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Botulinum toxin injection versus lateral internal sphincterotomy for the treatment of chronic anal fissure: randomized prospective controlled trial

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Abstract

Purpose

Lateral internal sphincterotomy has been the gold standard treatment for chronic anal fissure, but it still carries the risk of permanent damage of the anal sphincter, which has led to the implementation of alternative treatment like botulinum toxin injection. The aim of this randomized prospective controlled trial was to compare the efficacy and morbidity of botulinum toxin injection and lateral internal sphincterotomy in the treatment of chronic anal fissure.

Methods

Fifty consecutive adults with chronic anal fissure were randomly treated with either lateral internal sphincterotomy or botulinum toxin (BT) injection with 50 U BT into the internal sphincter. The complications, healing and recurrence rate, and incontinence score were assessed 2, 3, 6, 12 months after the procedure.

Results

Inspection at the 2-month visit revealed complete healing of the fissure in 11 (44 %) of the patients in the BT group and 22 (88 %) of the patients in the lateral internal sphincterotomy (LIS) group (p = 0.001). At the 3-month visit, there was no significant difference between the two groups in healing. The overall recurrence rate after 6 months in the BT group was higher than in the LIS group (p < 0.05). In the 3-month follow-up, the LIS group had a higher rate of anal incontinence compared to the BT group (p < 0.05). The final percentage of incontinence was 4 % in the LIS group (p > 0.05).

Conclusions

The treatment of chronic anal fissure must be individualized depending on the different clinical profiles of patients. Botulinum toxin injection has a higher recurrence rate than LIS, and LIS provides rapid and permanent recovery. However, LIS carries a higher risk of anal incontinence in patients.

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References

  1. Oh C, Divino CM, Steinhagen RM (1995) Anal fissure. 20-year experience. Dis Colon Rectum 38:378–382

    Article  PubMed  CAS  Google Scholar 

  2. Rohde H (2003) The pathogenetic mechanism causing anal fissure. Int J Colorectal Dis 18:95

    Article  PubMed  Google Scholar 

  3. Collins EE, Lund JN (2007) A review of chronic anal fissure management. Tech Coloproctol 11:209–223

    Article  PubMed  CAS  Google Scholar 

  4. Griffin N, Acheson AG, Tung P, Sheard C, Glazebrook C, Scholefield JH (2004) Quality of life in patients with chronic anal fissure. Colorectal Dis 6:39–44

    Article  PubMed  CAS  Google Scholar 

  5. Sailer M, Bussen D, Debus ES, Fuchs KH, Thiede A (1998) Quality of life in patients with benign anorectal disorders. Br J Surg 85:1716–1719

    Article  PubMed  CAS  Google Scholar 

  6. Weaver RM, Ambrose NS, Alexander-Williams J et al (1987) Manual dilatation of the anus vs. lateral subcutaneous sphincterotomy in the treatment of chronic fissure-in-ano. Results of a prospective, randomized, clinical trial. Dis Colon Rectum 30:420–423

    Article  PubMed  CAS  Google Scholar 

  7. Abcarian H (1980) Surgical correction of chronic anal fissure: results of lateral internal sphincterotomy vs. fissurectomy-midline sphincterotomy. Dis Colon Rectum 23:31–36

    Article  PubMed  CAS  Google Scholar 

  8. Leong AF, Seow-Choen F (1995) Lateral sphincterotomy compared with anal advancement flap for chronic anal fissure. Dis Colon Rectum 38:69–71

    Article  PubMed  CAS  Google Scholar 

  9. 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 42:1306–1310

    Article  PubMed  CAS  Google Scholar 

  10. Mínguez M, Melo F, Espí A et al (1999) Therapeutics effects of different doses of botulinum toxin in chronic anal fissure. Dis Colon Rectum 42:1016–1021

    Article  PubMed  Google Scholar 

  11. Jost W (2002) Ten years experience with botulin toxin in anal fissure. Int J Colorectal Dis 17:287–297

    Article  Google Scholar 

  12. Brisinda G, Maria G, Bentivoglio AR et al (1999) A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure. N Engl J Med 341:65–69

    Article  PubMed  CAS  Google Scholar 

  13. Maria G, Brisinda G, Bentivoglio AR et al (2000) Influence of botulinum toxin site of injections on healing rate in patients with chronic anal fissure. Am J Surg 179:46–50

    Article  PubMed  CAS  Google Scholar 

  14. Brisinda G, Maria G, Sganga G et al (2002) Effectiveness of higher doses of botulinum toxin to induce healing in patients with chronic anal fissures. Surgery 131:179–184

    Article  PubMed  Google Scholar 

  15. Richard CS, Gregoire R, Plewes EA et al (2000) Internal sphincterotomy is superior to topical nitroglycerin in the treatment of chronic anal fissure: results of a randomized, controlled trial by the Canadian Colorectal Surgical Trials Group. Dis Colon Rectum 43:1048–1057

    Article  PubMed  CAS  Google Scholar 

  16. Evans JE, Luck A, Hewett P (2001) Glyceryl trinitate vs lateral sphincterotomy for chronic anal fissure. Prospective, randomized trial. Dis Colon Rectum 44:93–97

    Article  PubMed  CAS  Google Scholar 

  17. Maria G, Sganga G, Civello IM et al (2002) Botulinum neurotoxin and other treatments for fissure-in-ano and pelvic floor disorders. Br J Surg 89:950–961

    Article  PubMed  CAS  Google Scholar 

  18. Shao WJ, Li GC, Zhang ZK (2009) Systemic review and meta-analysis of randomized controlled trails comparing botulinum toxin injection with lateral internal sphincterotomy for chronic anal fissure. Int J Colorectal Dis 24:995–1000

    Article  PubMed  Google Scholar 

  19. Klein AW (2001) Complications and adverse reactions with the use of botulinum toxin. Semin Cutan Med Surg 20:109–120

    Article  PubMed  CAS  Google Scholar 

  20. 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 338:217–220

    Article  PubMed  CAS  Google Scholar 

  21. Jost WH (1997) One hundred cases of anal fissure treated with botulinum toxin. Early and long term results. Dis Colon Rectum 40:1029–1032

    Article  PubMed  CAS  Google Scholar 

  22. Gui D, Cassetta E, Asastasio G, Bentivoglio AR, Maria G, Albanese A (1994) A comparison of botulinum toxin and saline for the treatment of chronic anal fissure. Lancet 344:1127–1128

    Article  PubMed  CAS  Google Scholar 

  23. Church JM, Fleshman JW, Kane RL et al (1999) Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index. Dis Colon Rectum 42:1525–1532

    Article  PubMed  Google Scholar 

  24. Jorge JMN, Wexner SD (1993) Etiology and management of fecal incontinence. Dis Colon Rectum 36:77–97

    Article  PubMed  CAS  Google Scholar 

  25. Jost WH, Schimrigk K (1993) Use of botulinum toxin in anal fissure. Dis Colon Rectum 36:974

    Article  PubMed  CAS  Google Scholar 

  26. Mentes BB, Irkorucu O, Akin M, Leventoglu S, Tatlicioglu E (2003) Comparison of botulinum toxin injection and lateral Internal sphincterotomy for the treatment of chronic anal fissure. Dis Colon Rectum 46:232–237

    Article  PubMed  Google Scholar 

  27. Arroyo A, Perez F, Serrano P, Candela F, Lacueva J, Calpena R (2005) Surgical versus chemical (botulinum toxin) sphincterotomy For chronic anal fissure: long-term results of a prospective randomized clinical and manometric study. Am J Surg 189:429–434

    Article  PubMed  CAS  Google Scholar 

  28. Massoud BW, Mehrdad V, Baharak T, Alireza Z (2005) Botulinum toxin injection versus internal anal sphincterotomy For the treatment of chronic anal fissure. Ann Saudi Med 25:140–142

    PubMed  Google Scholar 

  29. Iswariah H, Stephens J, Rieger N, Rodda D, Hewett P (2005) Randomized prospective controlled trial of lateral internal sphincterotomy versus injection of botulinum toxin for the treatment of idiopathic fissure in ano. ANZ J Surg 75:553–555

    Article  PubMed  Google Scholar 

  30. Acheson AG, Scholefield JH (2005) Anal fissure: the changing management of a surgical condition. Langenbecks Arch Surg 390:1–7

    Article  PubMed  CAS  Google Scholar 

  31. Nelson R (2004) A systemic review of medical therapy for anal fissure. Dis Colon Rectum 47:422–431

    Article  PubMed  Google Scholar 

  32. Giral A, Memisoglu K, Gultekin Y et al (2004) Botulinum toxin injection versus lateral internal sphincterotomy in the treatment chronic anal fissure: a non-randomized controlled trial. BMC Gastroenterol 4:7

    Article  PubMed  Google Scholar 

  33. Maria G, Brisinda G, Bentivoglio AR et al (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 228:664–669

    Article  PubMed  CAS  Google Scholar 

  34. Minguez M, Herreros B, Espi A et al (2002) Long-term follow-up (42 months) of chronic anal fissure alter healing with botulinum Toxin. Gastroenterology 123:112–117

    Article  PubMed  Google Scholar 

  35. Hallett M (1999) One man’s poison—clinical applications of botulinum toxin. N Engl J Med 341:118–120

    Article  PubMed  CAS  Google Scholar 

  36. Pitt J, Willilams S, Dawson PM (2001) Reason for failure of glyceryl trinitrate treatment of chronic fissure-in-ano. A multivariate analysis. Dis Colon Rectum 44:864–867

    Article  PubMed  CAS  Google Scholar 

  37. Aivaz O, Rayhanabad J, Nguyen V et al (2009) Botulinum toxin A with fissurectomy is a viable alternative to lateral internal sphincterotomy for chronic anal fissure. Am Surg 75:925–928

    PubMed  Google Scholar 

  38. Huppe D, Enck P, Kruskemper G et al (1992) Psychosocial aspects of fecal incontinence. Leber Megan Darm 22:138–142

    CAS  Google Scholar 

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Authors and Affiliations

  1. Department of General Surgery, Ayatollah Taleghani Hospital, Shahid Beheshti University of Medical Sciences, PO Box 1545633319, Tehran, Iran

    Neda Valizadeh, Niloufar Yahyapour Jalaly, Mohsen Hassanzadeh, Fereshteh Kamani & Shapour Azizi

  2. Department of Internal Medicine, Ayatollah Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    Zohreh Dadvar

  3. Gastroenterology, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    Babak Salehimarzijarani

Authors
  1. Neda Valizadeh
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  2. Niloufar Yahyapour Jalaly
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  3. Mohsen Hassanzadeh
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  4. Fereshteh Kamani
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Correspondence to Mohsen Hassanzadeh.

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Valizadeh, N., Jalaly, N.Y., Hassanzadeh, M. et al. Botulinum toxin injection versus lateral internal sphincterotomy for the treatment of chronic anal fissure: randomized prospective controlled trial. Langenbecks Arch Surg 397, 1093–1098 (2012). https://doi.org/10.1007/s00423-012-0948-2

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  • DOI: https://doi.org/10.1007/s00423-012-0948-2

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