Prospective manometric assessment of botulinum toxin and its correlation with healing of chronic anal fissure.
BACKGROUND
The efficacy and pharmacokinetics of botulinum toxin for chronic anal fissure continues to be debated. Addressing both issues we prospectively assessed the manometric impact of botulinum toxin on internal anal sphincter pressure, correlating this impact with chronic anal fissure healing.


METHODS
Sixty patients with chronic fissures were assessed. Fifty-seven patients had a total of 20 units of botulinum toxin injected into the intersphincteric groove at four o'clock and eight o'clock. Patients were prospectively assessed with a linear analog pain score, bleeding score, clinical fissure score, modified St. Mark's continence score, and anorectal manometry. Each parameter was reassessed two weeks following treatment and again at three months.


RESULTS
Fifty-six patients (30 female), median age 43 (range, 17-80) years, were followed for a median of five (range, 3-15) months with fissure healing assessed 12 weeks after treatment. Physical healing and symptom control were dependent on the baseline maximum anal resting pressure and baseline fissure score (P = 0.003, P = 0.009, respectively). Although maximum anal resting pressure fell by 17 (mean, range, 0-71) percent, pressure reduction did not correlate with clinical outcome (P > 0.2). Seventeen patients reported a mean 17 percent increase in continence score. There was no correlation between deterioration in continence and baseline or subsequent reduction in maximum anal resting pressure.


CONCLUSIONS
Patients with Grade 1 lower-pressure fissures are more likely to heal following treatment with 20 units of botulinum toxin. Healing does not appear to be dependent on a reduction in maximum anal resting pressure.
Thornton
M J
MJ
Department of Colorectal Surgery, St. George Hospital and University of New South Wales, Kogarah, New South Wales, Australia.
Kennedy
M L
ML
King
D W
DW
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D001905:Botulinum Toxins / Q000009:adverse effects / Q000627:therapeutic use*; D002908:Chronic Disease; D005260:Female; D005401:Fissure in Ano / Q000188:drug therapy* / Q000503:physiopathology; D006801:Humans; D007273:Injections, Intramuscular; D016014:Linear Models; D008297:Male; D008365:Manometry; D008875:Middle Aged; D011446:Prospective Studies; D018709:Statistics, Nonparametric; D016896:Treatment Outcome; D014945:Wound Healing / Q000187:drug effects
D001905:Botulinum Toxins