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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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Abstract
ZusammenfassungDie Analfissur ist eine der häufigsten Pathologien, welche sich dem Proktologen präsentiert. Entsprechend ist es wichtig, verlässliche Leitlinien dazu zu entwickeln. Die aktuelle Leitlinie wurde anhand eines systematischen Literaturreview von einem interdisziplinären Expertengremium diskutiert und verabschiedet.Die akute Analfissur, soll auf Grund ihrer hohen Selbstheilungstendenz konservativ behandelt werden. Die Heilung wird am besten durch die Einnahme von Ballaststoff reicher Ernährung und einer medikamentösen Relaxation durch Kalziumkanal-Antagonisten (CCA) unterstützt. Zur Behandlung der chronischen Analfissur (CAF), soll den Patienten eine medikamentöse Behandlung zur „chemischen Sphinkterotomie“ mittels topischer CCA oder Nitraten angeboten werden. Bei Versagen dieser Therapie, kann zur Relaxation des inneren Analsphinkters Botulinumtoxin injiziert werden. Es ist belegt, dass die operativen Therapien effektiver sind. Deshalb kann eine Operation schon als primäre Therapie oder nach erfolgloser medikamentöser Therapie erfolgen. Die Fissurektomie, evtl. mit zusätzlicher Botulinumtoxin Injektion oder Lappendeckung, ist die Operation der Wahl. Obwohl die laterale Internus Sphinkterotomie die CAF effektiver heilt, bleibt diese wegen dem höheren Risiko für eine postoperative Stuhlinkontinenz eine Option für Einzelfälle.
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Does the duration of symptoms of anal fissure impact its response to conservative treatment? A prospective cohort study. Int J Surg 2017. [PMID: 28629768 DOI: 10.1016/j.ijsu.2017.06.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Conservative treatment is the first line of treatment for anal fissure. The current study aimed to evaluate the impact of symptom duration on the response of anal fissure to conservative treatment. PATIENTS AND METHODS This prospective study was conducted on sixty patients with acute or chronic anal fissure who were treated conservatively with bulking agents, Sitz baths, and topical glyceryl trinitrate (GTN) 0.2%. Pain and constipation were assessed prior to treatment and at 6 weeks after therapy using visual analogue scale (VAS) and Wexner constipation score. Adverse effects as headache and postural hypotension were also queried. RESULTS The mean pre-treatment VAS for acute fissure was significantly higher than chronic fissure (8.8 ± 0.96 Vs 5.8 ± 1.12), also the post-treatment VAS for acute fissure was significantly lower at 6 weeks of treatment (0.47 ± 0.8 Vs 2.5 ± 1.3). The baseline Wexner constipation score was comparable in both groups; however, at six weeks of treatment it declined more significantly in patients with acute fissure. Patients with acute fissure achieved significantly better healing than chronic fissure (80% Vs 40%). Healing rates decreased from 100% in patients with symptoms < one month to 33.3% in patients with symptoms >6 months. CONCLUSION Conservative treatment including topical GTN 0.2% significantly hastened healing and relieved pain and other symptoms of acute more than chronic anal fissure. Healing rates of anal fissure in response to conservative treatment showed remarkable decrease in proportion to the duration of complaint.
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Abstract
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.
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Affiliation(s)
- Sherief Shawki
- Department of Colorectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Carroccio A, Mansueto P, Morfino G, D'Alcamo A, Di Paola V, Iacono G, Soresi M, Scerrino G, Maresi E, Gulotta G, Rini G, Bonventre S. Oligo-antigenic diet in the treatment of chronic anal fissures. Evidence for a relationship between food hypersensitivity and anal fissures. Am J Gastroenterol 2013; 108:825-32. [PMID: 23588240 DOI: 10.1038/ajg.2013.58] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Patients with chronic constipation due to food hypersensitivity (FH) had an elevated anal sphincter resting pressure. No studies have investigated a possible role of FH in anal fissures (AFs). We aimed to evaluate (1) the effectiveness of diet in curing AFs and to evaluate (2) the clinical effects of a double-blind placebo-controlled (DBPC) challenge, using cow's milk protein or wheat. METHODS One hundred and sixty-one patients with AFs were randomized to receive a "true-elimination diet" or a "sham-elimination diet" for 8 weeks; both groups also received topical nifedipine and lidocaine. Sixty patients who were cured with the "true-elimination diet" underwent DBPC challenge in which cow's milk and wheat were used. RESULTS At the end of the study, 69% of the "true-diet group" and 45% of the "sham-diet group" showed complete healing of AFs (P<0.0002). Thirteen of the 60 patients had AF recurrence during the 2-week cow's milk DBPC challenge and 7 patients had AF recurrence on wheat challenge. At the end of the challenge, anal sphincter resting pressure significantly increased in the patients who showed AF reappearance (P<0.0001), compared with the baseline values. The patients who reacted to the challenges had a significantly higher number of eosinophils in the lamina propria and intraepithelial lymphocytes than those who did not react to the challenges. CONCLUSIONS An oligo-antigenic diet combined with medical treatment improved the rate of chronic AF healing. In more than 20% of the patients receiving medical and dietary treatment, AFs recurred on DBPC food challenge.
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Affiliation(s)
- Antonio Carroccio
- Department of Internal Medicine, Hospital of Sciacca, ASP Agrigento, University of Palermo, Palermo, Italy.
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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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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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Karanlik H, Akturk R, Camlica H, Asoglu O. The effect of glyceryl trinitrate ointment on posthemorrhoidectomy pain and wound healing: results of a randomized, double-blind, placebo-controlled study. Dis Colon Rectum 2009; 52:280-5. [PMID: 19279424 DOI: 10.1007/dcr.0b013e31819c98a7] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Spasm of the internal sphincter may be a source of anal pain and delayed healing after hemorrhoidectomy. This study assessed whether glyceryl trinitrate (GTN) ointment reduces pain and promotes wound healing after hemorrhoidectomy. METHODS A prospective, randomized, double-blind, placebo-controlled trial was conducted comparing effects of an ointment containing GTN (0.2 percent) vs. a placebo ointment. The study preparations were self-applied by the patient to the surgical site twice per day for two weeks after the hemorrhoidectomy. Pain was assessed with a visual analog scale, and 24-hour analgesic use was recorded on postoperative days 1, 3, and 7. Complete healing was defined as complete epithelialization and evaluated at the end of the third postoperative week. RESULTS Sixty-nine patients were randomly assigned to receive topical 0.2 percent GTN group or placebo. Data from 30 patients in each group were available for analyses. Patients in the GTN group experienced significantly less postoperative pain than those with placebo on days 1, 3, and 7 (P < 0.05). Use of prescribed analgesics (metamizole and acetaminophen) was significantly greater for the placebo group on days 1 and 3. Wound healing at the end of the third postoperative week was significantly greater with GTN compared with placebo (76.7 percent vs. 46.7 percent, P = 0.02). CONCLUSIONS Compared with placebo, perianal application of 0.2 percent GTN ointment significantly decreases postoperative pain after hemorrhoidectomy and reduces analgesic requirements in the immediate postoperative period. GTN ointment also achieves more rapid healing of wounds.
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Affiliation(s)
- Hasan Karanlik
- Department of Surgery, Institute of Oncology, Istanbul University, Istanbul, Turkey.
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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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Abstract
Fissures in ano are linear ulcers situated in the anal canal and extending from the dentate line to the margin of the anus. They cause pain and spasms. Diagnosis is made by the history alone. Local medical treatment might consist of topical 0.4% glycerol trinitrate or 2% calcium blocker. In case of therapy resistance, botulinum toxin injection into the internal sphincter is an effective but expensive alternative with encouraging results. If medical treatment fails, then operation has to be recommended. As lateral internal sphincterotomy represents poses a clear danger to continence, fissurectomy combined with the excision of skin tags and any anal papilla is now the operative treatment of choice.
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Pascual M, Pera M, Courtier R, Gil MJ, Parés D, Puig S, Andreu M, Grande L. Endosonographic and manometric evaluation of internal anal sphincter in patients with chronic anal fissure and its correlation with clinical outcome after topical glyceryl trinitrate therapy. Int J Colorectal Dis 2007; 22:963-7. [PMID: 17216217 DOI: 10.1007/s00384-006-0251-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Anorectal pressure studies have demonstrated internal anal sphincter (IAS) hypertonia in patients with chronic anal fissure. It is unknown however, if these changes in IAS function are associated with any abnormality in sphincter morphology. The first aim was to investigate the clinical characteristics and the manometric and endosonographic findings of the IAS in a cohort of patients with chronic anal fissure. The second aim was to investigate the association between these findings and the outcome with topical Glyceryl trinitrate (GTN) therapy. MATERIALS AND METHODS All patients who presented with chronic anal fissure from November 1999 to May 2004 were included after failure of conservative therapy. Anorectal manometry and anal endosonography were performed before treatment with 0.2% GTN ointment twice daily was initiated. Patients were evaluated after 8 weeks. RESULTS One hundred and twenty-four patients (66 women, mean age, 45.2 +/- 14.8 years) were included. Hypertonia of the IAS was found in 84 (68%) patients. The mean maximum IAS thickness was 3.6 +/- 0.76 mm (1.6-5.5). An abnormally thick IAS, adjusted by age, was observed in 113 (91.1%) patients. We found no correlation between resting pressure and IAS thickness (r = 0.074; p = 0.41). At 8 weeks, 52 patients (42%) had healed with complete symptoms resolution. No statistically significant differences were observed when clinical features and manometric and endosonographic findings were compared between healing and no-healing fissures. CONCLUSION The majority of patients with chronic anal fissure present an abnormally thick IAS. Clinical, manometric and endosonographic features had no association with outcome after GTN treatment.
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Affiliation(s)
- Marta Pascual
- Colorectal Surgery Unit, Department of Surgery, Hospital del Mar, Passeig Marítim, 25-29, 08003, Barcelona, Spain
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Abstract
INTRODUCTION Anal fissures are commonly encountered in routine colorectal practice. Developments in the pharmacological understanding of the internal anal sphincter have resulted in more conservative approaches towards treatment. Simple measures are often effective for early fissures. Glyceryl trinitrate is well established as a first-line pharmacological therapy. The roles of diltiazem and botulinum, particularly as rescue therapy, are not well understood. Surgery has a defined role and should not be discounted completely. METHODS Data were obtained from Medline publications citing 'anal fissure'. Manual cross-referencing of salient articles was conducted. We have sought to highlight various controversies in the management of anal fissures. FINDINGS Acute fissures may heal spontaneously, although simple conservative measures are sufficient. Idiopathic chronic anal fissures need careful evaluation to decide what therapy is suitable. Pharmacological agents such as glyceryl trinitrate (GTN), diltiazem and botulinum toxin have been subjected to most scrutiny. Though practices in the UK vary, GTN or diltiazem would be suitable as first-line therapy with botulinum toxin used as rescue treatment. Sphincterotomy is indicated for unhealed fissures; fissurectomy has been revisited and advancement flaps have a role in patients in whom sphincter division is not suitable.
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Affiliation(s)
- R Bhardwaj
- Department of Surgery, Darent Valley Hospital, Dartford, Kent, UK
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Nash GF, Kapoor K, Saeb-Parsy K, Kunanadam T, Dawson PM. The long-term results of diltiazem treatment for anal fissure. Int J Clin Pract 2006; 60:1411-3. [PMID: 16911570 DOI: 10.1111/j.1742-1241.2006.00895.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The effects of diltiazem treatment on symptoms of chronic anal fissures and their long-term outcome were investigated. One hundred and twelve patients were supplied with 6-week course of 2% diltiazem cream for twice-daily topical application. The medical notes and extended follow-up by telephone for 112 patients were recorded and statistically analysed. The success rate and satisfaction of topical diltiazem were each over two thirds. Nearly 80% of patients reported no adverse effects, and it seems that those complaints attributed to diltiazem rarely led to reduced compliance. After diltiazem therapy for fissure, 59% of patients required further treatment (medical and/or surgical) over the average 2-year period of follow-up. The reported adverse effects of topical diltiazem treatment in patients with anal fissures were more common than previously thought, although compliance was rarely affected. During consultation regarding the advantages and disadvantages of surgical vs. chemical sphincterotomy, patients should be aware that the majority of patients receiving diltiazem as the primary treatment for anal fissure subsequently require further treatment.
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Wollina U, Konrad H, Petersen S. Botulinum toxin in dermatology - beyond wrinkles and sweat. J Cosmet Dermatol 2005; 4:223-7. [PMID: 17168867 DOI: 10.1111/j.1473-2165.2005.00195.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Botulinum toxin (BTX) types A and B have been used with success in cosmetic dermatology and hyperhidrosis treatment. The present review focuses on other uses of BTX in dermatology. Discussed in particular are the available data on BTX in inflammatory diseases, proctology, and some other indications. From studies in various types of eczema, it seems that BTX-A not only acts as a potent inhibitor of acetylcholine but also as an inhibitor of substance P and of glutamate as well. By those mechanisms, BTX-A may be antipruritic, which may help explain the benefits of BTX-A in lichen simplex and dyshidrotic hand eczema. In Hailey-Hailey disease, facial eccrine hidrocystomas, salivary fistulas, and intrinsic rhinitis, BTX-A blocks the secretion of sweat/saliva/mucus. BTX-A has important applications in proctology where it has become the most powerful nonsurgical therapy for anal fissures. In proctalgia fugax and after hemorrhoidectomy, BTX-A is analgesic. Current treatment applications of BTX-A and its limitations are reviewed in this paper.
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Affiliation(s)
- Uwe Wollina
- Department of Dermatology, Academic Teaching Hospital Dresden-Friedrichstadt, Dresden, Germany.
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Arroyo A, Pérez-Vicente F, Serrano P, Candela F, Sánchez A, Pérez-Vázquez MT, Calpena R. Tratamiento de la fisura anal crónica. Cir Esp 2005; 78:68-74. [PMID: 16420800 DOI: 10.1016/s0009-739x(05)70893-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Chronic anal fissure is a common benign anorectal problem in Western countries that substantially impairs the patient's life. Consequently, a rapid and effective solution is required. We reviewed the various treatments for chronic anal fissure described in the literature, with the aim of establishing a therapeutic protocol. We recommend surgical sphincterotomy (preferably open or closed lateral sphincterotomy) as the first therapeutic approach in patients with chronic anal fissure. However, we prefer the use of chemical sphincterotomy (preferably botulinum toxin) in patients aged more than 50 years old and in those with previous incontinence, risk factors for incontinence (previous anal surgery, multiple vaginal births, diabetes, inflammatory bowel disease, etc.), or without anal hypertonia, despite the higher recurrence rate with medical treatments, since this procedure avoids the greater risk of residual incontinence described in the literature with surgical sphincterotomy in this group of patients.
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Affiliation(s)
- Antonio Arroyo
- Servicio de Cirugía General y Aparato Digestivo, Hospital General Universitario de Elche, Elche, Alicante, Spain.
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Arroyo A, Pérez F, Serrano P, Candela F, Lacueva J, Calpena R. Surgical versus chemical (botulinum toxin) sphincterotomy for chronic anal fissure: long-term results of a prospective randomized clinical and manometric study. Am J Surg 2005; 189:429-34. [PMID: 15820455 DOI: 10.1016/j.amjsurg.2004.06.045] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2004] [Revised: 06/13/2004] [Accepted: 06/13/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND The aim of this prospective randomized trial was to compare the effectiveness and morbidity of surgical versus chemical sphincterotomy in the treatment of chronic anal fissure after a 3-year follow-up. METHODS Eighty patients with chronic anal fissure were treated by whether open lateral internal sphincterotomy (group 1) or chemical sphincterotomy with 25 U botulinum toxin injected into the internal sphincter (group 2). Clinical and manometric results were analyzed. RESULTS Overall healing was 92.5% in the open sphincterotomy group and 45% in the toxin botulinum group (P<.001). There is a group of patients with clinical (duration of disease >12 months and presence of a sentinel pile before treatment) and manometric factors (persistently elevated mean resting pressure, % of time presence of slow waves, and number of patients or the time presence ultra slow waves after treatment) associated with a higher recurrence of anal fissure. The final percentage of incontinence was 5% in the open sphincterotomy group and 0% in the botulinum toxin group (P>.05). CONCLUSION We recommend surgical sphincterotomy as the first therapeutic approach in patients with clinical and manometric factors of recurrence. We prefer the use of botulinum toxin in patients older than 50 years or with risk factors for incontinence, despite the higher rate of recurrence, since it avoids the greater risk of incontinence in the surgical group.
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Affiliation(s)
- Antonio Arroyo
- Coloproctology Unit, Department of Surgery, University Hospital of Elche, Elche (Alicante), Spain.
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Arroyo A, Perez F, Serrano P, Candela F, Calpena R. Long-term results of botulinum toxin for the treatment of chronic anal fissure: prospective clinical and manometric study. Int J Colorectal Dis 2005; 20:267-71. [PMID: 15526113 DOI: 10.1007/s00384-004-0644-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2004] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this prospective trial was to analyse the effectiveness and morbidity of chemical sphincterotomy in the treatment of chronic anal fissure after a 3-year follow-up. METHODS One hundred consecutive patients with chronic anal fissures were treated by chemical sphincterotomy with 25 U botulinum toxin injected into the internal sphincter. Clinical and manometric results were recorded. RESULTS No major complications were found; initial incontinence at the 2-month review (6%) spontaneously reversed at 6 months. There was a tendency of progressive recurrence over time, with an overall healing after 3 years of 47%. We found a group of patients with clinical (symptoms longer than 12 months and presence of a sentinel pile before treatment) and manometric factors (persistently elevated mean resting pressure, percentage of time with slow waves, and number of patients or percentage of time with ultra slow waves after treatment) associated with a higher recurrence of anal fissures. CONCLUSION Since it avoids the greater risk of incontinence associated with surgical sphincterotomy, we recommend the use of botulinum toxin as the first therapeutic approach for patients with chronic anal fissure and risk factors for incontinence; despite the higher rate of recurrence associated with this treatment. In patients with factors related to recurrence, re-injection with higher doses of botulinum toxin or complementary medical-surgical treatment should be considered.
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Affiliation(s)
- A Arroyo
- Coloproctology Unit, Department of Surgery, University Hospital of Elche, C/Huertos y Molinos s/n., 03203 Elche (Alicante), Spain.
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Lindsey I, Cunningham C, Jones OM, Francis C, Mortensen NJM. Fissurectomy-botulinum toxin: a novel sphincter-sparing procedure for medically resistant chronic anal fissure. Dis Colon Rectum 2004; 47:1947-52. [PMID: 15622590 DOI: 10.1007/s10350-004-0693-x] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Botulinum toxin heals only approximately one-half of glyceryl trinitrate-resistant chronic anal fissures, perhaps because chemical sphincterotomy alone treats internal sphincter spasm but not chronic fissure fibrosis. We aimed to assess whether a novel procedure, fissurectomy-botulinum toxin, improves the healing rate of medically resistant fissures over that achieved with botulinum toxin alone. METHODS A prospective pilot study of chronic fissure patients failing medical therapy was undertaken. Fissurectomy was performed, with excision of the fibrotic fissure edges, curetting of the fissure base, and excision of the sentinel pile if present. Twenty-five units of botulinum toxin (Botox) were injected into the internal sphincter. The primary end point was fissure healing, and secondary end points were improvement in symptoms, need for lateral internal sphincterotomy, and side effects. RESULTS Thirty patients underwent fissurectomy-botulinum toxin (57 percent female; median age, 39 years). Nineteen patients had failed glyceryl trinitrate, whereas 11 had failure of both glyceryl trinitrate and botulinum toxin. At a median of 16.4 weeks follow-up, 28 fissures (93 percent) were healed. Two fissures (7 percent) remained unhealed but were symptomatically better and avoided lateral internal sphincterotomy. Two patients (7 percent) experienced transitory flatus incontinence. CONCLUSION Fissurectomy-botulinum toxin heals over 90 percent of fissures resistant to medical therapy. Fissurectomy-botulinum toxin allows patients with medically resistant fissures to achieve a high rate of healing while avoiding the risk of incontinence associated with lateral internal sphincterotomy.
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Affiliation(s)
- Ian Lindsey
- Department of Colorectal Surgery, John Radcliffe Hospital, Oxford, United Kingdom.
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Abstract
BACKGROUND The treatment of chronic anal fissure has shifted in recent years from surgical to medical. METHODS A Medline search of studies relevant to modern management of chronic anal fissure was undertaken. RESULTS Traditional surgery that permanently weakens the internal sphincter is associated with a risk of incontinence. Medical therapies temporarily relax the internal sphincter and pose no such danger, but their limited efficacy has led to displacement rather than replacement of traditional surgery. Emerging medical therapies promise continued improvement and new sphincter-sparing surgery may render traditional surgery redundant. CONCLUSION First-line use of medical therapy cures most chronic anal fissures cheaply and conveniently. The few non-responders can be targeted for sphincter assessment before traditional surgery. If the initial good results of new sphincter-sparing surgery are confirmed, it may be possible to avoid any risk of incontinence, while achieving high rates of fissure healing.
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Affiliation(s)
- I Lindsey
- Department of Colorectal Surgery, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU,
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Bielecki K, Kolodziejczak M. A prospective randomized trial of diltiazem and glyceryltrinitrate ointment in the treatment of chronic anal fissure. Colorectal Dis 2003; 5:256-7. [PMID: 12780888 DOI: 10.1046/j.1463-1318.2003.00440.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of this study was to compare prospectively diltiazem with GTN ointment in the treatment of anal fissure. PATIENTS AND METHODS Of 43 outpatients with chronic anal fissure, 22 patients were randomized to topical diltiazem (2%) ointment and 21 patients to glyceryltrinitrate (GTN) (0.5%) ointment twice daily for 8 weeks. During the course of treatment each patient was seen three times. Side-effects and healing were recorded. RESULTS Healing occurred in 19 of 22 patients treated with diltiazem and 18 of 21 patients were cured with GTN (P = 0.95). Those who were treated with nitroglycerin ointment developed headache and dizziness developed after GTN in 33.3% of cases while no patient had any side-effects after diltiazem. CONCLUSIONS Diltiazem and glyceryltrinitrate (GTN) were equally effective in healing anal fissure but the former resulted in fewer side-effects.
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Affiliation(s)
- K Bielecki
- Department Surgery, Medical Centre for Postgraduate Education, Orlowski Hospital, 231 Czerniakowska str. 00-416, Warsaw, Poland.
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Utzig MJ, Kroesen AJ, Buhr HJ. Concepts in pathogenesis and treatment of chronic anal fissure--a review of the literature. Am J Gastroenterol 2003; 98:968-74. [PMID: 12809816 DOI: 10.1111/j.1572-0241.2003.07423.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Chronic anal fissures are associated with a persistent hypertonia and spasm of the internal anal sphincter. Classic treatment is surgical sphincterotomy to reduce the anal tone and eliminate sphincteric spasm. However, concerns have been raised about the incidence of fecal incontinence after surgery. Therefore, pharmacological means to treat chronic anal fissures have been explored. METHODS We conducted a literature review on MEDLINE database. RESULTS All treatments address the anomaly of a high anal pressure. Several studies have investigated the effect of topical glyceryl trinitrate ointment. Healing rates range from 30% to 86%. Therapy is limited because of a high incidence of moderate to severe headaches in up to 84% of patients. Comparable results are observed after injection of botulinum toxin into the anal sphincter (43-96%). Minor incontinence for flatus and soiling has been reported in up to 12% of patients. Further pharmacological approaches including treatment via calcium channel blockade and treatment with alpha-adrenoceptor antagonists are still at a developmental stage. CONCLUSIONS Topical glyceryl trinitrate ointment and injection of botulinum toxin into the anal sphincter are advocated as the first-line treatment for chronic anal fissure. Lateral sphincterotomy should be offered to patients with relapse and therapeutic failure of prior pharmacological treatment.
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Affiliation(s)
- M J Utzig
- Department of General, Vascular, and Thoracic Surgery, Benjamin Franklin Medical Center, Freie Universität Berlin, Berlin, Germany
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Abstract
BACKGROUND Anal fissures are common and painful. Botulinum toxin A (BTXA) is considered to be the most potent non-surgical treatment; however, no attention has been paid to associated hyperhidrosis. AIM To compare traditional BTXA treatment of muscular spasticity in anal fissures with combined treatment of spasticity and focal hyperhidrosis of the anal fold and perianal skin. SETTING Outpatient department of a dermatological hospital. PATIENTS AND METHODS Ten patients with chronic anal fissures (of more than 6 months duration who failed to respond to conservative treatment and who had refused surgery) associated with focal hyperhidrosis as assessed by Minor's sweat test were investigated in an open, two-armed trial. Intramuscular injections of 20-25 U BTXA (Botox) were performed in group A (n = 5). In group B (n = 5) those injections were combined with intracutaneous injection of 30-50 U BTXA to treat focal hyperhidrosis. Mean follow-up was 5 months. RESULTS Five of five patients in group B but only two of five patients in group A experienced a complete remission despite the fact that relief of pain was evident in eight of 10 patients within 2 weeks. Patient satisfaction with treatment was high but slightly better in group B. CONCLUSIONS This open trial suggests that combined therapy of both muscular spasticity and focal hyperhidrosis may provide better results than intramuscular injections alone in anal fissure therapy with BTXA.
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Affiliation(s)
- U Wollina
- Department of Dermatology, Krankenhaus Dresden-Friedrichstadt, Dresden, Germany.
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Minguez M, Herreros B, Espi A, Garcia-Granero E, Sanchiz V, Mora F, Lledo S, Benages A. Long-term follow-up (42 months) of chronic anal fissure after healing with botulinum toxin. Gastroenterology 2002; 123:112-7. [PMID: 12105839 DOI: 10.1053/gast.2002.34219] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Botulinum toxin is an effective treatment in idiopathic chronic anal fissure, but the long-term outcome after healing is not well documented. We analyzed the long-term outcome of patients in whom an anal fissure had healed after botulinum toxin injection and the factors contributing to recurrence. METHODS Fifty-seven patients who had completely healed 6 months after injection of botulinum toxin were reassessed every 6 months. The follow-up was 42 months in all patients. Clinical and manometric differences between the permanently healed and the relapsed group were statistically analyzed. RESULTS Four patients were lost to follow-up. A fissure recurrence was shown in 22 patients (41.5%). Statistical differences between the permanently healed and the relapsed group were detected when analyzing the anterior location of the fissure (6% vs. 45%), a longer duration of the disease (38% vs. 68%), the need for reinjection (26% vs. 59%), a higher total dose injected to achieve definitive healing (13% vs. 45%), and the percentage decrease of maximum squeeze pressure after injection (-28% vs. -13%; P < 0.05). CONCLUSIONS The late recurrence rate of chronic anal fissure is high when the effect of botulinum toxin disappears. The highest risk of recurrence is associated with anterior location of the anal fissure, prolonged illness, the need for reinjection and for high doses to achieve healing, and a lower decrease of maximum squeeze pressure after treatment.
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Affiliation(s)
- Miguel Minguez
- Department of Gastroenterology, Clinic Hospital, University of Valencia, Valencia, Spain.
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