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Treating chronic anal fissure with botulinum neurotoxin

Nature Clinical Practice Gastroenterology & Hepatology volume 1, pages 82–89 (2004)Cite this article

Abstract

Recent reports confirm that the management of chronic anal fissure has undergone extensive re-evaluation during the past few years. This rejuvenation of interest is attributable to the application of neurochemical treatment, which has contributed to the tendency to treat the disease on an outpatient basis. The use of botulinum neurotoxin seems to be a promising and safe approach for the treatment of chronic anal fissure, particularly in patients at high risk for incontinence. Indeed, botulinum neurotoxin has been successfully used selectively to weaken the internal anal sphincter as a treatment for chronic anal fissure. It is also more efficacious than nitrate therapy, and is not related to the patient's willingness to complete treatment.

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Figure 1: Chronic anal fissure.
Figure 2: Our technique of injections.

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References

  1. Brisinda G et al. (2002) In Scientific and Therapeutic Aspects of Botulinum Toxin. 269–285 (Eds Brin MF et al.) Philadelphia: Lippincott Williams & Wilkins

    Google Scholar 

  2. Lund JN and Scholefield JH (1996) Aetiology and treatment of anal fissure. Br J Surg 83: 1335–1344

    Article  CAS  Google Scholar 

  3. Brisinda G et al. (2003) Gastrointestinal smooth muscles and sphincters spasms: treatment with botulinum neurotoxin. Curr Med Chem 10: 603–623

    Article  CAS  Google Scholar 

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

    Article  CAS  Google Scholar 

  5. Lund JN and Scholefield JH (1997) Internal sphincter spasm in anal fissure. Br J Surg 84: 1723–1724

    Article  CAS  Google Scholar 

  6. Cook TA et al. (2001) The pharmacology of the internal anal sphincter and new treatments of ano-rectal disorders. Aliment Pharmacol Ther 15: 887–898

    Article  CAS  Google Scholar 

  7. Bhardwaj R et al. (2000) Neuromyogenic properties of the internal anal sphincter: therapeutic rationale for anal fissures. Gut 46: 861–868

    Article  CAS  Google Scholar 

  8. Brown AC et al. (1989) Histopathology of the internal anal sphincter in chronic anal fissure. Dis Colon Rectum 32: 680–683

    Article  CAS  Google Scholar 

  9. Schouten W et al. (1996) Ischaemic nature of anal fissure. Br J Surg 83: 63–65

    Article  CAS  Google Scholar 

  10. Shah V et al. (2004) Nitric oxide in gastrointestinal health and disease. Gastroenterology 126: 903–913

    Article  CAS  Google Scholar 

  11. Maria G and Brisinda G (2000) Nonoperative management of chronic anal fissure. Dis Colon Rectum 43: 721–726

    Article  CAS  Google Scholar 

  12. Maria G et al. (1999) Identification of anti-endothelial cell antibodies in patients with chronic anal fissure. Surgery 126: 535–540

    Article  CAS  Google Scholar 

  13. Regadas FS et al. (1993) Pharmacological study of the internal and sphincter in patients with chronic anal fissure. Br J Surg 80: 799–801

    Article  CAS  Google Scholar 

  14. Lindsey I et al. (2004) Chronic anal fissure. Br J Surg 91: 270–279

    Article  CAS  Google Scholar 

  15. Nyam DC and 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  CAS  Google Scholar 

  16. Lund JN and Scholefield JH (1997) A randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure. Lancet 349: 11–14

    Article  CAS  Google Scholar 

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

    Article  Google Scholar 

  18. Jonas M et al. (2001) A randomized trial of oral vs. topical diltiazem for chronic anal fissures. Dis Colon Rectum 44: 1074–1078

    Article  CAS  Google Scholar 

  19. Pitt J et al. (2000) Alpha-1 adrenoceptor blockade: potential new treatment for anal fissures. Dis Colon Rectum 43: 800–803

    Article  CAS  Google Scholar 

  20. MacKenzie I et al. (1982) The effects of purified botulinum neurotoxin type A on cholinergic, adrenergic and non-adrenergic, atropine-resistant autonomic neuromuscular transmission. Neuroscience 7: 997–1006

    Article  CAS  Google Scholar 

  21. Maria G and Brisinda G (2003) Chronic anal fissure: advances and insights in pathophysiology and treatment. Gastroenterology 125: 995–996

    Article  Google Scholar 

  22. Brisinda D et al. (2003) Safety of botulinum neurotoxin treatment in patients with chronic anal fissure. Dis Colon Rectum 46: 419–420

    Article  Google Scholar 

  23. Tonkin AL and Frewin DB (1999) Autonomic failure. In A Textbook of Clinical Disorders of the Autonomic Nervous System, 527–533 (Eds Mathias CJ and Bannister R) New York: Oxford University Press

    Google Scholar 

  24. Jost WH and Schimrigk K (1995) Botulinum toxin in therapy of anal fissure. Lancet 345: 188–189

    Article  CAS  Google Scholar 

  25. Madalinski M et al. (1999) Botulinum toxin injection into only one point in the external anal sphincter: a modification of the treatment for chronic anal fissure. Endoscopy 31: S63

    CAS  PubMed  Google Scholar 

  26. Gonzalez CP et al. (1999) The treatment of anal fissure with botulinum toxin. Gastroenterol Hepatol 22: 163–166

    Google Scholar 

  27. Maria G 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  CAS  Google Scholar 

  28. Minguez M et al. (1999) Therapeutic effects of different doses of botulinum toxin in chronic anal fissure. Dis Colon Rectum 42: 1016–1021

    Article  CAS  Google Scholar 

  29. Brisinda 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  Google Scholar 

  30. Mentes BB et al. (2003) Comparison of botulinum toxin injection and lateral internal sphincterotomy for the treatment of chronic anal fissure. Dis Colon Rectum 46: 232–237

    Article  Google Scholar 

  31. Siproudhis L et al. (2003) Lack of effficacy of botulinum toxin in chronic anal fissure. Aliment Pharmacol Ther 18: 515–524

    Article  CAS  Google Scholar 

  32. Tilney HS et al. (2001) Complication of botulinum toxin injections for anal fissure. Dis Colon Rectum 44: 1721–1724

    Article  CAS  Google Scholar 

  33. Brisinda G et al. (2004) Botulinum neurotoxin to treat chronic anal fissure: results of a randomized “Botox vs. Dysport” controlled trial. Aliment Pharmacol Ther 19: 695–701

    Article  CAS  Google Scholar 

  34. Albanese A et al. (2001) In The Autonomic Nervous System. Part II. Dysfunctions. 613–663 (Ed. Appenzeller O) Amsterdam: Elsevier

    Google Scholar 

  35. Gui D et al. (1994) Botulinum toxin for chronic anal fissure. Lancet 344: 1127–1128

    Article  CAS  Google Scholar 

  36. Jost WH and Schimrigk K (1994) Therapy of anal fissure using botulin toxin. Dis Colon Rectum 37: 1340

    Article  CAS  Google Scholar 

  37. Mason PF et al. (1996) The management of chronic fissure in ano with botulinum toxin. J R Coll Surg Edinb 41: 235–238

    CAS  PubMed  Google Scholar 

  38. Jost WH (1997) One hundred cases of anal fissure treated with botulin toxin: early and long-term results. Dis Colon Rectum 40: 1029–1032

    Article  CAS  Google Scholar 

  39. Espi A et al. (1997) Therapeutic use of botulinum toxin in anal fissure. Int J Colorectal Dis 12: 163

    Google Scholar 

  40. Maria G et al. (1998) A comparison of botulinum toxin and saline for the treatment of chronic anal fissure. N Engl J Med 338: 217–220

    Article  CAS  Google Scholar 

  41. Maria G 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  CAS  Google Scholar 

  42. Jost WH and Schrank B (1999) Repeat botulin toxin injections in anal fissure: in patients with relapse and after insufficient effect of first treatment. Dig Dis Sci 44: 1588–1589

    Article  CAS  Google Scholar 

  43. Brisinda G 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  CAS  Google Scholar 

  44. Fernandez LF et al. (1999) Botulinum toxin for the treatment of anal fissure. Dig Surg 16: 515–518

    Article  Google Scholar 

  45. Madalinski MH (1999) Nonsurgical treatment modalities for chronic anal fissure using botulinum toxin. Gastroenterology 117: 516–517

    Article  CAS  Google Scholar 

  46. Khademi A and Feldman DM (2000) A comparison of combination of botox (botulinum toxin) and nitroglycerin in the treatment of chronic anal fissure. Am J Gastroenterol 95: 2538

    Article  Google Scholar 

  47. Maria G 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  CAS  Google Scholar 

  48. Lysy J et al. (2001) Topical nitrates potentiate the effect of botulinum toxin in the treatment of patients with refractory anal fissure. Gut 48: 221–224

    Article  CAS  Google Scholar 

  49. Madalinski MH et al. (2001) Topical nitrates and the higher doses of botulinum toxin for chronic anal fissure. Hepatogastroenterology 48: 977–979

    CAS  PubMed  Google Scholar 

  50. Trzcinski R et al. (2002) Injections of botulinum A toxin for the treatment of anal fissures. Eur J Surg 168: 720–723

    Article  CAS  Google Scholar 

  51. Colak T et al. (2002) A randomized trial of botulinum toxin vs lidocain pomade for chronic anal fissure. Acta Gastroenterol Belg 65: 187–190

    PubMed  Google Scholar 

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

    Article  Google Scholar 

  53. Wollina U and Konrad H (2002) Botulinum toxin A in anal fissures: a modified technique. J Eur Acad Dermatol Venereol 16: 469–471

    Article  CAS  Google Scholar 

  54. Madalinski MH et al. (2002) Side effects of botulinum toxin injection for benign anal disorders. Eur J Gastroenterol Hepatol 14: 853–856

    Article  CAS  Google Scholar 

Download references

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Authors and Affiliations

  1. Department of Surgery, Catholic School of Medicine, University Hospital Agostino Gemelli, Rome, Italy

    Giuseppe Brisinda, Federica Cadeddu, Francesco Brandara, Donatella Brisinda & Giorgio Maria

  2. Clinical Physiology and Biomagnetism Research Center, Catholic School of Medicine, University Hospital Agostino Gemelli, Rome, Italy

    Giuseppe Brisinda, Federica Cadeddu, Francesco Brandara, Donatella Brisinda & Giorgio Maria

Authors
  1. Giuseppe Brisinda
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  2. Federica Cadeddu
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  3. Francesco Brandara
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  4. Donatella Brisinda
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  5. Giorgio Maria
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Corresponding author

Correspondence to Giuseppe Brisinda.

Glossary

β2 AGONISTS

Drugs that acts via β2 adrenergic receptors. They are used as a first-line therapy to alleviate asthma symptoms

AMINOGLYCOSIDES

Potent bactericidal antimicrobiotical agents used in the treatment of various severe infections caused by aerobic Gram-negative bacteria

BRACHIAL PLEXOPATHY

A decreased movement or sensation in the arm and shoulder caused by impaired function of the brachial plexus; it is a form of peripheral neuropathy

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Brisinda, G., Cadeddu, F., Brandara, F. et al. Treating chronic anal fissure with botulinum neurotoxin. Nat Rev Gastroenterol Hepatol 1, 82–89 (2004). https://doi.org/10.1038/ncpgasthep0048

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