Ebinger Sabrina Maria, Hardt Julia, Warschkow René, Schmied Bruno Martin, Herold Alexander, Post Stefan, Marti Lukas
Department of Surgery, Cantonal Hospital of St. Gallen, 9007, St. Gallen, Switzerland.
Department of Surgery, Spital STS AG, 3600, Thun, Switzerland.
J Gastroenterol. 2017 Jun;52(6):663-676. doi: 10.1007/s00535-017-1335-0. Epub 2017 Apr 10.
Anal fissures are a common problem and have a cumulative lifetime incidence of 11%. Previous reviews on anal fissures show inconsistent results regarding post-interventional healing and incontinence rates. In this review our aim was to compare the treatments for chronic anal fissures by incorporating indirect comparisons using network meta-analysis. The PubMed database was searched for randomized controlled trials (RCTs) published between 1975 and 2015. The primary outcome measures were healing and incontinence rates after lateral internal sphincterotomy (LIS), anal dilatation (DILA), anoplasty and/or fissurectomy (FIAP), botulinum toxin (BT) and noninvasive treatment (NIT). Random effects network meta-analyses were complemented by fixed effects and Bayesian models. The present analysis included 44 RCTs and 3268 patients. After a median follow-up of 2 months, the healing rates for LIS, DILA, FIAP, BT and NIT were 93.1, 84.4, 79.8, 62.6, and 58.6% and the incontinence rates were 9.4, 18.2, 4.9, 4.1, and 3.0%, respectively. Compared with NIT, the odds ratio (OR) [95% confidence interval (CI)] for healing after LIS, DILA, FIAP and BT was 9.9 (5.4-18.1), 8.6 (3.1-24.0), 3.5 (1.0-12.7) and 1.9 (1.1-3.5), respectively, on network meta-analysis. The OR (95% CI) for incontinence after LIS, DILA, FIAP and BT was 6.8 (3.1-15.1), 16.9 (6.0-47.8), 3.9 (1.0-15.1) and 1.6 (0.7-3.7), respectively. Ranking of treatments, fixed effects and Bayesian models confirmed these findings. In conclusion, based on our meta-analysis LIS is the most efficacious treatment but is compromised by a high rate of postoperative incontinence. Given the trade-offs between the risks and benefits, FIAP and BT might be good alternatives for the treatment of chronic anal fissures.
肛裂是一个常见问题，终生累计发病率为11%。既往关于肛裂的综述显示，干预后愈合率和失禁率的结果并不一致。在本综述中，我们的目的是通过网络荟萃分析纳入间接比较，以比较慢性肛裂的治疗方法。在PubMed数据库中检索1975年至2015年发表的随机对照试验（RCT）。主要结局指标是内括约肌侧切术（LIS）、扩肛术（DILA）、肛门成形术和/或肛裂切除术（FIAP）、肉毒杆菌毒素（BT）和非侵入性治疗（NIT）后的愈合率和失禁率。随机效应网络荟萃分析辅以固定效应和贝叶斯模型。本分析纳入了44项RCT和3268例患者。中位随访2个月后，LIS、DILA、FIAP、BT和NIT的愈合率分别为93.1%、84.4%、79.8%、62.6%和58.6%，失禁率分别为9.4%、18.2%、4.9%、4.1%和3.0%。网络荟萃分析显示，与NIT相比，LIS、DILA、FIAP和BT术后愈合的比值比（OR）[95%置信区间（CI）]分别为9.9（5.4 - 18.1）、8.6（3.1 - 24.0）、3.5（1.0 - 12.7）和1.9（1.1 - 3.5）。LIS、DILA、FIAP和BT术后失禁的OR（95%CI）分别为6.8（3.1 - 15.1）、16.9（6.0 - 47.8）、3.9（1.0 - 15.1）和1.6（0.7 - 3.7）。治疗方法的排序、固定效应和贝叶斯模型均证实了这些结果。总之，基于我们 的荟萃分析，LIS是最有效的治疗方法，但术后失禁率较高。考虑到风险和益处之间的权衡，FIAP和BT可能是治疗慢性肛裂的良好替代方法。
