title: Surgical versus chemical (botulinum toxin) sphincterotomy for chronic anal fissure: long-term results of a prospective randomized clinical and manometric study.
abstract: BACKGROUND
  The aim of this prospective randomized trial was to compare the effectiveness and morbidity of surgical versus chemical sphincterotomy in the treatment of chronic anal fissure after a 3-year follow-up.
  
  
  METHODS
  Eighty patients with chronic anal fissure were treated by whether open lateral internal sphincterotomy (group 1) or chemical sphincterotomy with 25 U botulinum toxin injected into the internal sphincter (group 2). Clinical and manometric results were analyzed.
  
  
  RESULTS
  Overall healing was 92.5% in the open sphincterotomy group and 45% in the toxin botulinum group (P<.001). There is a group of patients with clinical (duration of disease >12 months and presence of a sentinel pile before treatment) and manometric factors (persistently elevated mean resting pressure, % of time presence of slow waves, and number of patients or the time presence ultra slow waves after treatment) associated with a higher recurrence of anal fissure. The final percentage of incontinence was 5% in the open sphincterotomy group and 0% in the botulinum toxin group (P>.05).
  
  
  CONCLUSIONS
  We recommend surgical sphincterotomy as the first therapeutic approach in patients with clinical and manometric factors of recurrence. We prefer the use of botulinum toxin in patients older than 50 years or with risk factors for incontinence, despite the higher rate of recurrence, since it avoids the greater risk of incontinence in the surgical group.
authors.affiliation: Coloproctology Unit, Department of Surgery, University Hospital of Elche, Elche (Alicante), Spain. arroyocir@hotmail.com
authors.forename: Antonio
authors.initials: A
authors.lastname: Arroyo
authors.forename: Francisco
authors.initials: F
authors.lastname: Pérez
authors.forename: Pilar
authors.initials: P
authors.lastname: Serrano
authors.forename: Fernando
authors.initials: F
authors.lastname: Candela
authors.forename: Javier
authors.initials: J
authors.lastname: Lacueva
authors.forename: Rafael
authors.initials: R
authors.lastname: Calpena
mesh_terms: D000328:Adult; D000704:Analysis of Variance; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D002908:Chronic Disease; D013505:Digestive System Surgical Procedures / Q000379:methods*; D005260:Female; D005401:Fissure in Ano / Q000175:diagnosis / Q000188:drug therapy* / Q000601:surgery*; D005500:Follow-Up Studies; D006801:Humans; D007273:Injections, Intramuscular; D008297:Male; D008365:Manometry; D008875:Middle Aged; D011336:Probability; D011446:Prospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016896:Treatment Outcome
chemical_list: D019274:Botulinum Toxins, Type A