Fisurectomy and anoplasty with botulinum toxin injection in patients with chronic anal posterior fissure with hypertonia: a long-term evaluation

Abstract

Chronic anal fissure's (CAF) etiopathogenesis remain unclear. CAF of the posterior commissure (CAPF) are often characterized by internal anal sphincter (IAS) hypertonia. The treatment of this disease aimed to reduce IAS hypertonia. Due to the high rate of anal incontinence after LIS, the employment of sphincter preserving surgical techniques associated to pharmacological sphincterotomy appears more sensible. The aim of our study is to evaluate the long-term results of fissurectomy and anoplasty with V-Y cutaneous flap advancement associated to 30 UI of botulinum toxin injection for CAPF with IAS hypertonia. We enrolled 45 patients undergone to fissurectomy and anoplasty with V-Y cutaneous flap advancement and 30 UI botulinum toxin injection. All patients were followed up for at least 5 years after the surgical procedure, with evaluation of anal continence, recurrence rate and MRP (Maximum resting pressure), MSP (Maximum restricting pressure), USWA (Ultrasound wave activity). All patients healed within 40 days after surgery. We observed 3 "de novo" post-operative anal incontinence cases, temporary and minor; the pre-operative ones have only temporary worsened after surgery. We reported 3 cases of recurrences, within 2 years from surgery, all healed after conservative medical therapy. At 5 year follow-up postoperative manometric findings were similar to those of healthy subjects. At 5 years after the surgical procedure, we achieved good results, and these evidences show that surgical section of the IAS is not at all necessary for the healing process of the CAPF.

Safety and effectiveness of saving sphincter procedure in the treatment of chronic anal fissure in female patients

“…In fact, as for female patients a sphincter saving procedure appears mandatory given the higher risk of FI; these latter aim to perform a fissurectomy along with a wound debridement, removing the bradytrophic scar tissue, producing a fresh wound edges and finally creating an acute fissure. The subsequent employ of a flap to cover up for the naked area is designed to relocate on this area healthy and fresh blood supplied tissue, perfused by other arterial district [14].…”

“…The patients with hypertonic IAS were treated with intraoperative local injection of 30 U.I. of botulinum toxin A (Botox, Allergan Westport, Ireland) [14] or with local administration of post-operative nifedipine and lidocaine for 15 days after surgery (Antrolin ® ) [15]. Before surgery, all patients received a small volume of phosphate-saline enema.…”

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

“…Once fissurectomy was performed, patients in group II underwent a local injection of 30 UI of BT (Botox, Allergan Westport, Ireland)[ 11 ] directly into the IAS. Each patient received a total of 30 UI of BT: 15 UI injected at 3 h in gynaecological position and 15 UI injected at 9 h. None of the patients were taking concomitant oral medication that could interfere with the action of BT ( e.g.…”

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anal Fissures

“…66,82 A study of 45 patients treated with a combination of fissurectomy, V-Y cutaneous advancement flap, and botulinum toxin injection demonstrated resolution of pain by postoperative day 40, 7% recurrence rate at 5 years, and 7% rate of minor temporary FI. 83…”

“…66,82 A study of 45 patients treated with a combination of fissurectomy, V-Y cutaneous advancement flap, and botulinum toxin injection demonstrated resolution of pain by postoperative day 40, 7% recurrence rate at 5 years, and 7% rate of minor temporary FI. 83 In a retrospective study comparing the results of 30 consecutive patients who underwent tailored LIS plus V-Y perianal skin flap to 32 patients who previously underwent conventional LIS alone, the tailored LIS plus flap group experienced significantly less postoperative pain (p < 0.001), faster healing (80% vs 40% healed at 2 weeks; p < 0.01 with all healed at 3 months), and low rates of flatus incontinence (6.6% vs 28.1%; p < 0.05). 84 Lastly, a randomized study of 150 consecutive patients who underwent LIS (n = 50), V-Y advancement flap (n = 50), or combined LIS with V-Y advancement flap (n = 50) and who were followed for 1 year found healing rates were 84%, 48%, and 94% (p = 0.001), recurrence rates were 4%, 22%, and 2% (p = 0.01), and FI rates were 14%, 0%, and 2% (p = 0.03), respectively, suggesting that the addition of the flap may improve healing rates and possibly even mitigate rates of FI.…”