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Calderón T, Arriero L, Cruz P, Gómez L, Asanza J, Santiago JC, Garrido R, Bustamante C, Balsa T. Is chemodenervation with incobotulinumtoxinA an alternative to invasive chronic anal fissure treatments? BMC Gastroenterol 2024; 24:334. [PMID: 39350142 PMCID: PMC11440925 DOI: 10.1186/s12876-024-03428-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 09/20/2024] [Indexed: 10/04/2024] Open
Abstract
BACKGROUND Botulinum toxin type A is currently strongly recommended for the treatment of anal fissures (AFs). However, there is still no consensus on dosage or injection technique. This study provides further efficacy and safety evidence in a 2-year follow-up. METHOD Prospective, open-label, single-arm, single-center study carried out in adult patients with AFs non-responsive to previous treatments. Patients were treated with incobotulinumtoxinA (incoBoNT/A) injected in both laterals and posterior intersphincteric groove. Healing rate at 2 years was the primary endpoint. Secondary endpoints included internal anal sphincter pressures, incontinence, and safety. RESULTS A total of 49 patients were treated with a mean incoBoNT/A dose of 40.5 U (spread across three locations). Healing rate at 2 years was 83.9% with a 24.5% of recurrence throughout the study. Only 7 patients (14.3%) reported adverse events (AEs) that were mild and temporary. Mean reduction in anal resting pressure was -9.1 mmHg at 3 months (p = 0.001). Mean reduction in voluntary squeeze pressure was -27.5 mmHg at 3 months (p < 0.001). Mean pain perception measured with a visual analog scale decreased by -6.5 points at 2 years (p < 0.001). There was an incontinence increase at 1 month of 1.3 points (p = 0.006), but baseline values were restored at 6 months. CONCLUSION We present results that support the use of incoBoNT/A as a second line for AFs that do not respond to ointment therapy. IncoBoNT/A injection is a less invasive treatment that should be considered before surgery due to its efficacy and its safety which includes no permanent impairment. TRIAL REGISTRATION ISRCTN90354265; Registered on 16th February 2024. Retrospectively registered.
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Affiliation(s)
- T Calderón
- Servicio de Cirugía General y Aparato Digestivo, Hospital Nuestra Señora del Prado. Talavera de La Reina, Toledo, Spain.
| | - L Arriero
- Servicio de Cirugía General y Aparato Digestivo, Hospital Nuestra Señora del Prado. Talavera de La Reina, Toledo, Spain
| | - P Cruz
- Servicio de Cirugía General y Aparato Digestivo, Hospital Nuestra Señora del Prado. Talavera de La Reina, Toledo, Spain
| | - L Gómez
- Servicio de Cirugía General y Aparato Digestivo, Hospital Nuestra Señora del Prado. Talavera de La Reina, Toledo, Spain
| | - J Asanza
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, Castilla-La Mancha, Spain
| | - J C Santiago
- Servicio de Cirugía General y Aparato Digestivo, Hospital Nuestra Señora del Prado. Talavera de La Reina, Toledo, Spain
| | - R Garrido
- Servicio de Cirugía General y Aparato Digestivo, Hospital Nuestra Señora del Prado. Talavera de La Reina, Toledo, Spain
| | - C Bustamante
- Servicio de Cirugía General y Aparato Digestivo, Hospital Nuestra Señora del Prado. Talavera de La Reina, Toledo, Spain
| | - T Balsa
- Servicio de Cirugía General y Aparato Digestivo, Hospital Nuestra Señora del Prado. Talavera de La Reina, Toledo, Spain
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Roelandt P, Bislenghi G, Coremans G, De Looze D, Denis MA, De Schepper H, Dewint P, Geldof J, Gijsen I, Komen N, Ruymbeke H, Stijns J, Surmont M, Van de Putte D, Van den Broeck S, Van Geluwe B, Wyndaele J. Belgian consensus guideline on the management of anal fissures. Acta Gastroenterol Belg 2024; 87:304-321. [PMID: 39210763 DOI: 10.51821/87.2.11787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Introduction Acute and chronic anal fissures are common proctological problems that lead to relatively high morbidity and frequent contacts with health care professionals. Multiple treatment options, both topical and surgical, are available, therefore evidence-based guidance is preferred. Methods A Delphi consensus process was used to review the literature and create relevant statements on the treatment of anal fissures. These statements were discussed and modulated until sufficient agreement was reached. These guidelines were based on the published literature up to January 2023. Results Anal fissures occur equally in both sexes, mostly between the second and fourth decades of life. Diagnosis can be made based on cardinal symptoms and clinical examination. In case of insufficient relief with conservative treatment options, pharmacological sphincter relaxation is preferred. After 6-8 weeks of topical treatment, surgical options can be explored. Both lateral internal sphincterotomy as well as fissurectomy are well-established surgical techniques, both with specific benefits and risks. Conclusions The current guidelines for the management of anal fissures include recommendations for the clinical evaluation of anal fissures, and their conservative, topical and surgical management.
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Affiliation(s)
- P Roelandt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Diseases (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - G Bislenghi
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - G Coremans
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - D De Looze
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Ghent, Belgium
| | - M A Denis
- Department of Gastroenterology and Hepatology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - H De Schepper
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium
| | - P Dewint
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium
- Department of Gastroenterology and Hepatology, Maria Middelares Hospital, Ghent, Belgium
| | - J Geldof
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Ghent, Belgium
| | - I Gijsen
- Department of Gastroenterology and Hepatology, Noorderhart Hospital, Pelt, Belgium
| | - N Komen
- Department of Abdominal Surgery, Antwerp University Hospital, Edegem, Belgium
- Antwerp RESURG Group, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - H Ruymbeke
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Ghent, Belgium
- Department of Gastroenterology, VITAZ, Sint-Niklaas, Belgium
| | - J Stijns
- Department of Abdominal Surgery, University Hospital Brussels, Brussels, Belgium
| | - M Surmont
- Department of Gastroenterology and Hepatology, University Hospital Brussels, Brussels, Belgium
| | - D Van de Putte
- Department of Gastro-intestinal Surgery, University Hospital Ghent, Ghent, Belgium
| | - S Van den Broeck
- Department of Abdominal Surgery, Antwerp University Hospital, Edegem, Belgium
| | - B Van Geluwe
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Abdominal Surgery, General Hospital Groeninge, Kortrijk, Belgium
| | - J Wyndaele
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
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Borsuk DJ, Studniarek A, Park JJ, Marecik SJ, Mellgren A, Kochar K. Use of Botulinum Toxin Injections for the Treatment of Chronic Anal Fissure: Results From an American Society of Colon and Rectal Surgeons Survey. Am Surg 2023; 89:346-354. [PMID: 34092078 DOI: 10.1177/00031348211023446] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Chronic anal fissure (CAF) is commonly treated by colorectal surgeons. Pharmacological treatment is considered first-line therapy. An alternative treatment modality is chemical sphincterotomy with injection of botulinum toxin (BT). However, there is a lack of a consensus on the BT administration procedure among colorectal surgeons. METHODS A national survey approved by the American Society of Colon and Rectal Surgeons (ASCRS) Executive Council was sent to all members. An eight-question survey was sent via ASCRS email correspondence between December 2019 and February 2020. Questions were derived from available meta-analyses and expert opinions on BT use in CAF patients and included topics such as BT dose, injection technique, and concomitant therapies. The survey was voluntary and anonymous, and all ASCRS members were eligible to complete it. Responses were recorded and analyzed via an online survey platform. RESULTS 216 ASCRS members responded to the survey and 90% inject 50-100U of BT. Most procedures are performed under MAC anesthesia (56%). A majority of respondents (64%) inject into the internal sphincter and a majority (53%) inject into 4 quadrants in the anal canal circumference. Some respondents perform concomitant manual dilatation (34%) or fissurectomy (38%). Concomitant topical muscle relaxing agents are not used uniformly among respondents. DISCUSSION Injection of BT for CAF is used commonly by colorectal surgeons. There is consensus on BT dosage, administration site, technique, and the use of monitored anesthesia care.
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Affiliation(s)
- Daniel J Borsuk
- Division of Colon and Rectal Surgery, 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Adam Studniarek
- Division of Colon and Rectal Surgery, 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA.,Division of Colon and Rectal Surgery, 14681University of Illinois at Chicago, Chicago, IL, USA
| | - John J Park
- Division of Colon and Rectal Surgery, 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Slawomir J Marecik
- Division of Colon and Rectal Surgery, 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Anders Mellgren
- Division of Colon and Rectal Surgery, 14681University of Illinois at Chicago, Chicago, IL, USA
| | - Kunal Kochar
- Division of Colon and Rectal Surgery, 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
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Comparison of Different Doses Botulinum Toxin Type a Efficacy in Chronic Anal Fissure Treatment. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2022. [DOI: 10.2478/sjecr-2022-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Objective: To compare the results of chronic anal fissure treatment with 10 IU and 40 IU botulinum toxin type A.
Patients and methods: 56 patients were enrolled in case-control study divided into 2 groups consistent by the main clinical criteria. 28 patients in the study group had fissure excision in combination with 10 IU botulinum toxin type A (Xeomin) injection into internal anal sphincter, while 28 patients in control group received 40 IU product injections.
Results: No statistically significant results in the pain assessment during the day and after bowel movement were obtained (p=0.41 and p=0.93, respectively). The groups were comparable by the frequency of complications such as transient anal incontinence, perianal skin hematoma, acute urinary retention (p>0.05). Complications such as thrombosis of external hemorrhoids and chronic non-healing wounds were most common in the study group (p=0.43 and p=0.0005, respectively). The product dose increase to 40 IU has a more significant effect on the functional treatment results (p=0.0053 and p=0.0002, respectively) and increases the odds for postoperative wound epithelialization 15-fold (p=0.01). Conclusion: 40 IU Botulinum toxin type A shows improvement in the treatment of chronic anal fissure without any increased risk of postoperative complications.
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Botulinum Toxin Injection Plus Topical Diltiazem for Chronic Anal Fissure: A Randomized Double-Blind Clinical Trial and Long-term Outcome. Dis Colon Rectum 2021; 64:1521-1530. [PMID: 34747917 DOI: 10.1097/dcr.0000000000001983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Chemical sphincterotomy avoids the risk of permanent incontinence in the treatment of chronic anal fissure, but it does not reach the efficacy of surgery and recurrence is high. Drug combination has been proposed to overcome these drawbacks. OBJECTIVE This study aimed to compare the clinical, morphological, and functional effects of combined therapy with botulinum toxin injection and topical diltiazem in chronic anal fissure and to assess the long-term outcome after healing. DESIGN This is a randomized, controlled, double-blind, 2-arm, parallel-group trial with a long-term follow-up. SETTINGS This study was conducted at a tertiary care center. PATIENTS A total of 70 consecutive patients were referred to the gastroenterology department of a hospital in Valencia, Spain. INTERVENTION After botulinum toxin injection (20 IU), patients were randomly assigned to local diltiazem (diltiazem group) or placebo gel (placebo group) for 12 weeks. MAIN OUTCOME MEASURES The primary outcome was fissure healing (evaluated by video register by 3 independent physicians). Secondary outcomes included symptomatic relief (30-day diary), effect on anal sphincters (manometry), safety, and long-term recurrence (24 months and 10 years). RESULTS Healing was achieved per protocol in 13 of 25 (52%) patients of the diltiazem group and 11 of 30 (36.7%) patients of the placebo group (p = 0.25); on an intention-to-treat basis in 37.1% and 31.4% (p = 0.61). Both groups displayed significant reduction of anal pressures. Thirty percent reported minor and transitory incontinence, without differences between groups. Nine (69.2%) of the diltiazem group and 6 (54.5%) of the placebo group experienced a relapse at 24 months (p = 0.67). The overall recurrence rate at 10 years was 83.3% (20/24 patients). LIMITATIONS This study was limited by the loss of patients during the trial. The low healing rate led to a small cohort to assess recurrence. CONCLUSIONS Combined botulinum toxin injection and topical diltiazem is not superior to botulinum toxin injection in the treatment of chronic anal fissure. Both options offer suboptimal healing rates. Long-term recurrence is high (>80% at 10 years) and might appear at any time after healing. See Video Abstract at http://links.lww.com/DCR/B527. INYECCIN DE TOXINA BOTULNICA MS DILTIAZEM TPICO EN FISURA ANAL CRNICA UN ENSAYO CLNICO ALEATORIZADO DOBLE CIEGO Y RESULTADOS A LARGO PLAZO ANTECEDENTES:La esfinterotomía química evita el riesgo de incontinencia permanente en el tratamiento de la fisura anal crónica, pero no alcanza la eficacia de la cirugía y la recurrencia es alta. Se ha propuesto la combinación de fármacos para superar estos inconvenientes.OBJETIVO:Comparar los efectos clínicos, morfológicos y funcionales de la terapia combinada con inyección de toxina botulínica y diltiazem tópico en fisura anal crónica y evaluar el resultado a largo plazo después de la cicatrización.DISEÑO:Ensayo aleatorizado, controlado, doble ciego, de dos brazos, de grupos paralelos con un seguimiento a largo plazo.ESCENARIO:Estudio realizado en un centro de atención terciaria.PACIENTES:Un total de 70 pacientes consecutivos referidos al servicio de gastroenterología de un hospital de Valencia, España.INTERVENCIÓN:Después de la inyección de toxina botulínica (20UI), los pacientes fueron asignados al azar a diltiazem local (grupo de diltiazem) o gel de placebo (grupo de placebo) durante 12 semanas.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la cicatrización de la fisura (evaluado por registro de video por tres médicos independientes). Los resultados secundarios incluyeron alivio sintomático (diario de 30 días), efecto sobre los esfínteres anales (manometría), seguridad y recurrencia a largo plazo (24 meses y 10 años).RESULTADOS:La curación se logró por protocolo en 13/25 (52%) en el grupo de Diltiazem y 11/30 (36,7%) en el grupo de Placebo (p = 0.25); por intención de tratar en el 37.1% y el 31.4%, respectivamente (p = 0.61). Ambos grupos mostraron una reducción significativa de las presiones anales. El 30% refirió incontinencia leve y transitoria, sin diferencias entre grupos. 9 (69.2%) del grupo de Diltiazem y 6 (54.5%) del grupo de placebo recurrieron a los 24 meses (p = 0.67). La tasa global de recurrencia a los 10 años fue del 83.3% (20/24 pacientes).LIMITACIONES:La pérdida de pacientes a lo largo del ensayo. La baja tasa de curación llevó a una pequeña cohorte para evaluar la recurrencia.CONCLUSIONES:La inyección combinada de toxina botulínica y diltiazem tópico no es superior a la inyección de TB en el tratamiento de la fisura anal crónica. Ambas opciones ofrecen tasas de curación subóptimas. La recurrencia a largo plazo es alta (> 80% a los 10 años) y puede aparecer en cualquier momento después de la curación. Consulte Video Resumen en http://links.lww.com/DCR/B527.
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Cheng YC, Beh JYM, Wu PH, Tsai NY, Jao SW. Early botulinum toxin injection reduces pain after hemorrhoidectomy: a pilot study. Tech Coloproctol 2021; 26:53-60. [PMID: 34705137 DOI: 10.1007/s10151-021-02542-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/21/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Hemorrhoidectomy is the standard procedure for treating high-grade hemorrhoids. However, postoperative pain usually causes patients to delay or refuse surgical treatment. Because maximal resting pressure in the internal anal sphincter plays a major role in post-hemorrhoidectomy pain, Botulinum toxin injections have been proposed to reduce it. However, the optimal timing of Botulinum toxin injections is still unclear. The aim of the present study was to compare the effectiveness of early and intraoperative Botulinum toxin injections for postoperative pain control. METHODS In this pilot study, we enrolled patients who had grade III or IV hemorrhoids and underwent Ferguson hemorrhoidectomy at a single tertiary care center from October 1, 2018 to November 30, 2020. The experimental group received 50 U Botulinum toxin injections to the internal anal sphincter 1 week before the operation, and the control group received injections intraoperatively. The primary endpoint was the daily maximal and resting visual analogue scale (VAS) score recorded from postoperative days 0-6. The secondary endpoints were analgesia requirements, number of bowel movements per day, healing time, and postoperative length of stay. Power of the daily resting VAS score is at least 93%, but the power of the daily maximal VAS is a little lower (71%) (calculated by G*Power 3.1.9.2). RESULTS Sixty-two patients (male: female = 27:35; mean age = 47.6 ± 13.1 years) were randomized to the experimental group (n = 31) or control group (n = 31). The experimental group (n = 31) showed significantly shorter postoperative hospital stay than the controls (n = 31; p = 0.019). A generalized estimating equations model revealed that the group that received Botulinum toxin yielded a significantly lower maximal (OR 0.4, 95% CI 0.2-1.0, p = 0.041) and resting (OR 0.4, 95% CI 0.2-0.7, p < 0.001) VAS compared to controls at all time points. The Botulinum toxin group also had significantly less resting pain from postoperative days 1-5, and lower maximal subjective pain scores on postoperative days 1 (p = 0.024) and 4 (p = 0.044). Similar trends were observed on other days. CONCLUSIONS Early Botulinum toxin injection produced shorter hospital stays, and less reported pain after hemorrhoidectomy than intraoperative injections, especially for pain at rest. TRIAL REGISTRATION Identifier: NCT04485780 on ClinicalTrials.gov (retrospectively registered).
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Affiliation(s)
- Yi-Chiao Cheng
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Neihu District, Section 2, Cheng-Kong Rd, No. 325, Taipei, 114, Taiwan, ROC
| | | | - Po-Hsien Wu
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Neihu District, Section 2, Cheng-Kong Rd, No. 325, Taipei, 114, Taiwan, ROC
| | - Nien-Ying Tsai
- Department of General Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shu-Wen Jao
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Neihu District, Section 2, Cheng-Kong Rd, No. 325, Taipei, 114, Taiwan, ROC.
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Cariati M, Chiarello MM, Cannistra' M, Lerose MA, Brisinda G. Gastrointestinal Uses of Botulinum Toxin. Handb Exp Pharmacol 2020; 263:185-226. [PMID: 32072269 DOI: 10.1007/164_2019_326] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Botulinum toxin (BT), one of the most powerful inhibitors that prevents the release of acetylcholine from nerve endings, represents an alternative therapeutic approach for "spastic" disorders of the gastrointestinal tract such as achalasia, gastroparesis, sphincter of Oddi dysfunction, chronic anal fissures, and pelvic floor dyssynergia.BT has proven to be safe and this allows it to be a valid alternative in patients at high risk of invasive procedures but long-term efficacy in many disorders has not been observed, primarily due to its relatively short duration of action. Administration of BT has a low rate of adverse reactions and complications. However, not all patients respond to BT therapy, and large randomized controlled trials are lacking for many conditions commonly treated with BT.The local injection of BT in some conditions becomes a useful tool to decide to switch to more invasive therapies. Since 1980, the toxin has rapidly transformed from lethal poison to a safe therapeutic agent, with a significant impact on the quality of life.
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Affiliation(s)
- Maria Cariati
- Department of Surgery, "San Giovanni di Dio" Hospital, Crotone, Italy
| | | | - Marco Cannistra'
- Department of Surgery, "San Giovanni di Dio" Hospital, Crotone, Italy
| | | | - Giuseppe Brisinda
- Department of Surgery, "San Giovanni di Dio" Hospital, Crotone, Italy. .,Department of Surgery, "Agostino Gemelli" Hospital, Catholic School of Medicine, Rome, Italy.
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Ulyanov AA, Solomka AY, Achkasov EE, Antipova EV, Kuznetsova EV. [Chronic anal fissure: etiopathogenesis, diagnosis, treatment]. Khirurgiia (Mosk) 2018:89-95. [PMID: 30531762 DOI: 10.17116/hirurgia201811189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Etiology, epidemiology and pathophysiology of anal fissure are examined in the article in order to determine the most optimal treatment strategy. The authors concluded that the most effective treatment is combined approach using both minimally invasive surgery and various medicines for anal spasm reduction.
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Affiliation(s)
- A A Ulyanov
- Central Literary Fund Clinic, Moscow, Russia
| | - A Ya Solomka
- Municipal Clinical Hospital #24 of Moscow Healthcare Department, Moscow, Russia
| | - E E Achkasov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - E V Antipova
- Municipal Clinical Hospital #24 of Moscow Healthcare Department, Moscow, Russia
| | - E V Kuznetsova
- Municipal Clinical Hospital #24 of Moscow Healthcare Department, Moscow, Russia
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Pilkington SA, Bhome R, Welch RE, Ku F, Warden C, Harris S, Hicks J, Richardson C, Dudding TC, Knight JS, King AT, Mirnezami AH, Beck NE, Nichols PH, Nugent KP. Bilateral versus unilateral botulinum toxin injections for chronic anal fissure: a randomised trial. Tech Coloproctol 2018; 22:545-551. [PMID: 30022331 PMCID: PMC6097731 DOI: 10.1007/s10151-018-1821-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/29/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Botulinum toxin injected into the internal anal sphincter is used in the treatment of chronic anal fissure but there is no standardised technique for its administration. This randomised single centre trial compares bilateral (either side of fissure) to unilateral injection. METHODS Participants were randomised to receive bilateral (50 + 50 units) or unilateral (100 units) Dysport® injections into the internal anal sphincter in an outpatient setting. Injection-related pain assessed by visual analogue scale was the primary outcome measure. Secondary outcomes were healing rate, fissure pain, incontinence, and global health scores. RESULTS Between October 2008 and April 2012, 100 patients with chronic anal fissure were randomised to receive bilateral or unilateral injections. Injection-related pain was comparable in both groups. There was no difference in healing rate. Initially, there was greater improvement in fissure pain in the bilateral group but at 1 year the unilateral group showed greater improvement. Cleveland Clinic Incontinence score was lower in the unilateral group in the early post-treatment period and global health assessment (EuroQol EQ-VAS) was higher in the unilateral group at 1 year. CONCLUSIONS Injection-related pain was similar in bilateral and unilateral injection groups. Unilateral injection was as effective as bilateral injections in healing and improving fissure pain without any deterioration in continence.
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Affiliation(s)
- S A Pilkington
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - R Bhome
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
- Academic Surgical Unit, University of Southampton, Level C South Academic Block, Southampton General Hospital, Southampton, SO16 6YD, UK
| | - R E Welch
- School of Medicine, University of Southampton, Southampton, UK
| | - F Ku
- School of Medicine, University of Southampton, Southampton, UK
| | - C Warden
- Department of Colorectal Surgery, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - S Harris
- Primary Care and Population Studies Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - J Hicks
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - C Richardson
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - T C Dudding
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - J S Knight
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - A T King
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - A H Mirnezami
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
- Academic Surgical Unit, University of Southampton, Level C South Academic Block, Southampton General Hospital, Southampton, SO16 6YD, UK
| | - N E Beck
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - P H Nichols
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - K P Nugent
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK.
- Academic Surgical Unit, University of Southampton, Level C South Academic Block, Southampton General Hospital, Southampton, SO16 6YD, UK.
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Andjelkov K, Sforza M, Barisic G, Soldatovic I, Hiranyakas A, Krivokapic Z. A novel method for treatment of chronic anal fissure: adipose-derived regenerative cells - a pilot study. Colorectal Dis 2017; 19:570-575. [PMID: 28574663 DOI: 10.1111/codi.13555] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 07/26/2016] [Indexed: 02/08/2023]
Abstract
AIM The purpose of this study was to investigate the safety and feasibility of autologous adipose-derived regenerative cells (ADRC) in the treatment of chronic anal fissure. METHOD A prospective pilot study was conducted in six patients with chronic anal fissures at the First Surgical Clinic, Clinical Center of Serbia and at the BelPrime Clinic, Belgrade, Serbia. All patients were candidates for surgical treatment. The average duration of symptoms was 24 months. Pain assessment was quantified using a visual analogue scale and bowel continence was assessed using the Wexner incontinence score. Both were assessed before treatment and during each postoperative outpatient visit. Liposuction was performed under local or general anaesthesia. Extraction of ADRC was achieved with a closed automated medical device. The fat and ADRC were injected subcutaneously into the edge of the fissure. The rest of the pellet was infiltrated into the internal anal sphincter. The study has been registered at ClinicalTrials.gov (NCT02628522). RESULTS Complete healing of the anal fissure and the disappearance of symptoms was achieved in all patients. The average time to complete pain cessation was 33.7 ± 15.0 days. All fissures healed after 3 months and remained healed 12 months after the procedure. There were no complications related to the procedure. CONCLUSION The application of ADRC may be an alternative to lateral sphincterotomy and a reliable procedure which avoids faecal incontinence.
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Affiliation(s)
- K Andjelkov
- BelPrime Clinic, Belgrade, Serbia.,SESA University, Ponte Nova, Brazil
| | - M Sforza
- BelPrime Clinic, Belgrade, Serbia.,SESA University, Ponte Nova, Brazil
| | - G Barisic
- First Surgical Clinic, University of Belgrade, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - I Soldatovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Institute of Medical Statistics and Informatics, University of Belgrade, Belgrade, Serbia
| | - A Hiranyakas
- Colorectal Disease Institute, Bangkok Hospital, Phuket, Thailand
| | - Z Krivokapic
- First Surgical Clinic, University of Belgrade, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Bobkiewicz A, Francuzik W, Krokowicz L, Studniarek A, Ledwosiński W, Paszkowski J, Drews M, Banasiewicz T. Botulinum Toxin Injection for Treatment of Chronic Anal Fissure: Is There Any Dose-Dependent Efficiency? A Meta-Analysis. World J Surg 2016; 40:3064-3072. [PMID: 27539490 PMCID: PMC5104788 DOI: 10.1007/s00268-016-3693-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Chronic anal fissure (CAF) is a linear split of the anoderm. The minimally invasive management of CAF such as botulinum toxin (BT) injection is recommended. However, the exact efficient dose of BT, number of injections per session and the injection sites are still debatable. The aim of this analysis was to assess the dose-dependent efficiency of botulinum toxin injection for CAF. METHODS PubMed and Web of Science databases were searched for terms: "anal fissure" AND "botulinum toxin." Studies published between October 1993 and May 2015 were included and had to meet the following criteria: (1) chronic anal fissure, (2) prospective character of the study, (3) used simple BT injection without any other interventions and (4) no previous treatment with BT. RESULTS A total of 1577 patients from 34 prospective studies used either Botox or Dysport formulations were qualified for this meta-analysis. A total number of BT units per session ranged from 5 to 150 IU, whereas the efficiency across analyzed studies ranged from 33 to 96 %. Surprisingly, we did not observe a dose-dependent efficiency (Spearman's rank correlation coefficient, ρ = 0.060; p = 0.0708). Moreover, there were no BT dose-dependent postoperative complications or fecal incontinence and significant difference in healing rates compared BT injection into the anal sphincter muscles. CONCLUSIONS BT injection has been an accepted method for the management of CAF. Surprisingly, there is no dose-dependent efficiency, and the postoperative incontinence rate is not related to the BT dosage regardless the type of formulation of botulinum neurotoxin used. Moreover, no difference in healing rate has been observed in regard to the site and number of injections per session.
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Affiliation(s)
- Adam Bobkiewicz
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355, Poznan, Poland.
| | - Wojciech Francuzik
- Department of Dermatology, Venerology and Allergology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Lukasz Krokowicz
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355, Poznan, Poland
| | - Adam Studniarek
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355, Poznan, Poland
| | - Witold Ledwosiński
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355, Poznan, Poland
| | - Jacek Paszkowski
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355, Poznan, Poland
| | - Michal Drews
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355, Poznan, Poland
| | - Tomasz Banasiewicz
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355, Poznan, Poland
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12
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van Meegdenburg MM, Trzpis M, Heineman E, Broens PMA. Increased anal basal pressure in chronic anal fissures may be caused by overreaction of the anal-external sphincter continence reflex. Med Hypotheses 2016; 94:25-9. [PMID: 27515194 DOI: 10.1016/j.mehy.2016.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 06/04/2016] [Indexed: 10/21/2022]
Abstract
Chronic anal fissure is a painful disorder caused by linear ulcers in the distal anal mucosa. Even though it counts as one of the most common benign anorectal disorders, its precise etiology and pathophysiology remains unclear. Current thinking is that anal fissures are caused by anal trauma and pain, which leads to internal anal sphincter hypertonia. Increased anal basal pressure leads to diminished anodermal blood flow and local ischemia, which delays healing and leads to chronic anal fissure. The current treatment of choice for chronic anal fissure is either lateral internal sphincterotomy or botulinum toxin injections. In contrast to current thinking, we hypothesize that the external, rather than the internal, anal sphincter is responsible for increased anal basal pressure in patients suffering from chronic anal fissure. We think that damage to the anal mucosa leads to hypersensitivity of the contact receptors of the anal-external sphincter continence reflex, resulting in overreaction of the reflex. Overreaction causes spasm of the external anal sphincter. This in turn leads to increased anal basal pressure, diminished anodermal blood flow, and ischemia. Ischemia, finally, prevents the anal fissure from healing. Our hypothesis is supported by two findings. The first concerned a chronic anal fissure patient with increased anal basal pressure (170mmHg) who had undergone lateral sphincterotomy. Directly after the operation, while the submucosal anesthetic was still active, basal anal pressure decreased to 80mmHg. Seven hours after the operation, when the anesthetic had completely worn off, basal anal pressure increased again to 125mmHg, even though the internal anal sphincter could no longer be responsible for the increase. Second, in contrast to previous studies, recent studies demonstrated that botulinum toxin influences external anal sphincter activity and, because it is a striated muscle relaxant, it seems reasonable to presume that it affects the striated external anal sphincter, rather than the smooth internal anal sphincter. If our hypothesis is proved correct, the treatment option of lateral internal sphincterotomy should be abandoned in patients suffering from chronic anal fissures, since it fails to eliminate the cause of high anal basal pressure. Additionally, lateral internal sphincterotomy may cause damage to the anal-external sphincter continence reflex, resulting in fecal incontinence. Instead, higher doses of botulinum toxin should be administered to those patients suffering from chronic anal fissure who appeared unresponsive to lower doses.
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Affiliation(s)
- Maxime M van Meegdenburg
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Monika Trzpis
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Erik Heineman
- Department of Surgery, Division of Pediatric Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Paul M A Broens
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Surgery, Division of Pediatric Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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13
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Whatley JZ, Tang SJ, Glover PH, Davis ED, Jex KT, Wu R, Lahr CJ. Management of complicated chronic anal fissures with high-dose circumferential chemodenervation (HDCC) of the internal anal sphincter. Int J Surg 2015; 24:24-6. [DOI: 10.1016/j.ijsu.2015.10.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 10/01/2015] [Accepted: 10/12/2015] [Indexed: 11/28/2022]
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14
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Botulinum toxin A injection for chronic anal fissures and anal sphincter spasm improves quality of life in recessive dystrophic epidermolysis bullosa. Int J Womens Dermatol 2015; 1:167-169. [PMID: 28491983 PMCID: PMC5419760 DOI: 10.1016/j.ijwd.2015.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 08/12/2015] [Accepted: 08/12/2015] [Indexed: 11/30/2022] Open
Abstract
We report a 20-year-old female with generalized, severe, recessive dystrophic epidermolysis bullosa who developed secondary chronic anal fissures. This resulted in anal sphincter spasm and severe, disabling pain. She was treated with five botulinum toxin A injections into the internal anal sphincter over a period of 2 years and gained marked improvement in her symptoms. This case demonstrates the successful use of botulinum toxin A injections to relieve anal sphincter spasm and fissuring, with long-term improvement.
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15
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Fissurectomy Combined with High-Dose Botulinum Toxin Is a Safe and Effective Treatment for Chronic Anal Fissure and a Promising Alternative to Surgical Sphincterotomy. Dis Colon Rectum 2015; 58:967-73. [PMID: 26347969 DOI: 10.1097/dcr.0000000000000434] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is paucity of data on the long-term outcome of the combination of fissurectomy and botulinum toxin A injection for the management of chronic anal fissure. OBJECTIVES The aim of this study is to assess the safety, efficacy, and long-term outcome of the combination of fissurectomy and botulinum toxin A injection. DESIGN This is a nonrandomized prospective cohort study. SETTINGS This study was conducted at a district general hospital in the United Kingdom. PATIENTS The cohort included all patients treated with fissurectomy and botulinum toxin A for chronic anal fissure between September 2008 and March 2012. INTERVENTION The patients were treated with a combination of fissurectomy and botulinum toxin A injection. MAIN OUTCOME MEASURES Symptomatic relief, fissure healing, complications, recurrence, and the need for further surgical intervention. RESULTS One hundred and two patients received fissurectomy and botulinum toxin A injection for chronic anal fissure. At 12-week follow-up, 68 patients had resolution of symptoms and complete healing of chronic anal fissure, 29 patients had improvement of symptoms but incomplete healing and had further topical or botulinum toxin A treatment with subsequent complete healing. Ninety-five patients (93%) reported no postoperative complications. Seven patients reported a degree of incontinence in the immediate postoperative period. All reported normal continence at12-week follow-up. No local complications were observed or reported. At the mean follow-up of 33 months, there was no evidence of recurrence. Twelve-month follow-up was conducted via telephone interview only. LIMITATIONS This study is nonrandomized and did not examine the dose response of Botulinum Toxin A. CONCLUSIONS Fissurectomy combined with high-dose botulinum toxin A is a safe, effective, and durable option for the management of chronic anal fissure and a promising alternative to surgical sphincterotomy.
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16
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Glover PH, Tang SJ, Whatley JZ, Davis ED, Jex KT, Wu R, Lahr CJ. High-dose circumferential chemodenervation of the internal anal sphincter: A new treatment modality for uncomplicated chronic anal fissure: A retrospective cohort study (with video). Int J Surg 2015; 23:1-4. [PMID: 26365430 DOI: 10.1016/j.ijsu.2015.08.076] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 08/10/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND Botulinum toxin injection into the internal anal sphincter is gaining popularity as a second line therapy for chronic anal fissures if medical therapy fails. The dosage of botulinum toxin reported ranged from 20 to 50 IU with no more than 3 injection sites and results in a healing rate of 41%-88% at 3 months. We propose a new injection method of high-dose circumferential chemodenervation of 100 IU in treating chronic anal fissure. METHODS This was a retrospective review at a single academic center. 75 patients (50 women and 25 men) with uncomplicated chronic anal fissures underwent high-dose circumferential chemodenervation-internal anal sphincter (100 IU). We measured fissure healing, complication, and recurrence rates at 3 and 6 months post injection. RESULTS Of the 75 patients, healing rate was 90.7% at 3 months follow up with the first injection and 81.3% with the second injection. The recurrence rates were 20.6% and 12.5% at 6 months after the 1st and 2nd injections respectively. Excluding 5 patients who lost follow up, the total healing rate of the study cohort was 100%. At 2 weeks and 3 months, there were no major complications including hematoma, infection, flatus, fecal, and urinary incontinence. CONCLUSIONS High-dose circumferential chemodenervation-internal anal sphincter (100 IU) is a safe and effective method for uncomplicated chronic anal fissure.
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Affiliation(s)
- Porter H Glover
- Division of Gastroenterology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA
| | - Shou-jiang Tang
- Division of Gastroenterology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA.
| | - James Z Whatley
- Division of Gastroenterology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA
| | - Eric D Davis
- Division of Gastroenterology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA
| | - Kellen T Jex
- Division of Gastroenterology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA
| | - Ruonan Wu
- Division of Gastroenterology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA
| | - Christopher J Lahr
- Department of Surgery, University of Mississippi Medical Center, 2500 North State Street Jackson, MS 39216, USA
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17
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Agarwal N. Current status of various treatment modalities in the management of Fissure-in-ano. APOLLO MEDICINE 2015. [DOI: 10.1016/j.apme.2015.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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18
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Bibi S, Zutshi M, Gurland B, Hull T. Is Botox for anal pain an effective treatment option? Postgrad Med 2015; 128:41-5. [DOI: 10.1080/00325481.2015.1081047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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19
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Brisinda G, Sivestrini N, Bianco G, Maria G. Treatment of gastrointestinal sphincters spasms with botulinum toxin A. Toxins (Basel) 2015; 7:1882-916. [PMID: 26035487 PMCID: PMC4488680 DOI: 10.3390/toxins7061882] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 05/10/2015] [Accepted: 05/21/2015] [Indexed: 02/05/2023] Open
Abstract
Botulinum toxin A inhibits neuromuscular transmission. It has become a drug with many indications. The range of clinical applications has grown to encompass several neurological and non-neurological conditions. One of the most recent achievements in the field is the observation that botulinum toxin A provides benefit in diseases of the gastrointestinal tract. Although toxin blocks cholinergic nerve endings in the autonomic nervous system, it has also been shown that it does not block non-adrenergic non-cholinergic responses mediated by nitric oxide. This has promoted further interest in using botulinum toxin A as a treatment for overactive smooth muscles and sphincters. The introduction of this therapy has made the treatment of several clinical conditions easier, in the outpatient setting, at a lower cost and without permanent complications. This review presents current data on the use of botulinum toxin A in the treatment of pathological conditions of the gastrointestinal tract.
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Affiliation(s)
- Giuseppe Brisinda
- Department of Surgery, University Hospital "Agostino Gemelli", Largo Agostino Gemelli 8, 00168 Rome, Italy.
| | - Nicola Sivestrini
- Department of Surgery, University Hospital "Agostino Gemelli", Largo Agostino Gemelli 8, 00168 Rome, Italy.
| | - Giuseppe Bianco
- Department of Surgery, University Hospital "Agostino Gemelli", Largo Agostino Gemelli 8, 00168 Rome, Italy.
| | - Giorgio Maria
- Department of Surgery, University Hospital "Agostino Gemelli", Largo Agostino Gemelli 8, 00168 Rome, Italy.
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21
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Brisinda G, Bianco G, Silvestrini N, Maria G. Cost considerations in the treatment of anal fissures. Expert Rev Pharmacoecon Outcomes Res 2014; 14:511-25. [PMID: 24867398 DOI: 10.1586/14737167.2014.924398] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Anal fissure is a split in the lining of the distal anal canal. Lateral internal sphincterotomy remains the gold standard for treatment of anal fissure. Although technique is simple and effective, a drawback of this surgical procedure is its potential to cause minor but some times permanent alteration in rectal continence. Conservative approaches (such as topical application of ointment or botulinum toxin injections) have been proposed in order to treat this condition without any risk of permanent injury of the internal anal sphincter. These treatments are effective in a large number of patients. Furthermore, with the ready availability of medical therapies to induce healing of anal fissure, the risk of a first-line surgical approach is difficult to justify. The conservative treatments have a lower cost than surgery. Moreover, evaluation of the actual costs of each therapeutic option is important especially in times of economic crisis and downsizing of health spending.
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Affiliation(s)
- Giuseppe Brisinda
- Department of Surgery, Catholic School of Medicine, University Hospital "Agostino Gemelli", Largo Agostino Gemelli 8, 00168, Rome, Italy
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22
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Bach HH, Wang N, Eberhardt JM. Common anorectal disorders for the intensive care physician. J Intensive Care Med 2013; 29:334-41. [PMID: 23753241 DOI: 10.1177/0885066613485347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although anorectal disorders such as abscess, fissure, and hemorrhoids are typically outpatient problems, they also occur in the critically ill patient population, where their presentation and management are more difficult. This article will provide a brief review of anorectal anatomy, explain the proper anorectal examination, and discuss the current understanding and treatment concepts with regard to the most common anorectal disorders that the intensive care unit clinician is likely to face.
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Affiliation(s)
- Harold H Bach
- Division of Colon and Rectal Surgery, Department of Surgery, Loyola University Medical Center, Maywood, IL, USA Department of Molecular Pharmacology and Therapeutics, Loyola University Medical Center, Maywood, IL, USA
| | - Norby Wang
- Division of Colon and Rectal Surgery, Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Joshua M Eberhardt
- Division of Colon and Rectal Surgery, Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
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23
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Abstract
Anal fissure is one of the most common anorectal problems. Anal fissure is largely associated with high anal sphincter pressures and most treatment options are based on reducing anal pressures. Conservative management, using increased fiber and warm baths, results in healing of approximately half of all anal fissures. In fissures that fail conservative care, various pharmacologic and surgical options offer satisfactory cure rates. Lateral internal sphincterotomy remains the gold standard for definitive management of anal fissure. This review outlines the key points in the presentation, pathophysiology, and management of anal fissure.
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24
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Valizadeh N, Jalaly NY, Hassanzadeh M, Kamani F, Dadvar Z, Azizi S, Salehimarzijarani B. Botulinum toxin injection versus lateral internal sphincterotomy for the treatment of chronic anal fissure: randomized prospective controlled trial. Langenbecks Arch Surg 2012; 397:1093-8. [PMID: 22430300 DOI: 10.1007/s00423-012-0948-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Accepted: 03/06/2012] [Indexed: 12/16/2022]
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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Affiliation(s)
- Neda Valizadeh
- Department of General Surgery, Ayatollah Taleghani Hospital, Shahid Beheshti University of Medical Sciences, PO Box 1545633319, Tehran, Iran
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25
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Abstract
PURPOSE The main purpose of this study was to investigate the efficacy and safety of botulinum toxin in the treatment of anal fissure. An answer was attempted to the following research questions: (i) what is the efficacy of botulinum toxin in healing of anal fissure compared to placebo, (ii) what is the efficacy of botulinum toxin in healing of anal fissure compared to other means of chemical sphincterotomy, (iii) what is the efficacy of botulinum toxin in healing of anal fissure compared to surgical sphincterotomy, (iv) what is the short term safety of botulinum toxin injections and (v) what is the long term safety of botulinum toxin injections. METHODS Clinical trials investigating the effect of botulinum toxin in the treatment of anal fissure met inclusion criteria. Case reports and case series were also included for the estimation of safety. Meta-analysis was not performed due to clinical heterogeneity. RESULTS The comparator could be placebo, nitroglycerin ointment, or lateral internal sphincterotomy, with dosage ranging from 20 IU to 50 IU of botulinum toxin. Fissure healing was the most commonly reported primary endpoint but the time period from botulinum toxin injection to fissure healing ranged from 2 weeks to 4 months. Accordingly, outcome data were also heterogenous. CONCLUSIONS Botulinum toxin injections should be considered a minimally invasive therapeutic option for the treatment of chronic anal fissure. However, well designed randomized trials are needed for the valid estimation of the efficacy and safety of botulinum toxin in this therapeutic indication.
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Wollina U. Pharmacological sphincterotomy for chronic anal fissures by botulinum toxin a. J Cutan Aesthet Surg 2011; 1:58-63. [PMID: 20300345 PMCID: PMC2840903 DOI: 10.4103/0974-2077.44160] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Chronic anal fissure is a common proctologic disease. Botulinum toxin (BTX) can be used for temporary chemical denervation to treat this painful disorder. Its application is by intramuscular injections into either the external or internal anal sphincter muscle. The mode of action, application techniques, and possible complications or adverse effects of BTX therapy are discussed in this report. The healing rate is dependent on the BTX dosage. The short-term healing rate (</= 6 months) is 60-90%, whereas about 50% of the patients show a complete response in long-term follow-up studies (> 1 year). Adverse effects are generally mild, but relapses occur more often than with surgery. Conservative therapy is currently considered as a first-line treatment. With increasing evidence for its efficacy, BTX can now be considered among the first-line nonsurgical treatements. Although, surgical management by lateral sphincterotomy is the most effective treatment, it shows a higher incidence of incontinence and greater general morbidity rate than BTX. BTX is a useful alternative to surgery and in many cases, surgery can be avoided with the use of BTX.
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Affiliation(s)
- Uwe Wollina
- Department of Dermatology and Allergology, Hospital Dresden-Friedrichstadt, Academic Teaching Hospital of the University of Dresden, Friedrichstrasse 41, Dresden, Germany
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27
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Altomare DF, Binda GA, Canuti S, Landolfi V, Trompetto M, Villani RD. The management of patients with primary chronic anal fissure: a position paper. Tech Coloproctol 2011; 15:135-41. [PMID: 21538013 PMCID: PMC3099002 DOI: 10.1007/s10151-011-0683-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2010] [Accepted: 03/15/2011] [Indexed: 12/26/2022]
Abstract
Anal fissure is one of the most common and painful proctologic diseases. Its treatment has long been discussed and several different therapeutic options have been proposed. In the last decades, the understanding of its pathophysiology has led to a progressive reduction of invasive and potentially invalidating treatments in favor of conservative treatment based on anal sphincter muscle relaxation. Despite some systematic reviews and an American position statement, there is ongoing debate about the best treatment for anal fissure. This review is aimed at identifying the best treatment option drawing on evidence-based medicine and on the expert advice of 6 colorectal surgeons with extensive experience in this field in order to produce an Italian position statement for anal fissures. While there is little chance of a cure with conservative behavioral therapy, medical treatment with calcium channel blockers, diltiazem and nifepidine or glyceryl trinitrate, had a considerable success rate ranging from 50 to 90%. Use of 0.4% glyceryl trinitrate in standardized fashion seems to have the best results despite a higher percentage of headache, while the use of botulinum toxin had inconsistent results. Nonresponding patients should undergo lateral internal sphincterotomy. The risk of incontinence after this procedure seems to have been overemphasized in the past. Only a carefully selected group of patients, without anal hypertonia, could benefit from anoplasty.
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Affiliation(s)
- D F Altomare
- Department of Emergency and Organ Transplantation, University Aldo Moro, Policlinico, piazza G Cesare 11, 70124, Bari, Italy.
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Botulinum toxin injection versus lateral internal sphincterotomy in the treatment of chronic anal fissure: a randomized controlled trial. World J Surg 2011; 34:2730-4. [PMID: 20703472 DOI: 10.1007/s00268-010-0736-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although lateral internal sphincterotomy has been the gold standard of treatment for chronic anal fissure, the main concern remains its effects on anal continence. Intrasphincteric injection of botulinum toxin seems to be a reliable option providing temporary alleviation of sphincter spasm and allowing the fissure to heal. The aim of the present prospective controlled randomized study was to compare the outcome of lateral internal sphincterotomy and botulinum toxin injection treatments in patients with uncomplicated chronic anal fissure. METHODS Eighty consecutive patients with uncomplicated chronic anal fissure who had failed conservative treatment were randomized to receive either intrasphincteric injection of botulinum toxin (BT) or lateral internal sphincterotomy (LIS). Postoperative pain relief, healing of fissure, continence scores, and fissure relapse during 18 weeks of follow-up were the outcomes assessed. RESULTS There was a statistically significantly higher healing in the LIS group than the BT group (p = 0.0086 and 95% CI = 7.38-45.69%). In addition, LIS was associated with a high rate of anal incontinence as compared to BT (p = 0.0338 and 95% CI = -1.64-27.53%). The recurrence rate in the BT group was significantly higher statistically than that in the LIS group (p = 0.0111 and 95% CI = 6.68-46.13%). CONCLUSIONS Surgical internal sphincterotomy has a higher healing rate and a lower recurrence rate than intrasphincteric injection of botulinum toxin in the treatment of uncomplicated chronic anal fissure. Injection of botulinum toxin, however, is a simple noninvasive technique that avoids the greater risk of incontinence. It could be used as the first therapeutic approach in patients without clinical risk factors of recurrence.
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Lateral internal sphincterotomy for chronic idiopathic anal fissure: an alternative approach. J Gastrointest Surg 2011; 15:466-70. [PMID: 21207181 DOI: 10.1007/s11605-010-1407-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Accepted: 12/08/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND An alternative approach to lateral internal sphincterotomy in the management of chronic anal fissure is presented and its potential advantages are described. METHODS Using the conventional diathermy, the internal sphincter along with its overlying anoderm is cut to the caudal border of the dentate line. RESULTS This prospective study included 350 patients. Twenty-six patients (7.4%) reported spotting of blood with defecation and 266 patients (76%) reported minimal perianal discharge. The cessation of the discharge and spotting of blood correlated with the complete healing of the sphincterotomy wound. Urine retention requiring temporary catheterization was encountered in 19 patients (5.4%). Neither abscesses nor fistulae were encountered. Cure was achieved in all patients. Neither recurrences nor permanent fecal incontinence were encountered throughout the study period. CONCLUSION The alternative approach is efficient and safe and may be added to the surgeon's armamentarium when attempting lateral internal sphincterotomy for chronic anal fissure.
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Screening for the effectiveness of conservative treatment in chronic anal fissure patients using anorectal manometry. Int J Colorectal Dis 2010; 25:649-54. [PMID: 20127340 DOI: 10.1007/s00384-010-0885-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2010] [Indexed: 02/04/2023]
Abstract
PURPOSE Chemical sphincterotomy (CS) is routinely applied in order to avoid the irreversible anal incontinence associated with the surgical treatment of chronic anal fissure (CAF). However, CS has a lower cure rate than surgery. We developed a screening test (using anal manometry) to separate those patients that are unlikely to benefit from CS and should undergo a more aggressive treatment. METHODS Changes in pressure both at rest and during voluntary contraction of the anal sphincter in 187 patients with chronic anal fissure and 25 healthy subjects (control group) of both sexes were measured. Patients were then sequentially treated (1:1:1) with botulin toxin injections (TOX) (n = 63) or ointments of either nitroglycerine (NTG) (n = 65) or diltiazem (DTZ) (n = 59) for 2 months. The cure rate (overall and for each treatment group) and its relationship with changes in anal pressure were determined. RESULTS The overall cure rate was 53% (NTG = 54%, DTZ = 53% and TOX = 51%). Healing was not related to differences in resting or voluntary contraction pressure. However, the probability of healing was associated with an increase in the percentage change between resting and squeeze pressure (PI index) higher than 150% (190 +/- 122), similar to that of the control subjects (200 +/- 115). Failure of CS was observed in patients with a lower PI (114 +/- 77). CONCLUSIONS The ratio resting/voluntary contraction pressure may be predictive of healing in CAF, thus allowing the selection of patients at high risk of failure of conservative treatment.
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Ballester C, Sarriá B, García-Granero E, Mata M, Milara J, Morcillo EJ, Lledó S, Cortijo J. Relaxation by beta 3-adrenoceptor agonists of the isolated human internal anal sphincter. Life Sci 2010; 86:358-64. [PMID: 20093127 DOI: 10.1016/j.lfs.2010.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Revised: 12/22/2009] [Accepted: 01/12/2010] [Indexed: 11/27/2022]
Abstract
AIMS In this study, responses of beta(3)-adrenoceptor agonists were examined on human isolated internal anal sphincter (IAS) in order to explore their relaxant effects on hypertonicity of IAS. MAIN METHODS The relaxant efficacy (E(max)) and potency (-logIC(50)) of BRL37344 and SR58611A, beta(3)-adrenoceptor agonists, were examined in contracted IAS muscle strips. The presence of beta(3)-adrenoceptors, and changes in intracellular calcium and cyclic nucleotide levels in IAS muscle were tested by Western blotting, epifluorescence microscopy and enzyme immunoassay, respectively. KEY FINDINGS BRL37344 and SR58611A relaxed contracted IAS muscle (E(max)=27+/-3% and 35+/-3%; -logIC(50)=6.26+/-0.24 and 4.87+/-0.13; respectively). These relaxant responses were blocked by SR59230A, a selective beta(3)-antagonist but not by beta(1)/beta(2)-selective antagonists, neuronal inhibitor or inhibition of nitric oxide synthase. The E(max) of beta(3)-agonists was similar to that of beta(2)-selective agonists but smaller than that of isoprenaline (nonselective agonist) or beta(1)-selective agonists. BRL37344 (100 microM) increased cAMP (1.5-fold) without cGMP change, and depressed intracellular calcium signal. beta(3)-Adrenoceptor expression was smaller than that of beta(1)- and beta(2)-adrenoceptors. SIGNIFICANCE This is the first study demonstrating the presence of beta(3)-adrenoceptor in human IAS muscle and beta(3)-mediated relaxation of augmented sphincter tone. However, direct beta(3)-relaxation appears smaller than that obtained for nonselective agonists which may limit their potential use in the treatment of anorectal hypertonicity disorders.
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Adler CH. Perioperative use of botulinum toxins. Toxicon 2009; 54:654-7. [DOI: 10.1016/j.toxicon.2008.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Accepted: 11/28/2008] [Indexed: 11/28/2022]
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Singh B, Box B, Lindsey I, George B, Mortensen N, Cunningham C. Botulinum toxin reduces anal spasm but has no effect on pain after haemorrhoidectomy. Colorectal Dis 2009; 11:203-7. [PMID: 18462246 DOI: 10.1111/j.1463-1318.2008.01549.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Pain following haemorrhoidectomy is due to a combination of factors including spasm of the internal sphincter, an open wound and local infection. In this study, we investigated the effect of botulinum toxin on postoperative pain following Milligan-Morgan haemorrhoidectomy. METHOD A prospective randomized controlled trial was conducted in 32 patients undergoing haemorrhoidectomy. Routine postoperative care included metronidazole and bupivacaine. Patients were also given an inter-sphincteric injection of either placebo or botulinum toxin (150 units). Maximal resting pressure (MRP) and maximal squeeze pressure (MSP) were measured postoperatively. A linear analogue score was used to assess postoperative pain. The sample size calculation was calculated to show one standard deviation difference between groups. The primary endpoint was reduction in postoperative pain. RESULTS The MRP was significantly lower in the botulinum toxin group (mean 50.5 mmHg; 95% CI 39.77-61.23) compared with the placebo group (mean 64.94 mmHg; 95% CI 55.65-74.22) (P = 0.04) at week 6. At week 12 there was no significant difference in MRP between the two groups. In contrast MSP was significantly lower in the botulinum toxin group at weeks 6 and 12 (mean 87.1 mmHg; 95% CI 66.9-107.1) compared with the placebo group (mean 185.8 mmHg; 95% CI 134.2-237.4) at week 12 (P = 0.0014). There was no significant effect on overall or maximal pain scores. Median time for return to normal activities was not significantly different between groups. CONCLUSION Botulinum toxin reduces anal spasm but has no significant effect on postoperative pain.
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Affiliation(s)
- B Singh
- Nuffield Department of Surgery, John Radcliffe Hospital, Headington, Oxford, UK
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Abstract
Hemorrhoids and anal fissures are common benign anorectal conditions that form a significant part of a colorectal surgeon's workload. This review summarizes and evaluates the current techniques available in their management.
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Affiliation(s)
- Peter S Chong
- Department of Colorectal Surgery, Western General Hospital, Edinburgh EH4 2XU, UK.
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Medhi B, Rao RS, Prakash A, Prakash O, Kaman L, Pandhi P. Recent Advances in the Pharmacotherapy of Chronic Anal Fissure: An Update. Asian J Surg 2008; 31:154-63. [DOI: 10.1016/s1015-9584(08)60078-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Brisinda G, Cadeddu F, Brandara F, Marniga G, Vanella S, Nigro C, Maria G. Botulinum toxin for recurrent anal fissure following lateral internal sphincterotomy. Br J Surg 2008; 95:774-8. [PMID: 18425796 DOI: 10.1002/bjs.6080] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The aim of the study was to evaluate the efficacy of botulinum toxin injection in the treatment of recurrent anal fissure following lateral internal sphincterotomy. METHODS Eighty patients were treated with botulinum toxin (30 units Botox or 90 units Dysport), injected into two sites of the internal sphincter. Clinical and manometric results were recorded before and after treatment. If symptoms persisted at 2 months, the examiners could decide to re-treat the patient. The same preparation of serotype A of botulinum neurotoxin was used for reinjection. RESULTS One month after injection there was complete healing in 54 patients (68 per cent). Eight patients (10 per cent) reported mild incontinence of flatus that had disappeared spontaneously within 2 months. At 2 months, 59 patients (74 per cent) had a healing scar. After reinjection, 11 of 21 re-treated patients reported mild incontinence to flatus that lasted for a few weeks and resolved spontaneously. Anorectal manometry at 1 month demonstrated a significant reduction in both resting anal pressure and maximum voluntary squeeze pressure (P < 0.001). There were no relapses during a mean value of 57.9 months of follow-up. CONCLUSION Botulinum toxin is efficacious in patients with recurrent anal fissure following lateral internal sphincterotomy.
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Affiliation(s)
- G Brisinda
- Department of Surgery, Catholic University Hospital Agostino Gemelli, Rome, Italy.
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Baraza W, Boereboom C, Shorthouse A, Brown S. The long-term efficacy of fissurectomy and botulinum toxin injection for chronic anal fissure in females. Dis Colon Rectum 2008; 51:239-43. [PMID: 18175186 DOI: 10.1007/s10350-007-9161-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Revised: 05/29/2007] [Accepted: 08/25/2007] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Healing rates for botulinum toxin injection for anal fissure may be improved if combined with fissurectomy. This procedure has a decreased risk of incontinence, which is particularly important in females. We investigated the long-term efficacy of fissurectomy and botulinum toxin injection for chronic resistant fissures in females. METHODS Female patients who consented underwent excision of the fissure edges and injection of 25-100 units of botulinum into the intersphincteric space. Patients were followed up 2 months after the procedure and over a period of up to 39 months. RESULTS Forty-six patients (mean age, 42 years) were recruited. No patient had incontinence symptoms preoperatively. At a median follow-up period of 11 months, there was a cure rate of 85 percent in 44 patients. After a median follow-up of 22 months, 12 more patients were lost to follow-up. Of the remaining patients, 16 (50 percent) suffered recurrence during the follow-up period. Five patients required further surgical intervention. Three patients suffered chronic perianal infection requiring antibiotic treatment or surgery. There was one case of incontinence at final assessment: the patient complained of urge incontinence, which has persisted for more than 18 months. CONCLUSIONS Fissurectomy and botulinum toxin injection for the treatment of chronic anal fissure in females seems to be effective in the medium-term but there is a high rate of late recurrence. However, only a minority of patients proceed to more invasive surgical intervention, which may make it a useful option in patients not suitable for lateral sphincterotomy.
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Affiliation(s)
- Wal Baraza
- The Northern General Hospital, Sheffield, United Kingdom.
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Brisinda G, Cadeddu F, Mazzeo P, Maria G. Botulinum toxin A for the treatment of chronic anal fissure. Expert Rev Gastroenterol Hepatol 2007; 1:219-28. [PMID: 19072412 DOI: 10.1586/17474124.1.2.219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Since its introduction for the treatment of strabismus, botulinum toxin (BoNT) has been increasingly used in the treatment of several disorders with excessive or inappropriate muscle contractions. The therapeutic effects of BoNT occur through the temporary chemodenervation caused by the injection into the local target muscle or skin. Modulation of muscle relaxation may be achieved by varying the dose of BoNT solution injected; most adverse effects are transient. Indeed, botulinum neurotoxin has been used to selectively weaken the internal anal sphincter as a treatment for chronic anal fissure in several randomized, controlled trials and open-label studies. The use of botulinum neurotoxin seems to be an effective and safe approach for the treatment of chronic anal fissure, particularly in patients at high risk for incontinence.
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Affiliation(s)
- Giuseppe Brisinda
- Department of Surgery, Catholic School of Medicine, University Hospital 'Agostino Gemelli', Largo Agostino Gemelli 8, 00168 Rome, Italy.
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Collins EE, Lund JN. A review of chronic anal fissure management. Tech Coloproctol 2007; 11:209-23. [PMID: 17676270 DOI: 10.1007/s10151-007-0355-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2007] [Accepted: 06/26/2007] [Indexed: 12/14/2022]
Abstract
Anal fissure management has rapidly progressed in the last 15 years as our understanding of fissure pathophysiology has developed. All methods of treatment aim to reduce the anal sphincter spasm associated with chronic anal fissures. Surgical techniques have been used for over 100 years with success. Lateral internal sphincterotomy remains the surgical treatment of choice for many practitioners. Postoperative impairment of continence remains controversial. Recently, less invasive methods of treatment have been explored. Topical nitrates, calcium channel blockers and botulinum toxin are established treatments. These and other non-surgical treatments are described in this review. Various guidelines and treatment algorithms for anal fissure are also discussed.
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Affiliation(s)
- E E Collins
- Department of Surgery, University of Nottingham Medical School, Derby, Derby City General Hospital, Uttoxeter Road, Derby, DE22 3DT, UK.
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Singer M, Cintron J. New techniques in the treatment of common perianal diseases: stapled hemorrhoidopexy, botulinum toxin, and fibrin sealant. Surg Clin North Am 2006; 86:937-67. [PMID: 16905418 DOI: 10.1016/j.suc.2006.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
There have been several recent advances in the treatment of common perianal diseases. Stapled hemorrhoidopexy is a procedure of hemorrhoidal fixation, combining the benefits of rubber band ligation into an operative technique. The treatment of anal fissure has typically relied upon internal sphincterotomy; however, it carries a risk of incontinence. The injection of botulinum toxin represents a new form of sphincter relaxation, without division of any sphincter muscle; morbidity is minimal and results are promising. For the treatment of fistula in a fistulotomy remains the gold standard, however, it carries significant risk of incontinence. Use of fibrin sealant to treat fistulae has been met with variable success. It offers sealing of the tract, and then provides scaffolding for native tissue ingrowth.
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Affiliation(s)
- Marc Singer
- Department of Surgery (MC958), University of Illinois, Clinical Sciences Building, #518-E, 840 S. Wood Street, Chicago, IL 60612, USA
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Katsinelos P, Kountouras J, Paroutoglou G, Beltsis A, Chatzimavroudis G, Zavos C, Katsinelos T, Papaziogas B. Aggressive treatment of acute anal fissure with 0.5% nifedipine ointment prevents its evolution to chronicity. World J Gastroenterol 2006; 12:6203-6. [PMID: 17036396 PMCID: PMC4088118 DOI: 10.3748/wjg.v12.i38.6203] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the efficacy of topical application of 0.5% nifedipine ointment in healing acute anal fissue and preventing its progress to chronicity.
METHODS: Thirty-one patients (10 males, 21 females) with acute anal fissure from September 1999 to January 2005 were treated topically with 0.5% nifedipine ointment (t.i.d.) for 8 wk. The patients were encouraged to follow a high-fiber diet and assessed at 2, 4 and 8 wk post-treatment. The healing of fissure and any side effects were recorded. The patients were subsequently followed up in the outpatient clinic for one year and contacted by phone every three months thereafter, while they were encouraged to come back if symptoms recurred.
RESULTS: Twenty-seven of the 31 patients completed the 8-wk treatment course, of them 23 (85.2%) achieved a complete remission indicated by resolution of symptoms and healing of fissure. Of the remaining four unhealed patients (14.8%), 2 opted to undergo lateral sphincterotomy and the other 2 to continue therapy for four additional weeks, resulting in healing of fissure. All the 25 patients with complete remission had a mean follow-up of 22.9 ± 14 (range 6-52) mo. Recurrence of symptoms occurred in four of these 25 patients (16%) who were successfully treated with an additional 4-wk course of 0.5% nifedipine ointment. Two of the 27 (7.4%) patients who completed the 8-wk treatment presented with moderate headache as a side effect of nifedipine.
CONCLUSION: Topical 0.5% nifedipine ointment, used as an agent in chemical sphincterotomy, appears to offer a significant healing rate for acute anal fissure and might prevent its evolution to chronicity.
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Affiliation(s)
- Panagiotis Katsinelos
- Department of Endoscopy and Motility Unit, Central Hospital, Ethnikis Aminis 41, TK 54635, Thessaloniki, Greece.
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Jones OM, Ramalingam T, Merrie A, Cunningham C, George BD, Mortensen NJM, Lindsey I. Randomized clinical trial of botulinum toxin plus glyceryl trinitrate vs. botulinum toxin alone for medically resistant chronic anal fissure: overall poor healing rates. Dis Colon Rectum 2006; 49:1574-80. [PMID: 16988850 DOI: 10.1007/s10350-006-0679-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to assess whether addition of glyceryl trinitrate to botulinum toxin improves the healing rate of glyceryl trinitrate-resistant fissures over that achieved with botulinum toxin alone. METHODS Patients were randomized between botulinum toxin plus glyceryl trinitrate (Group A) and botulinum toxin plus placebo paste (Group B). Patients were seen at baseline, four and eight weeks, and six months. The primary end point was fissure healing at eight weeks. Secondary end points were symptomatic relief, need for surgery, side effects, and reduction in maximum resting and squeeze pressures. RESULTS Thirty patients were randomized. Two-thirds of patients had maximum anal resting pressures below or within the normal range at entry to the study. Healing rates in both treatment groups were disappointing. There was a nonsignificant trend to better outcomes in Group A compared with Group B in terms of fissure healing (47 vs. 27 percent), symptomatic improvement (87 vs. 67 percent), and resort to surgery (27 vs. 47 percent). CONCLUSIONS There is some evidence to suggest that combining glyceryl trinitrate with botulinum toxin is superior to the use of botulinum toxin alone for glyceryl trinitrate-resistant anal fissure. The poor healing rate may reflect the fact that many of the patients did not have significant anal spasm at trial entry.
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Affiliation(s)
- O M Jones
- Department of Colorectal Surgery, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, United Kingdom
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Rajasundaram R, Ayyathurai R, Narayanan S, Maw A. Botulinum toxin A and chronic anal fissures – a literature review. Eur Surg 2006. [DOI: 10.1007/s10353-006-0268-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Fruehauf H, Fried M, Wegmueller B, Bauerfeind P, Thumshirn M. Efficacy and safety of botulinum toxin a injection compared with topical nitroglycerin ointment for the treatment of chronic anal fissure: a prospective randomized study. Am J Gastroenterol 2006; 101:2107-12. [PMID: 16848808 DOI: 10.1111/j.1572-0241.2006.00722.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To evaluate the efficacy and safety of botulinum toxin A injection compared with topical nitroglycerin ointment for the treatment of chronic anal fissure (CAF). METHODS Fifty outpatients with CAF were randomized to receive either a single botulinum toxin injection (30 IU Botox) or topical nitroglycerin ointment 0.2% b.i.d. for 2 wk. If the initial therapy failed, patients were assigned to the other treatment group for a further 2 wk. If CAF still showed no healing at wk 4, patients received combination therapy of botulinum toxin and nitroglycerin for 4 additional wk. Persisting CAF at wk 8 was treated according to the investigator's decision. Healing rates, symptoms, and side effects of the therapy were recorded at wk 2, 4, 8, 12, and 24 after randomization. RESULTS The group initially treated with nitroglycerin showed a higher healing rate of CAF (13 of 25, 52%) as compared with the botulinum toxin group (6 of 25, 24%) after the first 2 wk of therapy (p < 0.05). At the end of wk 4, CAF healed in three additional patients, all receiving nitroglycerin after initial botulinum toxin injection. Mild side effects occurred in 13 of 50 (26%) patients, all except one were on nitroglycerin. CONCLUSIONS Nitroglycerin ointment was superior to the more expensive and invasive botulinum toxin injection for initial healing of CAF, but was associated with more but mild side effects.
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Affiliation(s)
- Heiko Fruehauf
- Gastroenterology and Hepatology, Department of Internal Medicine, University Hospital Zurich, Raemistrasse, Zurich, Switzerland
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Abstract
BACKGROUND Anal fissure is one of the most common anorectal conditions encountered in clinical practice. Most patients experience anal pain with defecation and minor bright red rectal bleeding, allowing a focused history to direct the evaluation. METHODS A systematic medical literature search of NIH, Pubmed, and MEDLINE using the search terms anal fissure, sphincterotomy, anal surgery and anal fissure medical therapy. English language was not a restriction. Cited references were used to find additional studies. RESULTS No single treatment is the best choice for all patients. Because pharmacological therapy is not associated with permanent alterations in continence, a trial of either a topical sphincter relaxant or botulin toxin injection, along with adequate fluid and fibre intake, is a reasonable option. However, because pharmacological therapy has lower healing and higher relapse rates, surgery can be offered in the first instance to patients without incontinence risk factors who have severe, unrelenting pain and are willing to accept a small risk of incontinence, for the highest likelihood of prompt healing and the lowest risk of recurrence. CONCLUSIONS Both non-operative and operative approaches currently exist for the management of anal fissure. Improved non-surgical therapies may continue to lessen the role of sphincter-dividing surgery in future.
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Affiliation(s)
- S R Steele
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA, USA
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Daniel F, de Parades V, Siproudhis L, Atienza P. Toxine botulique et fissure anale chronique. ACTA ACUST UNITED AC 2006; 30:687-95. [PMID: 16801892 DOI: 10.1016/s0399-8320(06)73262-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Lateral internal sphincterotomy is widely used in the treatment of chronic anal fissure. However, it is associated with a high rate of irreversible incontinence. For this reason the botulinum toxin has become a medical means of reversible sphincterotomy. Indeed, this neurotoxin induces relaxation of the smooth internal anal sphincter lasting one to three months after one injection. We reviewed the published studies about the use of this technique in the management of chronic anal fissure. Healing occurred in more than 70% of fissures without irreversible incontinence. Although further studies are needed to determine the best modalities of administration, especially due to the remaining significant recurrence rate, this toxin may be a valuable treatment for chronic anal fissure in the future.
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Affiliation(s)
- Fady Daniel
- Service de Proctologie Médico-Interventionnelle, Groupe hospitalier Diaconesses, Croix Saint Simon, Paris
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47
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De Nardi P, Ortolano E, Radaelli G, Staudacher C. Comparison of glycerine trinitrate and botulinum toxin-a for the treatment of chronic anal fissure: long-term results. Dis Colon Rectum 2006; 49:427-32. [PMID: 16456637 DOI: 10.1007/s10350-005-0287-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to compare the efficacy of two different "chemical sphincterotomies" for chronic anal fissure. METHODS From January to December 2001, 30 consecutive patients (17 males; mean age, 41.8 years) with chronic posterior anal fissure were enrolled. The patients were randomly assigned to receive 0.2 percent glycerine trinitrate ointment applied three times daily at the anal margin for eight weeks (Group A) or 20 units Botulinum toxin A injection into the internal anal sphincter on each side of the anterior midline (Group B). The patients were reviewed at 15 days, 1, 3, 6, 12, and every other 12 months. Follow-up ranged between 36 and 46 months. Patients in either group who failed to improve were referred for surgical treatment. RESULTS Twelve patients in Group A and 11 in Group B had improvement or relief from symptoms at the first visit. The fissure was healed in ten patients in Group A and in eight in Group B within three months (66.7 and 57.1 percent). Recurrence of the fissure occurred in five patients in each group during the follow-up. The healing rate at three years was 40 and 33.3 percent for Group A and B, respectively. No patients in either group reported serious adverse effects; however, three patients in Group A (20 percent) had transient headache. None had fecal incontinence. CONCLUSION Both treatments may be considered as first-line treatment even if less effective than surgery.
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Affiliation(s)
- Paola De Nardi
- Scientific Institute S. Raffaele Hospital, University Vita-Salute S. Raffaele, Milan, Italy.
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Sánchez Romero AM, Arroyo Sebastián A, Pérez Vicente FA, Serrano Paz P, Candela Polo F, Calpena Rico R. Tratamiento de la proctalgia fugax con toxina botulínica: resultados en 5 pacientes. Rev Clin Esp 2006; 206:137-40. [PMID: 16597379 DOI: 10.1157/13086207] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Proctalgia fugax can be defined as transitory but recurrent anal pain. Although its etiology remains unknown, an internal anal sphincter spasm seems to be the most likely, so that the different treatments focus on reducing the pressure of the internal anal sphincter. This study is aimed at evaluating the effectiveness of botulinum A toxin in the treatment of proctalgia fugax. PATIENTS AND METHODS Prospective clinical trial of patients with proctalgia fugax treated with botulinum A toxin at the Outpatient Clinic attached to the Coloproctogy Unit, University Hospital of Elche, from January 1999 to January 2002. The patients included in the study underwent rectal digital examination, anuscopy, rectoscopy, anal manometry and ultrasonography, barium enema and pelvic CT scan to rule out any organic cause for anal pain. The treatment consisted of 25 IU of botulinum A toxin, with a supplementary dose of 50 IU in those patients with persistence of anal pain episodes within the next two months. The patients were reviewed on the first week, second month, sixth month and first and second year. Anal pain was measured by the patients, using a linear analogue scale from 0 to 10, and continence was assessed at every visit using the Cleveland Continence Grading Scale. RESULTS Five patients were recluted for the study, with a predominance of females (4 vs. 1). Mean age was 45 years. Length of symptoms prior to the treatment was 13 months (range: 6-18 months). Only one female patient required a second dose of botulinum A toxin to handle the anal pain. All the patients healed and remained free of pain up to finishing the follow-up. There were no local complications. Anal manometry showed an increased MRP (mean resting pressure) in comparison to a control group of patients (114 mmHg vs. 66 mmHg; p < 0.001) that restore to normal values after the treatment (75.65 mmHg). As for the MSP (mean squeeze pressure), it showed no difference with respect to the control group nor did it vary after the treatment. CONCLUSION Botulinum A toxin offers a high rate of healing with no associate morbidity in the treatment of proctalgia fugax.
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Katsinelos P, Papaziogas B, Koutelidakis I, Paroutoglou G, Dimiropoulos S, Souparis A, Atmatzidis K. Topical 0.5% nifedipine vs. lateral internal sphincterotomy for the treatment of chronic anal fissure: long-term follow-up. Int J Colorectal Dis 2006; 21:179-83. [PMID: 16091912 DOI: 10.1007/s00384-005-0766-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2005] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this study was to compare the efficacy of the local application of 0.5% nifedipine ointment vs. lateral internal sphincterotomy in the healing of chronic anal fissure. PATIENTS AND METHODS Sixty-four patients with symptomatic chronic anal fissures were randomly assigned to 0.5% nifedipine ointment (n=32) every 8 h for 8 weeks or lateral internal sphincterotomy (n=32). Both groups received stool softeners and fiber supplements and were assessed at 2, 4, 6, and 8 weeks. Long-term outcomes were determined after a median follow-up of 19 months (nifedipine group) and 20.5 months (lateral internal sphincterotomy group). RESULTS Complete healing at 8 weeks was achieved in 30 out of 31 patients (96.7%) in the nifedipine group and 32 out of 32 patients (100%) in the lateral internal sphincterotomy group (p=0.49). The overall healing rates at the end of follow-up were 28 out of 30 (93%) vs. 32 out of 32 (100%) in the nifedipine and sphincterotomy groups respectively (p=0.48). Two of the 30 patients in the nifedipine group relapsed whereas none in the sphincterotomy group did. Sixteen patients (50%) developed side effects in the nifedipine group, compared with six patients (18.7%) in the sphincterotomy group. CONCLUSIONS Topical application of 0.5% nifedipine ointment represents a new, promising, easily handled, effective alternative to lateral internal sphincterotomy.
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Affiliation(s)
- Panagiotis Katsinelos
- Department of Endoscopy and Motility Unit, Central Hospital, Ethnikis Aminis 41, 54635 Thessaloniki, Greece.
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Acheson AG, Scholefield JH. Pharmacological advancements in the treatment of chronic anal fissure. Expert Opin Pharmacother 2005; 6:2475-81. [PMID: 16259578 DOI: 10.1517/14656566.6.14.2475] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Chronic anal fissure is a tear in the lining of the anal canal that, if not treated appropriately at an early stage, causes considerable anal pain during defaecation. Surgery is no longer considered the first-line treatment of this common condition, as recent advancements in medical treatment has produced promising results in the healing of fissures, thus avoiding the unwanted complications that frequently occur following operative treatment. This review looks at those pharmacological agents used commonly in the treatment of chronic anal fissures and explores alternative therapies that may be of benefit in the future.
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Affiliation(s)
- Austin G Acheson
- Division of Gastrointestinal Surgery, Queen's Medical Centre, Nottingham, NG7 2UH, UK.
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