment of chronic anal fissure","volume":"47","author":"Abd Elhady HM","year":"2009","journal-title":"S Afr J Surg"},{"key":"e_1_2_8_19_1","doi-asserted-by":"publisher","DOI":"10.1007\/s10350-005-0287-2"},{"key":"e_1_2_8_20_1","doi-asserted-by":"publisher","DOI":"10.1007\/BF02050307"},{"key":"e_1_2_8_21_1","doi-asserted-by":"publisher","DOI":"10.1111\/codi.12108"},{"key":"e_1_2_8_22_1","doi-asserted-by":"publisher","DOI":"10.1097\/SLA.0b013e318225178a"},{"key":"e_1_2_8_23_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM199104253241707"},{"key":"e_1_2_8_24_1","doi-asserted-by":"publisher","DOI":"10.4103\/0019-5154.60343"},{"key":"e_1_2_8_25_1","doi-asserted-by":"publisher","DOI":"10.1016\/S1015-9584(08)60078-0"},{"key":"e_1_2_8_26_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00268-005-0664-y"},{"key":"e_1_2_8_27_1","doi-asserted-by":"publisher","DOI":"10.1007\/s10151-014-1121-4"},{"key":"e_1_2_8_28_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1463-1318.2007.01388.x"},{"key":"e_1_2_8_29_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00384-011-1286-5"},{"key":"e_1_2_8_30_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00384-009-0683-5"},{"key":"e_1_2_8_31_1","doi-asserted-by":"publisher","DOI":"10.1097\/DCR.0000000000000612"},{"key":"e_1_2_8_32_1","first-page":"G107","article-title":"Role of nitric oxide as a mediator of internal anal sphincter relaxation","volume":"262","author":"Rattan S","year":"1992","journal-title":"Am J Physiol"},{"key":"e_1_2_8_33_1","doi-asserted-by":"publisher","DOI":"10.1016\/0016-5085(92)90084-C"},{"key":"e_1_2_8_34_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(96)06090-4"}],"container-title":["Colorectal Disease"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/api.wiley.com\/onlinelibrary\/tdm\/v1\/articles\/10.1111%2Fcodi.13969","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/codi.13969","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,9,23]],"date-time":"2023-09-23T23:40:12Z","timestamp":1695512412000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/codi.13969"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2018,1]]},"references-count":33,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2018,1]]}},"alternative-id":["10.1111\/codi.13969"],"URL":"https:\/\/doi.org\/10.1111\/codi.13969","archive":["Portico"],"relation":{},"ISSN":["1462-8910","1463-1318"],"issn-type":[{"value":"1462-8910","type":"print"},{"value":"1463-1318","type":"electronic"}],"subject":[],"published":{"date-parts":[[2018,1]]},"assertion":[{"value":"2017-09-04","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2017-11-06","order":1,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2018-01-03","order":2,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}