Treating chronic anal fissure with botulinum neurotoxin

Endoscopic Ultrasound-Guided Botox Injection for Refractory Anal Fissure

Background: Anal fissures cause severe pain and can be difficult to treat. Medical therapy is initially used, followed by sigmoidoscopy-guided botox injections if the medical therapy is not successful. With this technique, however, it is not clear whether botox is injected into the muscle layer or submucosa. Aim: To evaluate the efficacy of EUS-guided botox injection directly into the internal sphincter. Methods: Consecutive patients with chronic anal fissure refractory to conventional endoscopic botulinum toxin type A injection were enrolled in the study. EUS was performed using a linear array echoendoscope, and a 25 G needle was used to inject botox. All patients were followed up at one- and two-month intervals. Results: Eight patients with chronic anal fissures were included in the study. Six patients had an excellent response to botox at the two-month interval using a visual analog pain scale, while one patient had a moderate response with a pain score reduction of 40%. One patient had no response. No complications were noted. An improvement in visual analog scale (pre-score > post-score) was statistically significant at the p < 0.01 level. Conclusion: EUS-guided botox injection into the internal sphincter appears to be a promising technique for patients with refractory anal fissure with pain.

Gastrointestinal Uses of Botulinum Toxin

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.

Comparison of topical nifedipine with oral nifedipine for treatment of anal fissure: a randomized controlled trial

Background:

Medical sphincterotomy has gained popularity as a treatment for anal fissure. Calcium channel blockers in topical forms could also be appropriate with low adverse effects.

Objectives:

This was a prospective randomized controlled trial to compare topical and oral nifedipine in the treatment of chronic anal fissure.

Patients and Methods:

A prospective randomized controlled trial was conducted at two centers of Shahed University. One hundred and thirty patients with chronic anal fissure aged 18 to 60 years managed in our clinics were included in this study. The patients were randomly divided into two groups. Sixty-five patients received topical nifedipine (TN) and the same number received oral nifedipine (ON).

Results:

Ulcer healing occurred in 43 (73.33%) of topical nifedipine group compared to 29 (49.5%) patients in oral nifedipine, which was significantly different (P < 0.05). Side effects such as headache and flushing in oral nifedipine group were more prevalent than topical nifedipine, which was statistically different. Recurrence rates were the same after six months of follow-up.

Conclusions:

Although oral nifedipine can reduce symptom and signs of anal fissure, topical nifedipine has a superior role for anal fissure treatment with higher healing rate and lower side effects.

Cost considerations in the treatment of anal fissures

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.

Anal fissure and stenosis

Anal fissure is a common anorectal disorder resulting in anal pain and bleeding. Fissures can either heal spontaneously and be classified as acute, or persist for 6 or more weeks and be classified as chronic, ultimately necessitating treatment. Anal stenosis is a challenging problem most commonly resulting from trauma, such as excisional hemorrhoidectomy. This frustrating issue for the patient is equally as challenging to the surgeon. This article reviews these 2 anorectal disorders, covering their etiology, mechanism of disease, diagnosis, and algorithm of management.

Choice of treatments for anal fissure

Chronic anal fissure (CAF) is one of the most common and painful proctologic diseases. Its treatment has long been discussed and several different therapeutic options have been proposed. The understanding of its pathophysiology has led to a progressive reduction of invasive and potentially invalidating treatments in favor of conservative treatment. Lateral internal sphincterotomy (LIS) is a surgical treatment that is considered the 'gold standard' therapy for CAF. It relieves CAF symptoms with a high rate of healing. The risk of incontinence after this procedure seems to be severe. Chemical sphincterotomy (CS) is safe, with the rapid relief of pain, no risk of surgery or anesthesia, but is a statistically less effective therapy for CAF than LIS. In recent years, fissurectomy coupled with CS has been demonstrated to be a satisfactory treatment for chronic anal fissure and an alternative to lateral sphincterotomy when conservative measures fail.

Segmental internal sphincterotomy--a new technique for treatment of chronic anal fissure

OBJECTIVE

Lateral internal sphincterotomy is an effective treatment for fissure in ano but carries a definite risk of incontinence. In trial to avoid this complication, segmental lateral internal sphincterotomy was used to treat chronic anal fissures.

DESIGN

The lateral internal sphincterotomy was done in two parts and at different planes.

SETTING

This study was conducted in the General Surgery Department, Zagazig University Hospital, Egypt.

PATIENTS

This study was undertaken on 50 patients (43 men and seven women, with mean age of 37.3 years) with chronic fissure in ano from January 2009 to December 2010.

INTERVENTIONS

Under general or local anesthesia, lateral internal sphincterotomy was done in two segments under direct vision. Preoperative and postoperative anal manometry study was recorded.

MAIN OUTCOME MEASURES

Postoperative course with early and long-term results were recorded. Mean follow-up was 18.5 months (ranging from 6 to 24 months).

RESULTS

In 31 patients, the technique was done under general anesthesia and the remainder under local anesthesia. The fissures and anal wounds were healed within 4 weeks. Pain was significantly reduced in all patients at day 1 postoperative. Early complications included mild hematoma and urine retention in one male patient (2%). No transient or any persistent degree of incontinence occurred in these patients group.

CONCLUSION

Segmental lateral internal sphincterotomy is a safe, easy, and effective procedure and not associated with risk of incontinence for the treatment of chronic anal fissure.

Identifying the best therapy for chronic anal fissure

Chronic anal fissure (CAF) is a painful tear or crack which occurs in the anoderm. The optimal algorithm of therapy for CAF is still debated. Lateral internal sphincterotomy (LIS) is a surgical treatment, considered as the ‘gold standard’ therapy for CAF. It relieves CAF symptoms with a high rate of healing. Chemical sphincterotomy (CS) with nitrates, calcium blockers or botulinum toxin (BTX) is safe, with the rapid relief of pain, mild side-effects and no risk of surgery or anesthesia, but is a statistically less effective therapy for CAF than LIS. This article considers if aggressive treatment should only be offered to patients who fail pharmacological sphincterotomy. Aspects of anal fissure etiology, epidemiology and pathophysiology are considered with their meaning for further management of CAF. A molecular model of chemical interdependence significant for the chemistry of CAF healing is examined. Its application may influence the development of optimal therapy for CAF. BTX is currently considered the most effective type of CS and discussion in this article scrutinizes this method specifically. Although the effectiveness of BTX vs. LIS has been discussed, the essential focus of the article concerns identifying the best therapy application for anal fissure. Elements are presented which may help us to predict CAF healing. They provide rationale for the expansion of the CAF therapy algorithm. Ethical and economic factors are also considered in brief. As long as the patient is willing to accept the potential risk of fecal incontinence, we have grounds for the ‘gold standard’ (LIS) as the first-line treatment for CAF. We conclude that, when the diagnosis of the anal fissure is established, CS should be considered for both ethical and economic reasons. The author is convinced that a greater understanding and recognition of benign anal disorders by the GP and a proactive involvement at the point of initial diagnosis would facilitate the consideration of CS at an earlier, more practical stage with improved outcomes for the patient.

Botulinum toxin for recurrent anal fissure following lateral internal sphincterotomy

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.

Long-term follow-up after combined fissurectomy and Botox injection for chronic anal fissures

BACKGROUND AND AIMS

Chronic anal fissures are difficult to treat. The aim of this retrospective study was to determine the outcome of combined fissurectomy and injection of botulinum toxin Type A (BT).

MATERIALS AND METHODS

Between January 2001 and August 2004, 40 patients (21 women), median age 37 years (range 18 to 57), underwent fissurectomy and BT injection. Fissurectomy was performed followed by injection of 10 U of BT into the internal anal sphincter on both sides of the fissure. All patients were clinically checked 6 weeks after the operation. At 1 year, patients were sent a detailed questionnaire regarding symptoms, recurrence and further treatment for evaluation of long-term results.

RESULTS/FINDINGS

At 6 weeks, 38 patients (95%) were free of symptoms. No adverse effects were detected. The response rate of questionnaires was 93%; the median follow-up was 1 year (range 0.9 to 1.6). In the long-term, a recurrence was found in four patients. These patients were treated successfully with repeated fissurectomy and BT injections and salvage procedures, respectively. Overall, the success rate of combined fissurectomy and BT injection was 79%.

INTERPRETATION/CONCLUSION

Combined fissurectomy and Botox injection for chronic anal fissure is an excellent and safe procedure with low morbidity and a high healing rate.

Randomized clinical trial comparing botulinum toxin injections with 0.2 per cent nitroglycerin ointment for chronic anal fissure

BACKGROUND

In recent years treatment of chronic anal fissure has shifted from surgical to medical. This study compared the ability of two non-surgical treatments-botulinum toxin injections and nitroglycerin ointment-to induce healing in patients with idiopathic anal fissure.

METHODS

One hundred adults were assigned randomly to receive treatment with either type A botulinum toxin (30 units Botox or 90 units Dysport) injected into the internal anal sphincter or 0.2 per cent nitroglycerin ointment applied three times daily for 8 weeks.

RESULTS

After 2 months, the fissures were healed in 46 (92 per cent) of 50 patients in the botulinum toxin group and in 35 (70 per cent) of 50 in the nitroglycerin group (P=0.009). Three patients in the botulinum toxin group and 17 in the nitroglycerin group reported adverse effects (P<0.001). Those treated with botulinum toxin had mild incontinence to flatus that lasted 3 weeks after treatment but disappeared spontaneously, whereas nitroglycerin treatment was associated with transient, moderate-to-severe headaches. Nineteen patients who did not have a response to the assigned treatment crossed over to the other therapy.

CONCLUSION

Although treatment with either topical nitroglycerin or botulinum toxin is effective as an alternative to surgery for patients with chronic anal fissure, botulinum toxin is the more effective option.

Why the most potent toxin may heal anal fissure

An anal fissure is a painful linear ulcer in the lower part of the anal canal. It is very often referred to as an ischemic ulcer. Anodermal blood flow is negatively correlated with resting pressure of the anus. Increased activity of the internal anal sphincter may decrease the anodermal blood supply by compressing arterioles. Surgical procedures and botulinum treatment for patients with chronic anal fissure produce a temporary reduction in anal pressure, reverse sphincter spasm, and promote fissure healing. However, recent studies have shown that fissure healing does not appear to be dependent on reduction in mean resting anal pressure. On the basis of the published literature, this article attempts to explain this phenomenon in detail. The mechanism of action of botulinum toxin on the internal anal sphincter is not yet fully understood. This review focuses on problems associated with anal fissure treatment and presents them from the wider angle of science about botulinum toxin. In our opinion, anodermal blood flow depends not only on the "mechanical" force of sphincters but also on biochemical processes that occur in the fissure region.