Botulinum Toxin A Injection in ISDN Ointment-Resistant Chronic Anal Fissures

Abstract

Background: In the treatment of chronic anal fissures (CAFs), surgical sphincterotomy is more commonly being replaced by chemical sphincterotomy. After the good results of our pilot study including 32 patients, we now describe the effect of botulinum toxin A (BT-A) in a consecutive series of 100 patients with isosorbide dinitrate (ISDN) ointment-resistant CAFs. Methods: From October 2002 until August 2005, 100 patients (52 males, 48 females) with a median age of 45 (20–79) years were treated with an injection of 40–100 IU BT-A (Dysport®, Ipsen, The Netherlands) in the internal anal sphincter. Results: After a median follow-up of 10 (4–38) months, 77 of the 100 CAFs (77%) were cured. 20 patients were given a second injection, 1 a third and 1 a fourth injection. In 11 patients a fissure recurred (14%). In 1 patient (1%) there was temporary incontinence due to flatus. Conclusion: With an early response rate of 77% and an overall success rate of 66%, BT-A injections appear to be effective in patients with ISDN ointment-resistant CAFs if initial non-responders are retreated. These results are in concordance with the results of our pilot study. It is a simple technique with little or no side effects, that does not compromise future treatments. Its place in the first-line treatment of CAFs should be investigated further.

Botulinum Toxin Injection for Treatment of Chronic Anal Fissure: Is There Any Dose‐Dependent Efficiency? A Meta‐Analysis

“…Although the exact pathogenesis of anal fissure is still unclear, based on recent studies, a local ischemia seems to play a crucial role in the pathogenesis. The increased resting anal tone of internal sphincter muscle influences prolonged compression of anodermal arteries passing through the muscle, resulting in local ischemia [3, 4]. …”

Conservative and Surgical Treatment of Chronic Anal Fissure: Prospective Longer Term Results

“…47 Almost 4% of the patients discontinued the therapy and were switched to DIL. GTN therapy was discontinued because of headache (four patients) and pruritus ani (three patients).…”

“…When the DIL is heated, the relaxing effect is enhanced. 45 Short-term healing rates are reported as high as 95% when used in combination with GTN, [46][47][48][49] with about 10% reduction after 2 years follow-up. Recently, Schiano et al reported healing rates of 75% with DIL only and 93.7% with combined GTN/DIL treatment.…”

Fissurectomy combined with botulinum toxin A injection for medically resistant chronic anal fissures

“…In an earlier study, we found that the effect of botulinum toxin A injections was higher if initial nonresponders were retreated [1]. Therefore, all patients included in this study had undergone at least one botulinum toxin A injection; 11 patients had an injection of 60IE (0.3 ml) and 10 patients received 80IE (0.4 ml) as a first injection dosage.…”

“…Therefore, all patients included in this study had undergone at least one botulinum toxin A injection; 11 patients had an injection of 60IE (0.3 ml) and 10 patients received 80IE (0.4 ml) as a first injection dosage. The different first injection dosage of Dysport used was a result of changing our treatment policy from 60IE to 80IE Dysport in the latter years because even with this higher dosage, no continence problems were experienced [1]. Eight patients had received a second injection with 80IE and one patient four injections (each 80IE) before enrolling in this study.…”