Botulinum toxin associated with fissurectomy and anoplasty for hypertonic chronic anal fissure: A case-control study

Abstract

BACKGROUND Lateral internal sphincterotomy is still the approach of choice for the treatment of chronic anal fissure (CAF) with internal anal sphincter (IAS) hypertonia, but it is burdened by high-risk postoperative faecal incontinence (FI). Sphincter saving procedures have recently been reconsidered as treatments to overcome this risk. The most employed procedure is fissurectomy with anoplasty, eventually associated with pharmacological sphincterotomy. AIM To evaluate whether fissurectomy and anoplasty with botulinum toxin injection improves the results of fissurectomy and anoplasty alone. METHODS We conducted a case-control study involving 30 male patients affected by CAF with hypertonic IAS who underwent fissurectomy and anoplasty with V-Y cutaneous flap advancement. The patients were divided into two groups: Those in group I underwent surgery alone, and those in group II underwent surgery and a botulinum toxin injection directly into the IAS. They were followed up for at least 2 years. The goals were to achieve complete healing of the patient and to assess the FI and recurrence rate along with manometry parameters. RESULTS The intensity and duration of post-defecatory pain decreased significantly in both groups of patients starting with the first defecation, and this reduction was higher in group II. Forty days after surgery, we achieved complete wound healing in all the patients in group II but only in 80% of the patients in group I ( P < 0.032). We recorded 2 cases of recurrence, one in each group, and both healed with conservative therapy. We recorded one temporary and low-grade postoperative case of “ de novo ” FI. Manometry parameters reverted to the normal range earlier for group II patients. CONCLUSION The injection of botulinum toxin A in association with fissurectomy and anoplasty with a V-Y advancement flap improves the results of surgery alone in patients affected by CAF with IAS hypertonia.

The Association of Coloproctology of Great Britain and Ireland guideline on the management of anal fissure

“…Analysis of the literature revealed three different types of advancement flap; mucosal, anocutaneous and island flap. There are two systematic reviews [41, 42] and one additional cohort study on this topic [43]. The Sahebally review compared the efficacy of anal advancement flap with lateral internal sphincterotomy in patients with a chronic anal fissure.…”

“…The additional cohort study is included in this recommendation as it was specific to the recommendation. Analysis of a cohort with normotensive sphincter pressure and pre-existing incontinence was included [43]. All patients underwent an advancement flap, but a hypertonic sphincter cohort also had 30 U Botox injected.…”