Management of complicated chronic anal fissures with high-dose circumferential chemodenervation (HDCC) of the internal anal sphincter.
BACKGROUND
Botulinum toxin injection into the internal anal sphincter (IAS) is gaining popularity as a second line therapy for chronic anal fissures after patients fail medical therapy. The dosage of Botulinum toxin reported in the literature ranged from 20 to 50 IU. Complicated chronic anal fissure is defined as persistent fissure concurrent with other perianal pathology. We report a new approach involving high-dose circumferential chemodenervation (HDCC) of 100 IU in treating these complicated chronic anal fissures.


OBJECTIVE
The aim of this study was to evaluate the fissure healing, complication, and recurrence rates with HDCC.


METHODS
Complicated anal fissure was defined as fissure with other perianal pathologies including skin tag, hypertrophied papilla, fistula, symptomatic hemorrhoids, anal condylomata, and abscess. Between 2008 and 2012, 62 consecutive patients (28 Blacks, 33 Whites, 1 Hispanic) with complete follow-up data were included in this single arm study. These patients underwent HDCC-IAS with addition interventions by a single colorectal surgeon. Follow up data were obtained by chart review and office follow up.


RESULTS
Of the 62 patients, the overall success rate was greater than 70% at 3 months follow-up. A few patients developed transient flatus or fecal incontinence, but shortly resolved. There was no major complication following HDCC-IAS.


CONCLUSIONS
Combination therapy involving HDCC-IAS and local anorectal surgery for associated condition is both safe and effective for fissure healing.
Division of Gastroenterology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA.
James Z
JZ
Whatley
Division of Gastroenterology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA. Electronic address: stang@umc.edu.
Shou-Jiang
SJ
Tang
Division of Gastroenterology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA.
Porter H
PH
Glover
Division of Gastroenterology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA.
Eric D
ED
Davis
Division of Gastroenterology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA.
Kellen T
KT
Jex
Division of Gastroenterology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA.
Ruonan
R
Wu
Department of Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA.
Christopher J
CJ
Lahr
D001003:Anal Canal / Q000294:innervation*; D001905:Botulinum Toxins / Q000008:administration & dosage*; D002908:Chronic Disease; D004305:Dose-Response Relationship, Drug; D005242:Fecal Incontinence / Q000209:etiology / Q000628:therapy*; D005260:Female; D005401:Fissure in Ano / Q000150:complications / Q000628:therapy*; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D009364:Neoplasm Recurrence, Local / Q000601:surgery; D009407:Nerve Block / Q000379:methods*; D009498:Neurotoxins / Q000008:administration & dosage; D016896:Treatment Outcome
D009498:Neurotoxins; D001905:Botulinum Toxins
Botulinum toxin; Chronic anal fissure; Healing rate; High-dose circumferential chemodenervation; Injection; Lateral internal sphincterotomy