1. Gastroenterol Clin Biol. 2008 Jun-Jul;32(6-7):667-70. Epub 2008 May 12.

Combined fissurectomy and botulinum toxin injection. A new therapeutic approach

for chronic anal fissures.
Soll C, Dindo D, Hahnloser D.
Department of Visceral and Transplantation Surgery, University Hospital Zurich,
Raemistrasse 100, 8091 Zurich, Switzerland.
PMID: 18468825 [PubMed - indexed for MEDLINE]

2. Gastroenterol Clin Biol. 2007 Nov;31(11):985-92.

[Anal fissure]
[Article in French]
de Parades V, Daniel F, Atienza P.
Service de proctologie médico-interventionnelle, Goupe hospitalier
Diaconesses-Croix Saint-Simon, Paris. proctologie@hopital-dcss.org
PMID: 18166891 [PubMed - indexed for MEDLINE]

3. Afr Health Sci. 2007 Mar;7(1):14-7.

Botulinum toxin treatment for anal fissure.
Radwan MM, Ramdan K, Abu-Azab I, Abu-Zidan FM.
Department of Surgery, Al-Ain Hospital, Al-Ain, United Arab Emirates.
OBJECTIVES: To evaluate the effectiveness of Botulinum toxin injection in the
treatment of anal fissure. METHODS: 38 patients (22 males, 16 females; mean age
(SD) of 33.3 (8.3) years) who have presented to Surgical Outpatient Clinic at Al
Ain Hospital, United Arab Emirates, with anal fissure in the period between June
2000 and September 2001 and treated with Botulinum toxin injection were
retrospectively studied. They were followed up for at least 8 weeks to evaluate
the effects of treatment. RESULTS: Treatment with Botulinum toxin was effective
in 89% of patients with chronic uncomplicated anal fissure. Two patients
experienced minor incontinence in the form of a fecal soiling which disappeared
later. CONCLUSION: Botulinum toxin injection is an effective alternative for
surgery for treatment of uncomplicated idiopathic anal fissure. Surgery should b
e
offered to patients who do not improve with Botulinum toxin injection and to
those with complicated anal fissure.

PMCID: PMC2366122
PMID: 17604520 [PubMed - indexed for MEDLINE]

4. Aliment Pharmacol Ther. 2006 Jul 15;24(2):247-57.

Systematic review: the treatment of anal fissure.
Steele SR, Madoff RD.
Department of Surgery, Madigan Army Medical Center, Tacoma, WA, USA.
Comment in:
Aliment Pharmacol Ther. 2006 Dec;24(11-12):1651-2; author reply 1652.
BACKGROUND: Anal fissure is one of the most common anorectal conditions
encountered in clinical practice. Most patients experience anal pain with
defecation and minor bright red rectal bleeding, allowing a focused history to
direct the evaluation. METHODS: A systematic medical literature search of NIH,
Pubmed, and MEDLINE using the search terms anal fissure, sphincterotomy, anal
surgery and anal fissure medical therapy. English language was not a restriction
.
Cited references were used to find additional studies. RESULTS: No single
treatment is the best choice for all patients. Because pharmacological therapy i
s
not associated with permanent alterations in continence, a trial of either a
topical sphincter relaxant or botulin toxin injection, along with adequate fluid
and fibre intake, is a reasonable option. However, because pharmacological
therapy has lower healing and higher relapse rates, surgery can be offered in th
e
first instance to patients without incontinence risk factors who have severe,
unrelenting pain and are willing to accept a small risk of incontinence, for the
highest likelihood of prompt healing and the lowest risk of recurrence.
CONCLUSIONS: Both non-operative and operative approaches currently exist for the
management of anal fissure. Improved non-surgical therapies may continue to
lessen the role of sphincter-dividing surgery in future.

PMID: 16842451 [PubMed - indexed for MEDLINE]

5. J Gastrointestin Liver Dis. 2006 Jun;15(2):143-7.

Lateral subcutaneous internal sphincterotomy in the treatment of chronic anal
fissure: our experience.
Liratzopoulos N, Efremidou EI, Papageorgiou MS, Kouklakis G, Moschos J, Manolas
KJ, Minopoulos GJ.
1st Department of Surgery, University General Hospital, Alexandroupolis, Greece.
BACKGROUND: Chronic anal fissure is the most common cause of anal pain associate
d
with internal anal sphincter hypertonia. Reduction of hypertonia favours fissure
healing. Temporary reduction in sphincter tone can be achieved by conservative
treatment. Surgical sphincterotomy achieves permanent reduction of sphincter
hypertonia and is very successful at healing anal fissures, but requires an
operation with associated small morbidity. METHODS: A study was undertaken on 24
6
patients (120 men, 126 women, mean age 48.3 years), undergoing subcutaneous
lateral internal sphincterotomy for a chronic fissure-in-ano from January 1, 198
1
to December 31, 2004. Therapeutical outcome, postoperative course and early and
long-term results were recorded. RESULTS: During the study period, the 246
patients underwent total subcutaneous lateral internal sphincterotomy, 62 of the
m
under general anesthesia (1981-1991), and the remainder under local anesthesia.
Two-hundred-forty-two patients returned for their postoperative visits at 2, 6,
24 and 48 weeks, while four patients were lost to follow-up. At 3 months
postoperatively, 97.5% of fissures had healed; 224 fissures were healed by 6
weeks, 10 by 7 weeks and 2 by 3 months. Pain was significantly reduced in all
patients at Day 1 postoperative. Minor complications included hematoma (0.8%) an
d
pain (0.4%). New minor incontinence was seen in 7.02% of patients at 48-week
follow up. Patients' satisfaction was 91.7%. CONCLUSIONS: Total subcutaneous
internal sphincterotomy is a safe and effective treatment for chronic anal
fissures, that only rarely impairs continence to flatus.

PMID: 16802009 [PubMed - indexed for MEDLINE]

6. Can J Surg. 2006 Feb;49(1):41-5.

Nonsurgical treatment of chronic anal fissure: nitroglycerin and dilatation
versus nifedipine and botulinum toxin.
Tranqui P, Trottier DC, Victor C, Freeman JB.
Division of General Surgery, University of Ottawa, The Ottawa Hospital - General
Campus, Ottawa. ptranqui@hotmail.com
BACKGROUND: Surgical sphincterotomy for chronic anal fissure can cause fecal
incontinence. This has led to the investigation of nonsurgical treatment options
that avoid permanent damage to the internal anal sphincter. METHODS: We conducte
d
a retrospective, ongoing chart review with telephone follow-up of 88 patients
treated for chronic anal fissure between November 1996 and December 2002. During
the first half of the study period, patients were treated with topical
nitroglycerin and pneumatic dilatation. With the availability of new therapies i
n
June 1999, subsequent patients received topical nifedipine and botulinum toxin
injections (30-100 units). Lateral anal sphincterotomy was reserved for patients

who failed medical treatment. RESULTS: In 98% of patients the fissure healed wit
h
conservative nonsurgical treatment. The combination of nifedipine and botulinum
toxin was superior to nitroglycerin and pneumatic dilatation with respect to bot
h
healing (94% v. 71%, p < 0.05) and recurrence rate (2% v. 27%, p < 0.01). There
was no statistical difference between the number of dilatations and botulinum
toxin injections needed to achieve healing. Three patients who received botulinu
m
toxin reported mild transient flatus incontinence. At an average telephone
follow-up of 27 months, 92% of patients reported having no pain or only mild
occasional pain with bowel movements. CONCLUSIONS: Chronic anal fissures can be
simply and effectively treated medically without the risk of incontinence
associated with sphincterotomy. Topical nifedipine and botulinum toxin injection
s
are an excellent combination, associated with a low recurrence rate and minimal
side effects.

PMID: 16524142 [PubMed - indexed for MEDLINE]

7. Cir Esp. 2005 Dec;78 Suppl 3:24-7.

[Treatment of chronic anal fissure]
[Article in Spanish]
García-Granero E, Muñoz-Forner E, Mínguez M, Ballester C, García-Botello S, Lledó
S.
Unidad de Coloproctología, Servicio de Cirugía, Hospital Clínico Universitario,
Universidad de Valencia, Avda. Blasco Ibáñez 17, 46010 Valencia, Spain.
eggranero@telefonics.net
Current treatment of chronic anal fissure continues to be based on conventional
conservative measures in a high percentage of cases. What is known as chemical
sphincterotomy aims to achieve a temporary decrease of anal pressures that allow
s
fissures to heal. There are various alternatives such as nitroglycerine or
diltiazem ointment and botulinum toxin injections. However, because of collatera
l
effects and recurrences in the medium term, the definitive role of these
treatments remains to be elucidated. Nevertheless, chemical sphincterotomy shoul
d
be the first option in patients with a high risk of incontinence. "Open" or
"closed" lateral internal sphincterotomy performed in the ambulatory setting wit
h
local anesthesia can currently be considered the ideal treatment of chronic anal
fissure refractory to conservative measures so long as the patient is informed
about the risk of minor incontinence. This procedure provides rapid and permanen
t
recovery in more than 95% of patients. There is evidence demonstrating that the
incontinence rate is related to the extent of the lateral internal sphincterotom
y
and consequently the extent of this procedure should be reduced to the length of
the fissure.

PMID: 16478612 [PubMed - indexed for MEDLINE]

8. Cir Esp. 2005 Aug;78(2):68-74.

[Treatment of chronic anal fissure]
[Article in Spanish]
Arroyo A, Pérez-Vicente F, Serrano P, Candela F, Sánchez A, Pérez-Vázquez MT,
Calpena R.
Servicio de Cirugía General y Aparato Digestivo, Hospital General Universitario
de Elche, Elche, Alicante, Spain. arroyocir@hotmail.com
Comment in:
Cir Esp. 2005 Nov;78(5):337-8; author reply 338.
Chronic anal fissure is a common benign anorectal problem in Western countries
that substantially impairs the patient's life. Consequently, a rapid and
effective solution is required. We reviewed the various treatments for chronic
anal fissure described in the literature, with the aim of establishing a
therapeutic protocol. We recommend surgical sphincterotomy (preferably open or
closed lateral sphincterotomy) as the first therapeutic approach in patients wit
h
chronic anal fissure. However, we prefer the use of chemical sphincterotomy
(preferably botulinum toxin) in patients aged more than 50 years old and in thos
e
with previous incontinence, risk factors for incontinence (previous anal surgery
,
multiple vaginal births, diabetes, inflammatory bowel disease, etc.), or without
anal hypertonia, despite the higher recurrence rate with medical treatments,
since this procedure avoids the greater risk of residual incontinence described
in the literature with surgical sphincterotomy in this group of patients.

PMID: 16420800 [PubMed - indexed for MEDLINE]

9. Ann Saudi Med. 2005 Mar-Apr;25(2):140-2.

Botulinum toxin injection versus internal anal sphincterotomy for the treatment
of chronic anal fissure.
Massoud BW, Mehrdad V, Baharak T, Alireza Z.
Department of Surgery, Afzalipour Hospital, Kerman, Iran. mbaghaiw@yahoo.com
BACKGROUND: Anal fissure is a chronic condition characterized by painful
defecation and rectal bleeding. The aim of this study was to compare injection o
f
botulinum toxin versus surgical sphincterotomy for treatment of chronic anal
fissure. PATIENTS AND METHODS: In a quasi-experimental trial in a university
hospital in Kerman, 50 patients diagnosed with chronic anal fissure received 20
units botulinum toxin (n=25) or underwent lateral internal sphincterotomy (n=25)
.
All patients were evaluated for pain, bleeding and healing of the fissure from
one to six months later by another surgeon. The data was analyzed by SPSS
software with the Mann-Whitney and Fisher's exact tests. RESULTS: One month afte
r
treatment, the rate of healing and bleeding in the operation group was better
than in the toxin group (P<0.05), while pain was equal. After two months, none o
f
the patients in either group had complications. After six months follow-up,
bleeding, pain and healing were better in the operation group. CONCLUSION: In th
e
clinical evaluation, botulinum toxin is an effective alternative nonsurgical
modality for the treatment of chronic anal fissure. We recommend botulinum toxin
as the first step in treatment because of the 60% chance of cure with an easily
performed treatment.

PMID: 15977693 [PubMed - indexed for MEDLINE]

10. Rev Esp Enferm Dig. 2004 Dec;96(12):856-63.
Open lateral internal anal sphincterotomy under local anesthesia as the gold
standard in the treatment of chronic anal fissures. A prospective clinical and
manometric study.
[Article in English, Spanish]
Sánchez Romero A, Arroyo Sebastián A, Pérez Vicente F, Serrano Paz P, Candela
Polo F, Tomás Gómez A, Costa Navarro D, Fernández Frías A, Calpena Rico R.
General Surgery Department and Service of Digestive Diseases, Hospital General
Universitario, Elche, Alicante, Spain. anasanchez2@yahoo.com
BACKGROUND: Chronic anal fissure is one of the most frequent proctological
disorders in Western populations. Open lateral internal sphincterotomy is one of
the therapeutic options accepted as the treatment of choice for chronic anal
fissure, since it reduces the hypertonia of the internal anal sphincter (the mai
n
etiopathogenic mechanism of fissures), decreases anal pain, and allows the
fissure to heal. MATERIAL AND METHODS: We carried out a prospective study of 120
patients operated on for chronic anal fissure with open sphincterotomy under
local anesthesia at our Proctology Outpatient Unit from 1998 to 2001. No
preoperative studies, bowel preparation, or antibiotic prophylaxis were carried
out. All patients were followed up after 1 week, 2 months, 6 months, and 1 year,
and underwent an anal manometry before and after surgery. RESULTS: Early
complications: 3 hematoma-ecchymosis of the wound (2.5%), 3 self-limited
hemorrhage events (2.5%). No hemorrhoidal thrombosis, fistulas, or perianal
abscesses occurred. Fissures recurred in nine patients (7.5%) within one year.
The initial rate of incontinence of 7.5% at two months dropped down to 5% at six
months. The mean resting pressure (MRP) in incontinent patients was lower than i
n
continent patients (55 +/- 7 mmHg versus 80.7 +/- 21 mmHg). The difference in
mean squeeze pressure (MSP) between incontinent patients and continent patients
was not statistically significant. CONCLUSIONS: Open sphincterotomy under local
anesthesia has a long-term rate of healing and a morbidity rate similar to other
techniques. It may therefore be considered an effective treatment for chronic
anal fissure.

PMID: 15634186 [PubMed - indexed for MEDLINE]

11. Tidsskr Nor Laegeforen. 2003 Dec 4;123(23):3366-7.

[Surgical treatment of anal fissure]
[Article in Norwegian]
Landsend E, Johnson E, Johannessen HO, Carlsen E.
Gastrokirurgisk avdeling, Ullevål universitetssykehus, Oslo.
egil.johnson@ulleval.no
BACKGROUND: Anal fissure is very painful; surgery is warranted when medical
treatment fails. MATERIAL AND METHOD: We present a retrospective study of 34
patients (median age 42; 19-63) treated by subcutaneous lateral internal
sphincterotomy (n = 27) and anal dilatation (n = 7) from 1992 to 2002, carried
out by a questionnaire on pain, anal incontinence, and treatment result. RESULTS
:
There were no complications or treatment for recurrence of anal fissure. Median
pain score before surgery was 7.3 on a scale from 0 (no pain) to 10 (worst
imaginable pain), median 73 months (4-124) after surgery the median score was 0
(0-5) (p = 0.00). For sphincterotomy (n = 27), the median score was 7.8 before
surgery and 0 (0-5) after (p = 0.00), for anal dilatation 6 (3-10) before surger
y
and 2 (0-2) (p = 0.01) after. All patients had reduced pain scores after surgery
but their incontinence scores remained unchanged. Two patients (7%) who had
previously been dilated or irradiated developed faecal incontinence after
sphincterotomy. More patients became asymptomatic after sphincterotomy (n = 18;
67%) than after anal dilatation (n = 4; 57%). INTERPRETATION: Compared to anal
dilatation, sphincterotomy offers better pain relief for anal fissure. Doing a
shorter sphincterotomy corresponding to length of the fissure reduces the risk o
f
anal incontinence.

PMID: 14713969 [PubMed - indexed for MEDLINE]