title: Fissurectomy combined with anoplasty and injection of botulinum toxin in treatment of anterior chronic anal fissure with hypertonia of internal anal sphincter: a pilot study.
abstract: BACKGROUND
  In patients affected by anterior chronic anal fissure (CAAF) with hypertonia of the internal anal sphincter (IAS), the role of IAS hypertonia remains unclear. The aim of this study was to evaluate the efficacy of fissurectomy combined with advancement flap and IAS injection of botulinum toxin in healing the CAAF with hypertonia of IAS resistant to medical therapy.
  
  
  METHODS
  Ten consecutive patients were enrolled. Anorectal manometry was performed preoperatively and at 6 months. CAAF with hypertonia was defined as those associated with maximum resting pressure (MRP) values higher than 85 mmHg. All patients underwent fissurectomy and anoplasty with advancement skin flap combined with the intrasphincter injection of 30 UI of botulinum toxin. Complete healing, MRP changes, relief of symptoms and immediate and long-term complications were recorded.
  
  
  RESULTS
  Complete healing was observed in all patients within 30 days of the operation. The intensity and duration of pain post-defecation was reduced significantly starting from the first defecation. In all subjects, the preoperative MRP values were significantly reduced at 6 months. One month after surgery, three patients reported anal incontinence, two of them had complained preoperatively. The only postoperative complications were minor.
  
  
  CONCLUSIONS
  Fissurectomy combined with advancement flap and intrasphincter injection of botulinum toxin results in complete healing, significant MRP reduction and full relief of symptom in all patients, thus it represents a valid procedure in preventing the occurrence of anal incontinence.
authors.affiliation: Department of Surgical and Oncological Science, Division of General Surgery, University of Palermo, Via Liborio Giuffrè no 5, Palermo, Italy.
authors.forename: R
authors.initials: R
authors.lastname: Patti
authors.forename: F
authors.initials: F
authors.lastname: Famà
authors.forename: A
authors.initials: A
authors.lastname: Tornambè
authors.forename: G
authors.initials: G
authors.lastname: Asaro
authors.forename: G
authors.initials: G
authors.lastname: Di Vita
mesh_terms: D000293:Adolescent; D000328:Adult; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage / Q000627:therapeutic use*; D015331:Cohort Studies; D003672:Defecation; D005260:Female; D005401:Fissure in Ano / Q000150:complications / Q000188:drug therapy* / Q000601:surgery*; D006801:Humans; D007273:Injections, Intramuscular; D008297:Male; D008875:Middle Aged; D009122:Muscle Hypertonia / Q000150:complications / Q000188:drug therapy* / Q000601:surgery; D009465:Neuromuscular Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D010865:Pilot Projects; D020127:Recovery of Function; D013524:Surgical Flaps; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A