Quinn R, Ellis-Clark J, Albayati S
Department of Colorectal Surgery, Nepean Hospital, Derby St, Kingswood, NSW, 2747, Australia.
Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
Tech Coloproctol. 2025 May 22;29(1):118. doi: 10.1007/s10151-025-03153-z.
Despite the superior success rate of lateral internal sphincterotomy for managing chronic anal fissure (CAF), there is a trend towards sphincter-preserving treatment due to the increased risk of incontinence. Botulinum toxin (BT) and fissurectomy are two sphincter-preserving options for CAF. We aim to assess if combining fissurectomy with botox treatment is superior to botulinum toxin alone in the management of CAF.
This retrospective cohort study was conducted across two Sydney hospitals over 7 years. All patients with a CAF managed with either BT and fissurectomy (group 1) or BT only (group 2) were included. Primary outcome was healing rate defined as resolution or significant improvement of perianal symptoms at initial follow-up. Secondary outcomes were persistence, recurrence, re-intervention and faecal incontinence rate. Follow-up questionnaire was conducted to compare long-term outcomes between the two groups.
Fifty-seven patients met the inclusion criteria (group 1, 37; group 2, 20). Mean BT dose and injection location between the groups were similar (p = 0.259 and p = 0.427). There was a 65% response rate to the follow-up questionnaire. Median follow-up was 34.3 months (range 0.4-93). There was no difference in healing (56.7% vs. 50%, p = 0.561), recurrence (37.8% vs. 30%, p = 0.383) or re-intervention rate (13.5% vs. 20%, p = 0.888). Long-term incontinence rate was significantly higher in patients group 2 (0% vs. 10%, p = 0.010), with two patients reporting persistent flatus incontinence. Median overall satisfaction score was 3/4 (range 1-4), in both groups (p = 0.469).
Botulinum toxin with or without fissurectomy is a safe sphincter-sparing treatment option for CAF. However, the addition of fissurectomy to BT does not improve healing rates and we therefore recommend BT injection alone as a second-line treatment of CAF in patients who fail topical treatment.
尽管侧方内括约肌切开术治疗慢性肛裂（CAF）的成功率较高，但由于失禁风险增加，目前存在一种保留括约肌治疗的趋势。肉毒杆菌毒素（BT）和肛裂切除术是CAF的两种保留括约肌的治疗选择。我们旨在评估肛裂切除术联合肉毒杆菌毒素治疗在CAF管理中是否优于单独使用肉毒杆菌毒素治疗。
这项回顾性队列研究在悉尼的两家医院进行，为期7年。纳入所有采用BT联合肛裂切除术（第1组）或仅采用BT（第2组）治疗的CAF患者。主要结局是愈合率，定义为初次随访时肛周症状缓解或显著改善。次要结局包括持续性、复发率、再次干预率和大便失禁率。通过随访问卷比较两组的长期结局。
57例患者符合纳入标准（第1组37例；第2组20例）。两组之间的平均BT剂量和注射部位相似（p = 0.259和p = 0.427）。随访问卷的回复率为65%。中位随访时间为34.3个月（范围0.4 - 93个月）。在愈合率（56.7%对50%，p = 0.561）、复发率（37.8%对30%，p = 0.383）或再次干预率（13.5%对20%，p = 0.888）方面没有差异。第2组患者的长期失禁率显著更高（0%对10%，p = 0.010），有两名患者报告持续性排气失禁。两组的总体满意度中位数评分均为3/4（范围1 - 4）（p = 0.469）。
肉毒杆菌毒素联合或不联合肛裂切除术是CAF一种安全的保留括约肌的治疗选择。然而，在BT基础上加用肛裂切除术并不能提高愈合率，因此我们建议对于局部治疗失败的CAF患者，单独注射BT作为二线治疗方法。
