Abstract
Lateral partial internal sphicterotomy has been the goal standard for the treatment of chronic anal fissure. The main drawback of this approach remains its effect on the anal continence. Intrasphincteric of botulinum toxin seems to be a reliable and safe option resulting in temporary paralysis of the internal sphincter spasm and so promoting the chronic fissure to heal. The aim of this prospective control randomized study was to compare the effectiveness and the outcome of botulinum toxin injection with the lateral internal sphicterotomy in the treatment of the chronic anal fissure. Ninety male patients who have been presented with chronic uncomplicated anal fissure, were randomized to either lateral internal sphincterotomy or intrasphincteric injection of botulnium toxin. Postoperative complications and pain, healing rate of the fissure, anal incontinence and recurrence of the fissure after treatment during six months follow up period were studied and assessed. The healing rate was 95.5% in the surgical group with recurrence noted in only one patient and one patient had a partial permanent incontinence while in the botulnium toxin group the healing rate was 84.4%. Two patients had transient incontinence which improved spontaneously over six months period. Five patients had recurrence within the same follow period. Lateral internal sphicterotomy and botulinum toxin injection both seems to be effective treatment of the chronic anal fissure. Although surgical approach is still the most common and gold standard treatment for the chronic anal fissure, It shows a higher incidence of incontinence and greater morbidity and pain than botulinum toxin injection. We conclude that the use of botulinum toxin to treat chronic anal fissure is safe, simple and effective approach especially in patients older than 50 years or those with risk of anal incontinence despite the higher rate of recurrence which can be minimized by the second session of botulinum toxin injection.
Highlights
A nal fissure is a tear in the mucosal lining of the anus usually in the midline posteriorly below the dentate line
The toxin is injected directly into internal anal sphincter and in effect, it performs a chemical sphincterotomy. This effect last about three months period and allow anal fissure to heal and symptoms to resolve In cases were toxin injection provide initial relief of symptoms but there is a recurrence after three months period, these patients may benefit from a second trail of toxin injection or from a surgical sphincterotomy[6,7]
The aim of this study was to compare the therapeutic effects of botulinum toxin and lateral internal sphincterotomy in selected patients with chronic anal fissure
Summary
A nal fissure is a tear in the mucosal lining of the anus usually in the midline posteriorly below the dentate line. The current surgical treatment of the chronic anal fissure is lateral partial internal sphincterotomy and not anal dilatation This surgical approach can be effective for more than 90% of cases but need general or local anesthesia. It temporarily paralyzed muscles for up to three months and can be injected into internal anal sphincter muscles in a clinician office without anesthesia or sedation This method has been described initially by Jost and Schmrigk and found to be effective treatment in comparison with placebo. The toxin is injected directly into internal anal sphincter and in effect, it performs a chemical sphincterotomy. The aim of this study was to compare the therapeutic effects of botulinum toxin and lateral internal sphincterotomy in selected patients with chronic anal fissure
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