Abstract
PurposeAnal fissure is caused by a pathological contraction of the internal anal sphincter. Lateral internal sphincterotomy remains the gold standard for the treatment of fissure. Botulinum toxin injections have been proposed to treat this condition without any risk of permanent injury of the internal sphincter. We investigate clinical and pathological variables and the effects of different dosage regimens of botulinum toxin to induce healing in patients with idiopathic anal fissure.MethodsThis is a retrospective study at a single center. The patients underwent a pre-treatment evaluation that included clinical inspection of the fissure and anorectal manometry. We collected and analyzed demographic data, pathological variables, associated pathological conditions, and treatment variables. Success was defined as healing of the fissure, and improvement of symptoms was defined as asymptomatic persistent fissure.ResultsThe findings of 1003 patients treated with botulinum toxin injections were reported. At 2 months evaluation, complete healing was evident in 780 patients (77.7%). Resting anal tone (77.1 ± 18.9 mmHg) was significantly lower from baseline (P < 0.0001) and from 1-month value (P = 0.0008). Thirty-nine not healed patients underwent lateral internal sphincterotomy, and 184 were re-treated with 50 UI of botulinum toxin. In these patients, the healing rate was 93.9% (171 patients). Dose and injection site of toxin correlates with healing rate. There were no relapses during an average of about 71 months.ConclusionOur data show that injection of botulinum toxin into the internal anal sphincter is a safe and effective alternative to surgery in patients with chronic anal fissure.
Highlights
Chronic anal fissure (AF) is an ulcer of the distal anal canal
A recent systematic review demonstrates that healing rates were 95.13% in patients treated with sphincterotomy, the benefit of surgical procedure was at a cost of increased complications, notably permanent incontinence [2]
We report the results of a retrospective non-randomized study of patients undergoing botulinum toxin injections for the treatment of chronic AF, in a 10-year period
Summary
Chronic anal fissure (AF) is an ulcer of the distal anal canal. Fissure causes substantial morbidity in otherwise healthy people [1]. Chronic AF is characterized by a marked reluctance to healing in the absence of treatment [4]. Spasm of the internal anal sphincter has been associated to chronic AF [5,6,7]. Treatment has focused on alleviating hypertonia of the sphincter. The most common surgical treatment is partial internal lateral sphincterotomy [8, 9]. A recent systematic review demonstrates that healing rates were 95.13% in patients treated with sphincterotomy, the benefit of surgical procedure was at a cost of increased complications, notably permanent incontinence [2]. A drawback of this surgery is its potential to cause minor but sometimes permanent alterations in gas, mucus, and occasionally, stool control [10, 11]: Mechanisms of continence can be acutely
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