Abstract
Background and aims
Chronic anal fissures are difficult to treat. The aim of this retrospective study was to determine the outcome of combined fissurectomy and injection of botulinum toxin Type A (BT).
Materials and methods
Between January 2001 and August 2004, 40 patients (21 women), median age 37 years (range 18 to 57), underwent fissurectomy and BT injection. Fissurectomy was performed followed by injection of 10 U of BT into the internal anal sphincter on both sides of the fissure. All patients were clinically checked 6 weeks after the operation. At 1 year, patients were sent a detailed questionnaire regarding symptoms, recurrence and further treatment for evaluation of long-term results.
Results/findings
At 6 weeks, 38 patients (95%) were free of symptoms. No adverse effects were detected. The response rate of questionnaires was 93%; the median follow-up was 1 year (range 0.9 to 1.6). In the long-term, a recurrence was found in four patients. These patients were treated successfully with repeated fissurectomy and BT injections and salvage procedures, respectively. Overall, the success rate of combined fissurectomy and BT injection was 79%.
Interpretation/conclusion
Combined fissurectomy and Botox injection for chronic anal fissure is an excellent and safe procedure with low morbidity and a high healing rate.
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References
De Nardi P, Ortolano E, Radaelli G, Staudacher C (2006) Comparison of glycerine trinitrate and botulinum toxin-a for the treatment of chronic anal fissure: long-term results. Dis Colon Rectum 4:427–432
Oh C, Divino CM, Steinhagen RM (1995) Anal fissure. 20-year experience. Dis Colon Rectum 4:378–382
Notaras MJ (1969) Lateral subcutaneous sphincterotomy for anal fissure—a new technique. Proc R Soc Med 7:713
Argov S, Levandovsky O (2000) Open lateral sphincterotomy is still the best treatment for chronic anal fissure. Am J Surg 3:201–202
Nyam DC, Pemberton JH (1999) Long-term results of lateral internal sphincterotomy for chronic anal fissure with particular reference to incidence of fecal incontinence. Dis Colon Rectum 10:1306–1310
Ortiz H, Marzo J, Armendariz P, De Miguel M (2005) Quality of life assessment in patients with chronic anal fissure after lateral internal sphincterotomy. Br J Surg 7:881–885
Casillas S, Hull TL, Zutshi M, Trzcinski R, Bast JF, Xu M (2005) Incontinence after a lateral internal sphincterotomy: are we underestimating it? Dis Colon Rectum 6:1193–1199
Lindsey I, Jones OM, Cunningham C, Mortensen NJ (2004) Chronic anal fissure. Br J Surg 3:270–279
Jorge JM, Wexner SD (1993) Etiology and management of fecal incontinence. Dis Colon Rectum 1:77–97
Lindsey I, Jones OM, Cunningham C, George BD, Mortensen NJ (2003) Botulinum toxin as second-line therapy for chronic anal fissure failing 0.2 percent glyceryl trinitrate. Dis Colon Rectum 3:361–366
Brisinda G, Maria G, Bentivoglio AR, Cassetta E, Gui D, Albanese A (1999) A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure. N Engl J Med 2:65–69
Gupta PJ (2004) Hypertrophied anal papillae and fibrous anal polyps, should they be removed during anal fissure surgery? World J Gastroenterol 16:2412–2414
Ram E, Alper D, Stein GY, Bramnik Z, Dreznik Z (2005) Internal anal sphincter function following lateral internal sphincterotomy for anal fissure: a long-term manometric study. Ann Surg 2:208–211
Rotholtz NA, Bun M, Mauri MV, Bosio R, Peczan CE, Mezzadri NA (2005) Long-term assessment of fecal incontinence after lateral internal sphincterotomy. Tech Coloproctology 2:115–118
Floyd ND, Kondylis L, Kondylis PD, Reilly JC (2006) Chronic anal fissure: 1994 and a decade later—are we doing better? Am J Surg 3:344–348
Arroyo A, Perez F, Serrano P, Candela F, Calpena R (2005) Long-term results of botulinum toxin for the treatment of chronic anal fissure: prospective clinical and manometric study. Int J Colorectal Dis 3:267–271
Brisinda G, Cadeddu F, Brandara F, Brisinda D, Maria G (2004) Treating chronic anal fissure with botulinum neurotoxin. Nat Clin Pract Gastroenterol Hepatol 2:82–89
Orsay C, Rakinic J, Perry WB, Hyman N, Buie D, Cataldo P, Newstead G, Dunn G, Rafferty J, Ellis CN, Shellito P, Gregorcyk S, Ternent C, Kilkenny J 3rd, Tjandra J, Ko C, Whiteford M, Nelson R (2004) Practice parameters for the management of anal fissures (revised). Dis Colon Rectum 12:2003–2007
Lindsey I, Cunningham C, Jones OM, Francis C, Mortensen NJ (2004) Fissurectomy-botulinum toxin: a novel sphincter-sparing procedure for medically resistant chronic anal fissure. Dis Colon Rectum 11:1947–1952
Gupta PJ, Kalaskar S (2003) Removal of hypertrophied anal papillae and fibrous anal polyps increases patient satisfaction after anal fissure surgery. Tech Coloproctology 3:155–158
Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2:205–213
Khubchandani IT, Reed JF (1989) Sequelae of internal sphincterotomy for chronic fissure in ano. Br J Surg 5:431–434
Lunniss PJ, Gladman MA, Hetzer FH, Williams NS, Scott SM (2004) Risk factors in acquired faecal incontinence. J R Soc Med 3:111–116
Jones OM, Brading AF, Mortensen NJ (2002) The physiology, pharmacology and therapeutic manipulation of the internal anal sphincter. Can J Gastroenterol 4:249–257
Jost WH, Schimrigk K (1994) Therapy of anal fissure using botulin toxin. Dis Colon Rectum 12:1340
Gui D, Cassetta E, Anastasio G, Bentivoglio AR, Maria G, Albanese A (1994) Botulinum toxin for chronic anal fissure. Lancet 8930:1127–1128
Maria G, Cassetta E, Gui D, Brisinda G, Bentivoglio AR, Albanese A (1998) A comparison of botulinum toxin and saline for the treatment of chronic anal fissure. N Engl J Med 4:217–220
Jost WH (1997) One hundred cases of anal fissure treated with botulin toxin: early and long-term results. Dis Colon Rectum 9:1029–1032
Maria G, Brisinda G, Bentivoglio AR, Cassetta E, Gui D, Albanese A (1998) Botulinum toxin injections in the internal anal sphincter for the treatment of chronic anal fissure: long-term results after two different dosage regimens. Ann Surg 5:664–669
Nelson R (2004) A systematic review of medical therapy for anal fissure. Dis Colon Rectum 4:422–431
Lambe GF, Driver CP, Morton S, Turnock RR (2000) Fissurectomy as a treatment for anal fissures in children. Ann R Coll Surg Engl 4:254–257
Engel AF, Eijsbouts QA, Balk AG (2002) Fissurectomy and isosorbide dinitrate for chronic fissure in ano not responding to conservative treatment. Br J Surg 1:79–83
Kocher HM, Steward M, Leather AJ, Cullen PT (2002) Randomized clinical trial assessing the side-effects of glyceryl trinitrate and diltiazem hydrochloride in the treatment of chronic anal fissure. Br J Surg 4:413–417
Mustafa NA, Cengiz S, Turkyilmaz S, Yucel Y (2006) Comparison of topical glyceryl trinitrate ointment and oral nifedipine in the treatment of chronic anal fissure. Acta Chir Belg 1:55–58
Nelson R (2003) Non surgical therapy for anal fissure. Cochrane Database Syst Rev 4:CD003431
Jones OM, Moore JA, Brading AF, Mortensen NJ (2002) The site and mechanism of action of botulinum toxin on the porcine anal sphincter. Colorectal Dis 1:71
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Scholz, T., Hetzer, F.H., Dindo, D. et al. Long-term follow-up after combined fissurectomy and Botox injection for chronic anal fissures. Int J Colorectal Dis 22, 1077–1081 (2007). https://doi.org/10.1007/s00384-006-0261-z
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DOI: https://doi.org/10.1007/s00384-006-0261-z