A Cochrane review [Abstract] included 77 studies with a total of 5031 patients to assess the efficacy and morbidity of various medical therapies for anal fissure. 49 different comparisons of the ability of medical therapies to heal anal fissure have been reported in 75 RCTs. Alltogether seventeen agents were used. The effect of topical nitroglycerin ointment (GTN) is summarized in Table 1. GTN was found to be marginally but significantly better than placebo in healing anal fissure (48.9% vs. 35.5%, p < 0.0009), but late recurrence of fissure was common, in the range of 50% of those initially cured.
Surgery is more effective than medical therapy; any surgery compared to any medical therapy resulted in significantly less treatment failures (OR 0.11; 95% CI 0.06 to 0.23; 15 studies, n = 979).
Comment: The quality of evidence is downgraded by inconsistency of results.
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