Treatment of chronic anal fissure using fissurectomy combined with botulinum toxin

Background Fissurectomy and lateral internal sphincterotomy are the two most widely used surgical procedures for treatment of chronic anal fissure. A combined treatment consisting of fissurectomy and intrasphincteric injection of botulinum toxin was proposed to solve problems caused by the abovementioned methods: the lack of sphincter relaxation after sole fissurectomy and permanent fecal incontinence following lateral sphincterotomy. Material and methods A systemic review of the literature was performed using the keywords "fissurectomy" and "botulinum toxin" or "botox". The combined treatment technique includes an excision of fibrotic fissure margins and the secondary characteristics of chronic anal fissure: skin tags, hypertrophic anal papilla and injection of 20-100 & x202f;IU of botulinum toxin into the internal anal sphincter. Results Few retrospective studies were identified, mostly without any control population. The combined treatment leads to complete resolution or improvement of symptoms 6-12 weeks after treatment in up to 90% of patients. A temporary fecal incontinence (soiling) was observed in approximately 7% of patients. Complete healing was achieved in 73-93% of cases, however, the results varied greatly. Conclusion An injection of botulinum toxin additionally to fissurectomy leads to favorable short- and long-term results with low morbidity; however, there is a need for further high-quality studies.