The Impact of Fissurectomy Combined with Botulinum Toxin Injection in the Treatment of Chronic Anal Fissure

Abstract

Objective: The aim of this prospective randomized study was to determine the outcome of fissurectomy combined with botulinum toxin type-A (BTX-A) on the healing of medically resistant fissures over that achieved with BTX-A alone. Materials and Methods: A total of 36 consecutive patients with chronic anal fissure located on posterior midline who failed healing after topical medical therapy were enrolled. The patients were divided into 2 groups. The patients were divided into, BTX and BTX+fissurectomy (FIS) groups. They were clinically checked 1, 2, 4, and 8 weeks after the procedures. Symptomatic relief, early postoperative complications, clinical and anoscopic findings were recorded. The demograpic and clinical parameters were compared using Mann-Whitney U and Chi-squre tests. Results: There were no significant difference between the two groups regarding the age and gender. The most common complaints were rectal bleeding, constipation and pain during and/or after defaecation. All of the procedures performed without any postprocedural complications. Symptoms were reduced significantly with respect to the preoperative value. Symtomatic relief was assesesed in more patients in BTX+FIS group than BTX only group, but the difference was not significant. On 4th week anoscopic examination, complete healing was assesed in 14 (%77.8) and 11 (%61.1) patients in BTX+FIS and BTX groups, respectively. The median follow-up was 5 months. There was no recurrence during the follow-up. None of the patients had continence disturbance. Conclusion: Although BTX-A injection is an effective and safe treatment option in patients with a posterior chronic anal fissure non-responsive to other medical treatments, combining it with fissurectomy does not increase the healing rate.

Keywords

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Kronik Anal Fissür Tedavisinde Botulinum Toksini ile Birlikte Fissürektominin Etkinliği

Öz

Amaç: Bu randomize prospektif çalışmanın amacı, medikal tedaviye dirençli kronik anal fissür tedavisinde, fissürektomi ile kombine edilen botulinum toksini tip A (BTX-A) ile tek başına kullanılan BTX-A'nın etkinliklerini karşılaştırmaktır. Gereç ve Yöntem: Arka orta hatta topikal ilaç tedavisine dirençli kronik anal fissürü bulunan, 36 ardışık hasta değerlendirildi. Hastalar, BTX ve BTX+fissürektomi (FİS) olarak iki gruba ayrıldılar. Girişimlerden 1, 2, 4 ve 8 hafta sonra klinik olarak kontrol edildiler. Semptomatik düzelme, erken ameliyat sonrası komplikasyonlar, klinik ve anoskopik bulgular kaydedildi. Demografik ve klinik parametreler Mann-Whitney U ve Ki-kare testleri kullanılarak karşılaştırıldı. Bulgular: Gruplar arasında yaş ve cinsiyet açısından anlamlı fark yoktu. En sık karşılaşılan şikayetler, rektal kanama, kabızlık ve dışkılama sırasında ve/veya sonrasında ağrıydı. Girişimlerin tamamı komplikasyonsuz olarak gerçekleştirildi. İşlem öncesine kıyasla semptomlar anlamlı olarak azaldı. BTX+FİS grubunda BTX grubuna göre daha fazla hastada semptomatik düzelme sağlandı ancak aradaki fark anlamlı değildi. Dördüncü haftada yapılan anoskopik muayenede, BTX+FİS ve BTX gruplarında sırasıyla 14 (%77.8) ve 11 (%61.1) hastada fissürün tamamen iyileştiği tespit edildi. Ortanca takip süresi 5 aydı. Takip sürecinde nüks görülmedi. Hastaların hiçbirinde inkontinans ortaya çıkmadı. Sonuç: Diğer medikal tedavilere cevap vermeyen posterior kronik anal fissürde BTX-A enjeksiyonu etkili ve güvenli bir tedavi yöntemi olmakla beraber, BTX-A'ya fissürektomi eklenmesi iyileşme oranlarını arttırmamaktadır.

Anahtar Kelimeler

• Anal fissür, Fissürektomi, Botulinum toksini

References

1. Memon AS, Siddiqui FG, Hamad A. Fissurectomy with posterior midline sphincterotomy for management of chronic anal fissure. J Coll Physicians Surg Pak 2010; 20: 229-31.
2. Patti R, Fama F, Tornambe A, Asaro G, Di Vita G. Fissurectomy combined with anoplasty and injection of botulinum toxin in treatment of anterior chronic anal fissure with hypertonia of internal anal sphincter: A pilot study. Tech Coloproctol 2010; 14: 31-6.
3. Bode WE, Culp CE, Spencer RJ, Beart RW Jr. Fissurectomy with superficial midline sphincterotomy. A viable alternative for the surgical correction of chronic fissure/ulcer-in-ano. Dis Colon Rectum 1984; 27: 93-5.
4. Mousavi SR, Sharifi M, Mehdikhah Z. A comparison between the results of fissurectomy and lateral internal sphincterotomy in the surgical management of chronic anal fissure. J Gastrointest Surg 2009; 13: 1279-82.
5. Srinivasaiah N, Laden G, Duthie GS, Chapple KS. The longterm efficacy of fissurectomy and botulinum toxin injection for chronic anal fissure in females. Dis Colon Rectum 2008; 51: 1589-90.
6. Soll C, Dindo D, Hahnloser D. Combined fissurectomy and botulinum toxin injection. A new therapeutic approach for chronic anal fissures. Gastroenterol Clin Biol 2008; 32: 66770.
7. Sileri P, Mele A, Stolfi VM, et al. Medical and surgical treatment of chronic anal fissure: A prospective study. J Gastrointest Surg 2007; 11: 1541-8.
8. Sileri P, Stolfi VM, Franceschilli L, et al. Conservative and surgical treatment of chronic anal fissure: Prospective longer term results. J Gastrointest Surg 2010; 14: 773-80.

9. Poh A, Tan KY, Seow-Choen F. Innovations in chronic anal fissure treatment: A systematic review. World J Gastrointest Surg 2010; 2: 231-41.
10. Bhardwaj R, Parker MC. Modern perspectives in the treatment of chronic anal fissures. Ann R Coll Surg Engl 2007; 89: 4728.
11. Baraza W, Boereboom C, Shorthouse A, Brown S. The longterm efficacy of fissurectomy and botulinum toxin injection for chronic anal fissure in females. Dis Colon Rectum 2008; 51: 239-43.
12. Witte ME, Klaase JM, Koop R. Fissurectomy combined with botulinum toxin A injection for medically resistant chronic anal fissures. Colorectal Dis 2010; 12: 163-9.
13. Aigner F, Conrad F. Fissurectomy for treatment of chronic anal fissures. Dis Colon Rectum 2008; 51: 1163-64.
14. Jost WH, Schimrigk K. Use of botulinum toxin in anal fissure. Dis Colon Rectum 1993; 36: 974.
15. Arthur JD, Makin CA, El-Sayed TY, Walsh CJ. A pilot comparative study of fissurectomy/diltiazem and fissurectomy/botulinum toxin in the treatment of chronic anal fissure. Tech Coloproctol 2008; 12: 331-6.
16. Brisinda G, Maria G, Bentivoglio AR, Cassetta E, Gui D, Albanese A. A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure. N Engl J Med 1999; 341: 65-9.
17. Lindsey I, Cunningham C, Jones OM, Francis C, Mortensen NJ. Fissurectomy-botulinum toxin: A novel sphincter-sparing procedure for medically resistant chronic anal fissure. Dis Colon Rectum 2004; 47: 1947-52.
18. Patti R, Fama F, Tornambe A, Restivo M, Di Vita G. Early results of fissurectomy and advancement flap for resistant chronic anal fissure without hypertonia of the internal anal sphincter. Am Surg 2010; 76: 206-10.
19. Hsu TC, MacKeigan JM. Surgical treatment of chronic anal fissure. A retrospective study of 1753 cases. Dis Colon Rectum 1984; 27: 475-8.
20. Aivaz O, Rayhanabad J, Nguyen V, Haigh PI, Abbas M. Botulinum toxin A with fissurectomy is a viable alternative to lateral internal sphincterotomy for chronic anal fissure. Am Surg 2009; 75: 925-8.
21. Gingold BS. Simple in-office sphincterotomy with partial fissurectomy for chronic anal fissure. Surg Gynecol Obstet 1987; 165: 46-8.
22. Hosseini SV, Sabet B, Nouri Amirkolaee M, Bolandparvaz S. A randomized clinical trial on the effect of oral metronidazole on wound healing and pain after anal sphincterotomy and fissurectomy. Arch Iran Med 2008; 11: 550-2.
23. Abcarian H. Surgical correction of chronic anal fissure: Results of lateral internal sphincterotomy vs. fissurectomymidline sphincterotomy. Dis Colon Rectum 1980; 23: 31-6.