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Ascanelli S, Rossin E, Aisoni F, Sette E, Chimisso L, Valpiani G, Costanzini A, DE Giorgio R, Feo CV. Botulinum toxin injection for chronic anal fissure: a prospective controlled study with long follow-up. Minerva Surg 2024; 79:293-302. [PMID: 38551598 DOI: 10.23736/s2724-5691.24.10228-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2024]
Abstract
BACKGROUND Botulinum toxin is an effective therapeutic option for chronic anal fissure. However, there is no evidence about treatment standardization and long-term follow-up. We aimed to evaluate the short- and long-term efficacy and safety of botulinum toxin compared to close lateral internal sphincterotomy, with a 5-year follow-up. METHODS This was a prospective, controlled, single-center study conducted at University Hospital of Ferrara, Ferrara, Italy. The primary outcome was fissure healing at 1 month. Secondary outcomes were Quality-of-Life (QoL) at 1 month and after 5 years, and fissure recurrence at 6 months and 5 years. RESULTS A total of 59 patients received botulinum toxin injection (Botox), and 32 underwent lateral internal sphincterotomy. At 1 month after treatments, postoperative pain decreased faster and significantly more in the Botox group (30 vs. 60 mm; P<0.001); fissure re-epithelization was observed in 59.4% of the surgical group compared to 25.4% of Botox (P=0.0001). Anal sphincter pressures decreased more in surgical group (P=0.044), although severe anal incontinence was present only in this subset (6.2%; P=0.041). Compared to surgery, patients who received Botox had higher satisfaction rates (P<0.001). Fissure recurrence at 6 months was more common in Botox than surgical group (16.9% vs. 3.2%, respectively; P=0.053). The overall healing rate improved in all patients and persisted at 12 months and 5 years in both groups with overall high patient satisfaction despite mild anal incontinence in 21.8% in the surgery group (P<0.05). CONCLUSIONS Botox, rather than surgery, should be considered the first-line treatment for chronic anal fissure.
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Affiliation(s)
- Simona Ascanelli
- Section of General Surgery, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Eleonora Rossin
- Section of General Surgery, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Filippo Aisoni
- Section of General Surgery, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Elisabetta Sette
- Unit of Neurology, Department of Neuroscience Rehabilitation, University Hospital Ferrara, Ferrara, Italy
| | - Laura Chimisso
- Section of General Surgery, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Giorgia Valpiani
- Accreditation Office Quality Research Innovation, University Hospital Ferrara, Ferrara, Italy
| | - Anna Costanzini
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Roberto DE Giorgio
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Carlo V Feo
- Section of General Surgery, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
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Dokcu Ş, Başçeken Sİ. Botulinum toxin injection in outpatients for chronic anal fissure. Acta Chir Belg 2024; 124:131-136. [PMID: 37440688 DOI: 10.1080/00015458.2023.2234179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 07/04/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVES The aim of the study was to evaluate the effect of botulinum toxin (BT) injection on fissure healing in the treatment of chronic anal fissure (CAF) in outpatient conditions without any analgesia and sedation to the internal anal sphincter (IAS). The primary outcome measure was post-procedural pain. The secondary outcome measures were fissure healing and complications. METHODS Prospectively preserved data of 67 patients who received BT injections for CAF were analyzed prospectively. Demographic data, duration of symptomatic improvement, fissure location and number, parity, post-procedural pain, complications, continence status, response to treatment, and duration of follow-up were examined. Participants received bilateral (50 + 50 units) BT injections into the internal anal sphincter (IAS) in an outpatient setting. RESULTS Symptomatic improvement was observed in 58% of patients within 1 week. The complete response rate to treatment was 82% at a mean follow-up of 6 months. Patients with partial response to treatment (10%) were successfully treated with topical therapy, and patients with persisting fissures (8%) were successfully treated with partial lateral internal sphincterotomy (LIS). 14 patients (21%) reported some degree of transient incontinence at follow-up. Multiparous women experienced more symptoms of Incontinence (p = 0.00). Pre- and post-procedural Vas Score median values were 4. The 7th-week VAS score median value was 3. CONCLUSION Dysport injection under sedation-free outpatient conditions is an effective and safe alternative to LIS for the treatment of CAF, with tolerable procedural pain. All patients should be warned of transient incontinence.
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Affiliation(s)
- Şeref Dokcu
- Gazi Yaşargil Training and Research Hospital Surgical Oncology Department, Health Sciences University, Kayapınar Diyarbakır, Turkey
| | - Salim İlksen Başçeken
- Gazi Yaşargil Training and Research Hospital Surgical Oncology Department, Health Sciences University, Kayapınar Diyarbakır, Turkey
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Chiarello MM, Fico V, Brisinda G. A commentary on "Comparison of doses and injection sites of botulinum toxin for chronic anal fissure: A systematic review and network meta-analysis of randomized controlled trials" [Int. J. Surg. 104 (2022) 106798]. Int J Surg 2022; 106:106880. [PMID: 36113840 DOI: 10.1016/j.ijsu.2022.106880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 08/30/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Maria Michela Chiarello
- Unità Operativa di Chirurgia Generale, Azienda Sanitaria Provinciale di Cosenza, Cosenza, Italy
| | - Valeria Fico
- Chirurgia d'Urgenza e del Trauma, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy
| | - Giuseppe Brisinda
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
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Off-Label Use of Botulinum Toxin in Dermatology—Current State of the Art. Molecules 2022; 27:molecules27103143. [PMID: 35630620 PMCID: PMC9147387 DOI: 10.3390/molecules27103143] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 01/01/2023] Open
Abstract
Botulinum toxin (BoNT) is a neurotoxin produced by the Clostridium botulinum bacteria. Among seven different isoforms, only BoNT-A and BoNT-B are commercially used. Currently, botulinum toxin has been indicated by the U.S. Food and Drug Administration in several disorders, among others: chronic migraine, hyperhidrosis, urinary incontinence from detrusor overactivity, or cosmetics. However, there are numerous promising reports based on off-label BTX usage, indicating its potential effectiveness in other diseases, which remains unknown to many. Among them, dermatological conditions, such as rosacea, annal fissure, Raynaud phenomenon, hypertrophic scars and keloids, and also hidradenitis suppurativa, are currently being investigated. This article aims to provide a comprehensive update on the off-label use of botulinum toxin in dermatology, based on an analysis and summary of the published literature.
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Brisinda G, Chiarello MM, Crocco A, Bentivoglio AR, Cariati M, Vanella S. Botulinum toxin injection for the treatment of chronic anal fissure: uni- and multivariate analysis of the factors that promote healing. Int J Colorectal Dis 2022; 37:693-700. [PMID: 35149889 PMCID: PMC8885481 DOI: 10.1007/s00384-022-04110-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 02/05/2023]
Abstract
PURPOSE Anal fissure is caused by a pathological contraction of the internal anal sphincter. Lateral internal sphincterotomy remains the gold standard for the treatment of fissure. Botulinum toxin injections have been proposed to treat this condition without any risk of permanent injury of the internal sphincter. We investigate clinical and pathological variables and the effects of different dosage regimens of botulinum toxin to induce healing in patients with idiopathic anal fissure. METHODS This is a retrospective study at a single center. The patients underwent a pre-treatment evaluation that included clinical inspection of the fissure and anorectal manometry. We collected and analyzed demographic data, pathological variables, associated pathological conditions, and treatment variables. Success was defined as healing of the fissure, and improvement of symptoms was defined as asymptomatic persistent fissure. RESULTS The findings of 1003 patients treated with botulinum toxin injections were reported. At 2 months evaluation, complete healing was evident in 780 patients (77.7%). Resting anal tone (77.1 ± 18.9 mmHg) was significantly lower from baseline (P < 0.0001) and from 1-month value (P = 0.0008). Thirty-nine not healed patients underwent lateral internal sphincterotomy, and 184 were re-treated with 50 UI of botulinum toxin. In these patients, the healing rate was 93.9% (171 patients). Dose and injection site of toxin correlates with healing rate. There were no relapses during an average of about 71 months. CONCLUSION Our data show that injection of botulinum toxin into the internal anal sphincter is a safe and effective alternative to surgery in patients with chronic anal fissure.
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Affiliation(s)
- Giuseppe Brisinda
- Università Cattolica del Sacro Cuore, Roma, Italy.
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy.
| | | | - Anna Crocco
- Unità Operativa Di Chirurgia Oncologica Della Tiroide E Della Paratiroide, Istituto Nazionale Tumori, IRCCS Fondazione Pascale, Napoli, Italy
| | - Anna Rita Bentivoglio
- Università Cattolica del Sacro Cuore, Roma, Italy
- Unità Operativa Di Neurologia, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy
| | - Maria Cariati
- Unità Operativa Di Chirurgia Generale, Ospedale San Giovanni Di Dio, Crotone, Italy
| | - Serafino Vanella
- Unità Operativa Di Chirurgia Generale E Oncologica, Azienda Ospedaliera San Giuseppe Moscati, Avellino, Italy
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van Reijn-Baggen DA, Dekker L, Elzevier HW, Pelger RCM, Han-Geurts IJM. Management of chronic anal fissure: results of a national survey among gastrointestinal surgeons in the Netherlands. Int J Colorectal Dis 2022; 37:973-978. [PMID: 35194670 PMCID: PMC8976773 DOI: 10.1007/s00384-022-04115-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Chronic anal fissure (CAF) is a common, bothersome condition frequently accompanied by pelvic floor complaints. Despite current guidelines, optimal management is challenging. The aim of this study is to evaluate current management of CAF among gastrointestinal surgeons in the Netherlands. METHODS Dutch gastrointestinal surgeons and residents were sent a survey invitation by email, which was available online between June 2021 and September 2021. The questionnaire consisted of 21 questions concerning work experience, physical examination, diagnostic and surgical techniques, and follow-up. RESULTS Overall, 106 (33%) respondents completed the survey. Most respondents (59%) had at least 10 years of experience in treating CAF. Only 23% always addressed pelvic floor complaints. Fifty-one percent performed digital rectal examination and 22% always, or almost always, examined the pelvic floor muscles. Most respondents started treatment with fibers and/or laxatives and ointment (96%). Diltiazem was in 90% the preferred ointment. Twenty-two percent referred patients for pelvic floor physical therapy. Botulinum toxin was in 54% performed under general or spinal anesthesia or sedation. The surgical procedure of choice was fissurectomy (71%) followed by lateral internal sphincterotomy (27%). Fissurectomy was in 51% always combined with botulinum toxin. Fifty-seven percent of the respondents preferred a physical follow-up appointment. CONCLUSION Guideline recommendations are largely followed in the Netherlands, starting with conservative measures followed by surgical procedures. Surgeons do not consistently assess pelvic floor complaints, nor do they routinely examine the pelvic floor muscles. Awareness of pelvic floor dysfunctions is important to refer patients for pelvic floor physical therapy.
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Affiliation(s)
- Danielle A. van Reijn-Baggen
- Department of Surgery, Proctos Clinic, Bilthoven, The Netherlands ,Department of Urology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lisette Dekker
- Department of Surgery, Proctos Clinic, Bilthoven, The Netherlands ,Department of Surgery, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Henk W. Elzevier
- Department of Urology, Leiden University Medical Center, Leiden, The Netherlands ,Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Rob C. M. Pelger
- Department of Urology, Leiden University Medical Center, Leiden, The Netherlands
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