Comparison of botox and lateral internal sphincterotomy treatment outcomes in chronic anal fissures

Öz

Objective: Both botox and lateral internal sfinkterotomi are treatment technics used in chronic anal fissure; provide the relaxation of anal sphincter and as a result of this, healing occurs. Aim of this study is to compare efficacy of botox and LIS treatment in chronic anal fissure and discussing with the literature. Methods: 60 of 66 patients who has chronic anal fissure, that we reached, treated but not healed with medical therapy, appealed to the Dr. Sami Ulus Hospital included the study. Gender, age, fissure localization, complaints (pain, bleeding, itching, constipation), complaint length, recurrences after treatment, continence conditions and complications of patients were registered. Results: Sixty patients were enrolled the study. Of the 60 patients; 38(63.3%) were male and 22 (27.7%) were female. Mean age of all patients was 35.93 ± 11.45 (21 -60). Pain was the common complaint of the all patients. 10 (32.3%) recurrence were detected in botox treatment group (Group-I), only 1 (3.4%) recurrence was in LIS group (Group-II). There was no complication as an incontinence in group-I but 3 cases with incontinence (10.39%) were obtained in group-II. In the evaluation of these 3 cases by Cleveland Clinic Continence Scoring System, 2 cases classified as gas incontinence and 1 case as moderate fecal incontinence. Conclusion: Although botulinum toxin injection seen as an alternative treatment method with low complication rates such as incontinence, high recurrence is an important shortcoming of this technic. LIS performed by experienced surgeons remained the most popular treatment modality with low complication rates and great deal of healing success.

Anahtar Kelimeler

• Botox, lateral internal sphincterotomy, incontinence

Comparison of botox and lateral internal sphincterotomy treatment outcomes in chronic anal fissures

Öz

Amaç: Botoks, anal sfinkteri gevşeterek fissür iyileşmesine zemin hazırlayan bir tedavi metodudur. Çalışmamızın amacı; Kronik anal fissür tanısı alan hastalarda uygulanan botoks ve lateral interanal sifinkterotomi tedavilerinin etkinliklerini değerlendirmek ve komplikasyon oranlarını karşılaştırarak tartışmaktır. Yöntemler: Ankara Dr. Sami Ulus Hastanesine Genel Cerrahi polikliniğine başvuran, kronik anal fissür tanısı alan ve konservatif tedaviden fayda görmeyen toplam 66 hastadan, ulaşılan 60 erişkin hasta çalışma kapsamına alındı. Hastaların yaşları, cinsiyetleri, fissür lokalizasyonları, şikayetleri (ağrı, kanama, kaşıntı, kabızlık), şikayet süreleri, tedavi sonrası nüks, inkontinans durumları ve komplikasyonlar kayıt altına alındı. Hastalar lateral internal sfinkterotomi (LİS) uygulananlar ve botoks ile tedavi edilenler olmak üzere gruplandırıldı. Bulgular: Altmış hastanın, 38\'i (%63,3) erkek, 22\'si (%26,7) kadındı. Hastaların genel yaş ortalaması, 35,93 ± 11,45 (21 -60)\'di. Ağrı, tüm hastalarda izlenen ortak şikayetti. Nüks açısından değerlendirildiğinde; botoks uygulanan grup-I\'de 10 (%32,3) hastada, LİS uygulanan grup-II\'de ise 1 (%3,4) hastada nüks saptandı. Grup-I\'de inkontinans saptanmazken, grup II\'de 3 (%10,39) hastada inkontinans saptanmıştır. İnkontinans saptanan 3 hastanın Cleveland Klinik Skorlama Sistemine göre değerlendirilmesinde, 2 hastada gaz inkontinansı, 1 hastada orta derecede gaita inkontinansı saptanmıştır. Sonuç: Botilunum toksin enjeksiyonu, anal fissür tedavisinde, inkontinans gibi can sıkıcı komplikasyonların çok daha az izlendiği alternatif bir tedavi gibi görünse de, yüksek nüks oranları büyük dezavantaj olarak karşımıza çıkmaktadır. Deneyimli ellerde LIS, daha düşük komplikasyon oranları ve yüksek tedavi başarısı ile halen en önemli tedavi metodudur.

Anahtar Kelimeler

• Botoks, lateral internal sfinkterotomi, inkontinans

Kaynakça

1. Maria G, Brisinda G, Bentivoglio A, Cassetta E. Botulinum toxin injections in the internal anal sphincter for the treat- ment of chronic anal fissure. Ann Surg 1998;228:664-669.
2. Oh C, Divino M, Steinhagen M. Anal fissure: 20-year experi- ence. Dis Colon Rectum 1995;38:378–382.
3. Arroyo A, Pe´rez F, Serrano P. Open vs. close lateral sphinc- terotomy performed as an outpatient procedure under lo- cal anesthesia for chronic anal fissure. J Am Coll Surg 2004;199:361–367.
4. Garcia J, Belmonte C, Perez. Incontinence after lateral inter- nal sphincterotomy: anatomical and functional evaluation. Dis Colon Rectum 1998;41:423–427.
5. Madoff D, Fleshman W. Technical review on the diagnosis and care of patients with anal fissure. Gastroenterology 2003;124:235–245.
6. Mason P, Watkins M, Hall H, Hall A. The management of chronic fissure in ano with botulinum toxin. J R Coll Surg Edinb 1996;41:235-238.
7. Albanese A, Colosimo C, Carretta D. Botulinum toxin as a treatment for blepharospasm, spasmodic torticollis and hemifacial spasm. Eur Neurol 1992;32:112-117.
8. Cumaoglu A, Karasu C. Pharmacological aspects and thera- peutic perspective. J Int Med Sci 2007;3:1-6.

9. Jorge M, Wexner D. Etiology and management of fecal in- continence. Dis Colon Rec 1993; 36:77-97.
10. Bennett R, Goligher C. Results of internal sphincterotomy for anal fissure. Br Med J 1962;2:1500-1503.
11. Keighley M, Williams N. Chronic anal fissures. Surgery of the anus, rectum and colon London: WB Saunders; 1993;428-485.
12. Khubchandani I, Reed J. Sequelae of internal sphincteroto- my for chronic fissure. Br J Surg 1989;76:431–434.
13. Notaras M. Lateral subcutaneous sphincterotomy for anal fissure: a new technique. J R Soc Med 1969;62:713.
14. Lindsey I, Jones O, Cunningham C, Mortensen N. Chronic anal fissure. Br J Surg 2004;91:270–279.
15. Evans J, Luck A, Hewett P. Glyceryl trinitrate vs. lateral sphincterotomy for chronic anal fissure: prospective, ran- domized trial. Dis Colon Rectum 2001;44:93–97.
16. Maria G, Cassetta E, Gui D, Brisinda G. A comparison of botulinum toxin and saline for the treatment of chronic anal fissure. N Engl JMed 1998;338:217–220.
17. Dhawan S, Chopra S. Nonsurgical approaches for the treat- ment of anal fissures. Am J Gastroenterol 2007;102:1312– 1321.
18. Brisinda G, Maria G, Bentivoglio A, et al. A comparison of injections of botulinum toxinand topical nitroglycerin oint- ment for the treatment of chronic anal fissure. N Engl J Med 1999;341:65–69.
19. Jankovic J, Brin M. Therapeutic uses of botulinum toxin. N Engl J Med 1991;324:1186-1194.
20. Gui D, Cassetta E, Anastasio G, et al. Albanese A. Botuli- num toxin for chronic anal fissure. Lancet 1994;34:1127– 1128.
21. Menteş B, İrkörücü O, Akın M. Comparison of botulinum toxin injection and lateral internal sphincterotomy for the treatment of chronic anal fissure. Dis Colon Rectum 2003;46:232-237.
22. Sajid MS, Hunte S, Hippolyte S. Comparison of surgical vs. chemical sphincterotomy using botulinum toxin for the treatment of chronic anal fissure: a meta-analysis. Colorec- tal
23. Dis 2008;10:547–552.
24. Shao WJ, Li GC, Zhang ZK. Systematic review and meta- analysis of randomized controlled trials comparing botu- linum toxin injection with lateral internal sphincterotomy for chronic anal fissure. Int J Colorectal Dis 2009;24:995– 1000.
25. Nelson R. Operative prosedure for fissure ano. Cochrane Database Syst Rev 2005;18:2.
26. Pernikoff B, Eisenstat T, Rubin R, Oliver C, Salvati P. Re- appraisal of partial lateral internal sphincteretomy. Dis Co- lon Rectum 1994;37;1291-1295.
27. Hsu T, Mac-Keigan M. Surgical Treatment of chronic anal fissure A. Retrospective study of 1753 cases. Dis Colon Rectum 1984;27:475-478.
28. Nasr M, Ezzat H,Elsebae M. Botulinum toxin injection versus lateral internal sphincterotomy in the treatment of chronic anal fissure: a randomized controlled trial. World J Surg 2010;34:2730-2734.
29. Nelson RL, Thomas K,Morgan J,Jones A. Non-surgical therapy for anal fissure. Cochrane Database Syst Rev 2012;15:3431-3432.