Abstract
PURPOSE: Botulinum toxin injection into the internal anal sphincter has been shown to be an effective treatment for chronic anal fissure. A randomized, prospective trial was conducted to compare botulinum toxin with lateral internal anal sphincterotomy as definitive management for chronic anal fissure. METHODS: Patients diagnosed as having chronic anal fissure were randomly assigned to one of the two treatment arms. In the botulinum toxin group (n = 61), 20 to 30 U (approximately 0.3 U/kg) of type A botulinum toxin (Botox®) was injected into the internal anal sphincter. The injection was repeated two months later if complete healing was not accomplished. Patients in the sphincterotomy group (n = 50) underwent lateral internal anal sphincterotomy. The same investigators evaluated the patients on postoperative/postinjection days 7 and 28, and then in a blinded manner at 2, 6, and 12 months. RESULTS: In the botulinum group, single injection resulted in complete healing in 45 of the 61 patients (73.8 percent) at the second month. Of the 16 failures, 6 patients refused further treatment, and 10 were treated with a second injection, which resulted in an overall healing rate of 86.9 percent (53/61) at 6 months. In the sphincterotomy group, the success rate was 82 percent (41/50) at day 28 and 98 percent (49/50) at the second month (P = 0.023 and P < 0.0001, respectively, compared with the botulinum group—single injection). At 6 months, 2 patients in the LIS group developed recurrences, and the healing rate was similar to that of the botulinum group (86.9 vs. 96.4 percent; P = 0.212). At 12 months, the success rate of the Botox® group fell to 75.4 percent (46/61) with 7 recurrences, whereas it remained stable in the sphincterotomy group (94 percent, P = 0.008). Sphincterotomy was associated with a significantly higher complication rate (8 cases of anal incontinence vs. none in the botulinum toxin group; P < 0.001). Full return to daily activities took significantly less time in the botulinum group (1 vs. 14.8 ± 5.7 days; P < 0.0001). CONCLUSION: Although the healing rate of chronic anal fissure is considerably high with botulinum toxin injection with earlier recovery and less complications compared with sphincterotomy, it occasionally requires a repeat injection, and the healing is slower. The early (two months) and late (one year) healing rates are significantly higher in the sphincterotomy group, the two groups reaching similar healing rates only at six months.
Similar content being viewed by others
References
SL Jensen (1986) ArticleTitleTreatment of first episodes of acute anal fissure BMJ 292 1167–1169
WP Mazier (1994) ArticleTitleHemorrhoids, fissures and pruritus ani Surg Clin North Am 74 1277–1292
JN Lund JH Scholefield (1996) ArticleTitleAetiology and treatment of anal fissure Br J Surg 83 1335–1344
MJ Notaras (1971) ArticleTitleThe treatment of anal fissure by lateral subcutaneous sphincterotomy—a technique and results Br J Surg 58 96–100
H Abcarian (1980) ArticleTitleSurgical correction of chronic anal fissure Dis Colon Rectum 23 31–36
JM Watts RC Bennett JC Goligher (1964) ArticleTitleStretching of anal sphincters in the treatment of fissure-in-ano BMJ 2 342–343
IT Khubchandani JF Reed (1989) ArticleTitleSequelae of internal sphincterotomy for chronic fissure in ano Br J Surg 76 431–434
WR Schouten JW Briel JJ Aurwerda EJ De Graaf (1996) ArticleTitleIschaemic nature of anal fissure Br J Surg 83 63–65
PB Loder MA Kamm RJ Nicholls RK Phillips (1994) ArticleTitleReversible chemical sphincterotomy by local application of glyceryl trinitrate Br J Surg 81 1386–1389
SR Gorfine (1995) ArticleTitleTreatment of benign anal disease with topical nitroglycerine Dis Colon Rectum 38 453–457
JN Lund JH Scholefield (1997) ArticleTitleA randomized, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure Lancet 349 11–14
GJ Oettle (1997) ArticleTitleGlyceryl trinitrate vs. sphincterotomy for treatment of chronic fissure-in-ano Dis Colon Rectum 40 1318–1320
EA Carapeti MA Kamm PJ McDonald SJ Chadwick D Melville RK Phillips (1999) ArticleTitleRandomised controlled trial shows that glyceryl trinitrate heals anal fissures, higher doses are not more effective, and there is a high recurrence rate Gut 44 727–730
J Evans A Luck P Hewett (2001) ArticleTitleGlyceryl trinitrate vs. lateral sphincterotomy for chronic anal fissure Dis Colon Rectum 44 93–97
WH Jost (1997) ArticleTitleOne hundred cases of anal fissure treated with botulinum toxin Dis Colon Rectum 40 1029–1032
G Maria G Brisinda AR Bentivoglio E Cassetta D Gui A Albenese (1998) ArticleTitleBotulinum toxin injections in the internal anal sphincter for the treatment of chronic anal fissure. Long term results after two different dosage regimens Ann Surg 228 664–669
G Brisinda G Maria AR Bentivoglio E Cassetta D Gui A Albanese (1999) ArticleTitleA comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure N Engl J Med 341 65–69
G Maria E Cassetta D Gui G Brisinda AR Bentivoglio A Albanese (1998) ArticleTitleComparison of botulinum toxin and saline for the treatment of chronic anal fissure N Engl J Med 338 217–220
R Miller DC Bartolo JC Locke-Edmunds NJ Mortensen (1988) ArticleTitleProspective study of conservative and operative treatment for faecal incontinence Br J Surg 75 101–105
JC Goligher (1965) ArticleTitleAn evaluation of internal sphincterotomy and simple sphincter stretching in the treatment of fissure-in-ano Surg Clin North Am 42 1299–1304
DC Nyam JH Pemberton (1999) ArticleTitleLong-term results of lateral internal sphincterotomy for chronic anal fissure with particular reference to incidence of fecal incontinence Dis Colon Rectum 42 1306–1310
B Fries KA Rietz (1964) ArticleTitleTreatment of fissure in ano Acta Chir Scand 128 312–315
MJ Gough A Lewis (1983) ArticleTitleThe conservative treatment of fissure-in-ano Br J Surg 70 175–176
EE Frezza F Sandei G Levni M Biral (1992) ArticleTitleConservative and surgical treatment in acute and chronic anal fissure. A study on 308 patients Int J Colorectal Dis 7 188–191
E Antebi P Schwartz E Gilon (1985) ArticleTitleSclerotherapy for the treatment of fissure in ano Surg Gynecol Obstet 160 204–206
D Gui E Cassetta G Anastasia AR Bentivoglio G Maria A Albanese (1994) ArticleTitleBotulinum toxin for chronic anal fissure Lancet 34 1127–1128
JN Lund NC Armitage JH Scholefield (1996) ArticleTitleUse of glyceryl trinitrate ointment in the treatment of anal fissure Br J Surg 83 776–777
H Bacher HJ Mischinger G Werkgartner (1997) ArticleTitleLocal nitroglycerin for treatment of anal fissures Dis Colon Rectum 40 840–845
CS Richard R Gregoire EA Plewes (2000) ArticleTitleInternal sphincterotomy is superior to topical nitroglycerin in the treatment of chronic anal fissure Dis Colon Rectum 43 1048–1058
J Jankovic MF Brin (1991) ArticleTitleTherapeutic uses of botulinum toxin N Engl J Med 324 1186–1194
MS Bhutani (1997) ArticleTitleGastrointestinal uses of botulinum toxin Am J Gastroenterol 92 929–933
G Maria G Brisinda AR Bentivoglio E Cassetta D Gui A Albenese (2000) ArticleTitleInfluence of botulinum toxin site of injections on healing rate in patients with chronic anal fissure Am J Surg 179 46–49
M Minguez F Melo A Espi (1999) ArticleTitleTherapeutic effects of different doses of botulinum toxin in chronic anal fissure Dis Colon Rectum 42 1016–1021
Author information
Authors and Affiliations
About this article
Cite this article
Menteş, B.B., İrkörücü, O., Akın, M. et al. Comparison of Botulinum Toxin Injection and Lateral Internal Sphincterotomy for the Treatment of Chronic Anal Fissure. Dis Colon Rectum 46, 232–237 (2003). https://doi.org/10.1007/s10350-004-6528-y
Issue Date:
DOI: https://doi.org/10.1007/s10350-004-6528-y