De Robles Marie Shella, Young Christopher J
Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; The University of Sydney, Discipline of Surgery, Sydney, New South Wales, Australia.
Asian J Surg. 2022 Jan;45(1):184-188. doi: 10.1016/j.asjsur.2021.04.027. Epub 2021 May 6.
Lateral internal sphincterotomy (LIS) remains the gold standard surgical approach for the management of chronic anal fissures (CAF). The procedure however, is complicated by the risk of postoperative incontinence. Intrasphincteric Botulinum Toxin (BT) has gained popularity as an alternative approach, despite being inferior to LIS with regards to cure rates. In the real world, patients at high risk for postoperative incontinence are likely to be offered BT as a preliminary procedure. The aim of this study was to explore the real-world outcomes of LIS and BT for a cohort of CAF patients.
251 consecutive patients treated with either BT or LS for CAF by a single surgeon were reviewed. Patients were offered BT as a preliminary procedure if they had risk factors for faecal incontinence, whereas all other patients underwent LIS. Primary outcomes included rates of recurrence and faecal incontinence.
LIS was superior to BT with regards to recurrence rates throughout the mean follow up period of five years (5% vs 15%, p = 0.012). A total of 17 patients experienced a minor degree of flatal incontinence at the 6-week follow up, although there was no difference between LIS and BT (7% vs 6%, p = 1.000). Four LIS patients (2%) continued to experience some minor incontinence to flatus at the 12-month follow up and were managed with biofeedback.
For patients with CAF, individualizing the treatment approach according to risk factors for incontinence could mitigate this risk in LIS. High risk patients should be offered BT as a preliminary procedure.
外侧内括约肌切开术（LIS）仍然是慢性肛裂（CAF）治疗的金标准手术方法。然而，该手术存在术后失禁的风险。括约肌内注射肉毒杆菌毒素（BT）作为一种替代方法已受到欢迎，尽管在治愈率方面不如LIS。在现实世界中，术后失禁高风险患者可能会先接受BT治疗。本研究的目的是探讨一组CAF患者接受LIS和BT治疗的实际效果。
回顾了由一名外科医生对251例连续接受BT或LIS治疗CAF的患者。如果患者有大便失禁的风险因素，则先接受BT治疗，而所有其他患者接受LIS治疗。主要结局包括复发率和大便失禁率。
在平均五年的随访期内，LIS在复发率方面优于BT（5%对15%，p = 0.012）。共有17例患者在6周随访时出现轻度排气失禁，尽管LIS和BT之间无差异（7%对6%，p = 1.000）。4例LIS患者（2%）在12个月随访时仍有轻度排气失禁，并接受生物反馈治疗。
对于CAF患者，根据失禁风险因素个体化治疗方法可降低LIS的这种风险。高风险患者应先接受BT治疗。
