Treatment of a chronic anal fissure with a botulin toxin A injection and fissurectomy.

Abstract

espanolIntroduccion: el tratamiento farmacologico de la fisura anal cronica (FAC) consigue la cicatrizacion en la mitad de los casos, siendo la esfinterotomia lateral interna (ELI) el tratamiento definitivo. El objetivo del estudio fue evaluar la combinacion de una fisurectomia con la inyeccion de toxina botulinica A (TBA). Metodos: estudio retrospectivo de 54 pacientes tratados por FAC e hipertonia esfinteriana con inyeccion de TBA y fisurectomia, que no habian respondido al tratamiento con nitroglicerina (NTG) durante ocho semanas. En el mismo acto se realizo la fisurectomia e inyeccion de TBA (33 o 50 U) en el esfinter anal interno. El objetivo principal fue la tasa de cicatrizacion de la fisura y los secundarios, el desarrollo de incontinencia y la necesidad de una ELI. Resultados: se excluyeron dos pacientes, uno por enfermedad de Crohn y otro perdido en el seguimiento. Los 52 pacientes finalmente incluidos fueron 36 mujeres (70%) y 16 (30%) hombres con una edad media de 49 anos (22-75 anos). Inicialmente, 49 pacientes (94%) cicatrizaron y los tres restantes precisaron de una ELI (6%). Tras la cicatrizacion inicial, 18 pacientes (37%) sufrieron 23 recidivas a los 27 meses de media (5-83 meses). De estos, once cicatrizaron con medidas conservadoras de esfinter (ocho con NTG y tres con TBA mas fisurectomia), dos estan en tratamiento con NTG y cinco precisaron una ELI. Conclusiones: en pacientes con FAC, la inyeccion de TBA asociada a una fisurectomia es un procedimiento seguro y efectivo, que evita la realizacion de una ELI en un elevado porcentaje de pacientes. EnglishIntroduction: pharmacological treatment of a chronic anal fissure (CAF) achieves healing in half of cases and lateral internal sphincterotomy (LIS) is the definite treatment. The objective of this study was to assess the combination of fissurectomy and botulin toxin A (BTA) injection. Methods: this was a retrospective study of 54 patients with anal sphincter hypertonia and CAF treated with an injection of BAT and fissurectomy, after an unsuccessful management with topical nitroglycerin (NGT) for eight weeks. Fissurectomy and an injection of BTA (33 or 50 units) in the internal anal sphincter was performed during the same session. The main outcome measure was the healing rate, with incontinence and the need of LIS as secondary outcomes. Results: two patients were excluded from the study, one due to Crohn’s disease and the other was lost to follow-up. Of the 52 patients included in the study, there were 36 females (70%) and 16 (30%) males, with a mean age of 49 years (range 22-75). Fissure healing was initially achieved in 49 patients (94.2%) and LIS was required in the remaining three patients (5.8%). After initial healing, 18 patients (34.7%) developed 23 recurrences at a mean time of 27 months (5-83 months). Of these patients, healing with conservative sphincter measures was obtained in eleven cases (NGT in eight and repeat fissurectomy and BAT in three); two patients are currently under treatment with NGT and five underwent LIS. Conclusions: BTA injection associated with fissurectomy is a safe and effective procedure in patients with CAF, avoiding the need of LIS in a high percentage of patients.