Introduction: To assess the role of botulinum toxin in the treatment of chronic anal fissure compared to conservative non-surgical treatment.
Method: A retrospective chart review was performed on all patients who presented with anal fissure for more than 4 weeks. These patients were given the option of continuing conservative management of topical analgesic, fiber and hot sitzs bath or the option of having a fissurectomy with botulinum toxin (BTX) injection. Most of our patients did not want a sphincterotomy as a first line treatment so those were excluded from the study.
Results: a total of 722 patients were diagnosed with chronic fissure from January 2000 to December 2005. 490 were female and 232 male. The average duration of the CAF was 9weeks. 115 patients underwent fissurectomy with botulinum toxin injection while 607 patients had conservative treatment. An average of 50 units of BTX were injected in those who had surgery. 697 (96percent) were in the posterior midline while the rest of the fissures were located in the anterior midline. Overall fissure healing in those who underwent BTX injections and fissurectomy was 93 percent at 4 weeks. Thirteen of those still have a visible deep fissure but was asymptomatic since the surgery. For those who failed, 5 percent went on to have lateral internal sphincterotomy which cured their fissure. None of the patients reported problems with incontinence. The average follow up was 8 months. Twenty three of the 107 patients who were healed needed repeat treatment of either LIS or BTX injection an average of 13 months after the fissure was declared healed.
Conclusion: BTX injection along with fissurectomy is a good first line surgical intervention for patient who does not want a sphincterotomy. The risk of incontinence is low and the potential benefit of a healed fissure is high. However, those patients who have extremely hypertrophied internal sphincters, they should be prepared for possible repeat treatment.