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Follow-Up Results of Combination Treatment of Chronic Anal Fissure.
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| Author:
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YU.A.SHELYGIN , O.V.TKALICH, A.A.PONOMARENKO, O.YU.FOMENKO, R.YU.KHRYUKIN, K.I.ARSLANBEKOVA, V.K.MISIKOV, E.E.ZHARKOV
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| Abstract:
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Introduction: Despite the fact that the incidence of anal incontinence after lateral subcutaneous sphincterotomy can reach 35%, this technique for the rectum internal sphincter relaxation is still the "gold standard" of anal fissure treatment. Over the past 50 years, any attempts by investigators to reduce the incidence of anal incontinence (ASI) have been associated with the decreased treatment efficacy or increased frequency of relapse in the follow-up postoperative period. The authors have studied the follow-up (patient follow-up period over 1 year) results of randomized study ISRCTN97413456.
Objective: Improvement of the chronic anal fissure treatment outcomes.
Patients and Methods: 80 patients were enrolled in the study and randomized in 2 groups by a random number generation using computer software. In 40 patients the fissure excision was combined with botulinum toxin type A (incobotulinumtoxinA, total 10 U) injection into the internal anal sphincter (study group) and in 40 patients it was combined with pneumodivulsion of the anal sphincter (control group). The follow-up results of the treatment were studied in 26 patients (16 patients in the study group and 10 patients in control group). The average duration of the follow-up period was 15.7 (5.5; 21.7) months. Patients called in to the clinic were subjected to clinical examination, profilometry and sphincterometry.
Results: Amid 13 patients with ASI observed earlier on day 60 after surgical intervention (3 patients in the study group and 10 patients in control group), the sphincter ani externum incompetence persisted in only 8 (33.3%) subjects in control group (p=0.0009). No patients in control group had relapses, which were observed in only 6 patients (21.4%) in the study group (BTA). The univariate analysis has found the predictors of postoperative anal sphincter incompetence and disease relapses.
Conclusion: The use of botulinum toxin type A for the internal sphincter relaxation helps to reduce the incidence of postoperative anal incontinence compared to pneumodivulsion, though it is associated with a higher frequency of disease relapse. The risk of anal incontinence is increased in women with a history of multiple births, and the risk of disease relapse increases, if the sphincter spasm persists in the postoperative period; in this case, the increase in BTA dose and number of injection sites can be the possible solution requiring further studies.
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| Keyword:
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anal fissure, internal sphincter spasm, botulinum toxin type A, incobotulinumtoxinA, pneumodivulsion
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| EOI:
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| DOI:
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https://doi.org/10.31838/ijpr/2020.SP2.040
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| Download:
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