Gaia Marniga

Randomized clinical trial comparing botulinum toxin injections with 0·2 per cent nitroglycerin ointment for chronic anal fissure

In recent years treatment of chronic anal fissure has shifted from surgical to medical. This study compared the ability of two non‐surgical treatments—botulinum toxin injections and nitroglycerin ointment—to induce healing in patients with idiopathic anal fissure.

Experience with Type A Botulinum Toxin for Treatment of Outlet-Type Constipation

BACKGROUND:Puborectalis syndrome remains a therapeutic challenge for todays physicians. Traditional approaches include use of fiber, laxatives, enemas, biofeedback training, and surgery. These often were tried sequentially and had conflicting or even disappointing results. We investigated the efficacy of injections of botulinum toxin in improving rectal emptying in patients with defecatory disorders involving spastic pelvic-floor muscles.METHODS:Twenty-four consecutive patients with chronic outlet obstruction constipation resulting from puborectalis syndrome were included in the study. The patients were treated with 60 units of type A botulinum toxin, injected into two sites on either side of the puborectalis muscle under ultrasonographic guidance.RESULTS:At 2 months, evaluation inspection revealed a symptomatic improvement in 19 patients. Anorectal manometry demonstrated decreased tone during straining from 98 ± 24 to 56 ± 20 mmHg at a 1-month evaluation (p < 0.01) and 56 ± 29 mmHg at a 2-month follow-up (p < 0.01). Pressure during straining was lower than resting anal pressure at the same time in all patients. Defecography after the treatment showed improvement in anorectal angle during straining, which increased from 98 ± 9° to 121 ± 15° (p < 0.01).CONCLUSIONS:Botulinum toxin injections should be considered as a simple therapeutic approach in patients with obstructed defecation. The treatment is safe and effective, especially with the use of the ultrasonographic guidance that accounts for a more precise injection and consequently better long-term results. Otherwise, given the limited effect of the toxin, repeated injections may be necessary to maintain the clinical improvement.

Botulinum neurotoxin to treat chronic anal fissure: results of a randomized ‘Botox vs. Dysport’ controlled trial

Background : Botulinum neurotoxin induces healing in patients with idiopathic fissure. The optimal dosage is not well established.

Outlet type constipation in Parkinson's disease: results of botulinum toxin treatment

Background : Constipation is one of the most common autonomic dysfunctions observed in Parkinsons disease.

End-to-end versus end-to-side stapled anastomoses after anterior resection for rectal cancer.

Sphincter‐saving procedures for resection of mid and, in some cases, of distal rectal tumors have become prevalent as their safety have been established. Increased anastomotic leak rate, associated with the type of anastomosis and the distance from the anal verge, has been reported. To compare surgical outcomes of end‐to‐end and end‐to‐side anastomosis after anterior resection for T1–T2 rectal cancer.

Botulinum toxin for recurrent anal fissure following lateral internal sphincterotomy.

The aim of the study was to evaluate the efficacy of botulinum toxin injection in the treatment of recurrent anal fissure following lateral internal sphincterotomy.

Management of bladder, prostatic and pelvic floor disorders

Since its introduction in the late 1970s for the treatment of strabismus and blepharospasm, botulinum toxin (BoNT) has been increasingly used in the interventional treatment of several other disorders characterized by excessive or inappropriate muscle contractions. Over the years, the number of primary clinical publications has grown exponentially, and still continues to increase. It has been shown that BoNT blocks cholinergic nerve endings in the autonomic nervous system but does not block non-adrenergic non-cholinergic responses mediated by nitric oxide (NO).The present paper reviews a number of recent clinical indications for urological and pelvic floor dysfunctions, such as overactive and neurogenic bladder, non-bacterial prostatitis, benign prostatic hyperplasia, chronic anal fissure, or conditions associated to hyperactivity of the puborectalis muscle during straining. These indications provide a new promising palette of indications for future usage of BoNT in clinical practice.

Botulinum toxin for chronic anal fissure after biliopancreatic diversion for morbid obesity

AIM To study the effect of botulinum toxin in patients with chronic anal fissure after biliopancreatic diversion (BPD) for severe obesity. METHODS Fifty-nine symptomatic adults with chronic anal fissure developed after BPD were enrolled in an open label study. The outcome was evaluated clinically and by comparing the pressure of the anal sphincters before and after treatment. All data were analyzed in univariate and multivariate analysis. RESULTS Two months after treatment, 65.4% of the patients had a healing scar. Only one patient had mild incontinence to flatus that lasted 3 wk after treatment, but this disappeared spontaneously. In the multivariate analysis of the data, two registered months after the treatment, sex (P = 0.01), baseline resting anal pressure (P = 0.02) and resting anal pressure 2 mo after treatment (P < 0.0001) were significantly related to healing rate. CONCLUSION Botulinum toxin, despite worse results than in non-obese individuals, appears the best alternative to surgery for this group of patients with a high risk of incontinence.

Treating Benign Prostatic Hyperplasia with Botulinum Neurotoxin

Botulinum toxin (BoNT) has been increasingly used in the interventional treatment of several disorders; the use of this agent has extended to a plethora of conditions including focal dystonia, spasticity, inappropriate contraction in most gastrointestinal sphincters, eye movement disorders, hyperhidrosis, genitourinary disorders and aesthetically undesirable hyperfunctional facial lines. In addition, BoNT is being investigated for the control of pain, and for the management of tension or migraine headaches and myofascial pain syndrome. Benign prostatic hyperplasia (BPH) is a common condition in ageing men; the goal of therapy is to reduce the lower urinary tract symptoms (LUTS) associated with BPH and to improve the quality of life. However, medical treatment, including drugs that relax smooth muscle within the prostate and drugs that shrink the gland are not totally effective or without complications. The standard surgical treatment for BPH is progressively changing to minimally invasive therapies, but none of them has provided clear results. The use of BoNT-A to inhibit the autonomic efferent effects on prostate growth and contraction, and inhibit the abnormal afferent effects on prostate sensation, might be an alternative treatment for BPH. BoNT injections have several advantages over drugs and surgical therapies in the management of intractable or chronic disease; systemic pharmacologic effects are rare, permanent destruction of tissue does not occur, and graded degrees of relaxation may be achieved by varying the dose injected. In this paper, clinical experience over the last years with BoNT in BPH impaired patients will be illustrated.

Evaluation of multiple prognostic scores in patients with acute pancreatitis.

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