BACKGROUND: Chronic anal fissures are a painful condition characterized by a tear in the anal mucosa. Botulinum toxin injection is a minimally invasive treatment option, but long-term effectiveness in recurrent or persistent cases remain unclear. OBJECTIVE: Evaluate long-term outcomes of botulinum toxin injections for the treatment of fissures. DESIGN: Retrospective review. SETTINGS: Tertiary academic center. PATIENTS: Adults with chronic fissures treated with botulinum toxin between 2018-2023. MAIN OUTCOME MEASURES: Short and long-term healing, recurrence, or persistence after botulinum toxin injection. Persistent or recurrent fissure(s) were followed for outcomes after subsequent repeat injections or surgery (lateral internal sphincterotomy or fissurectomy). RESULTS: Among 161 patients, 45.3% (n = 73) experienced short-term healing following botulinum toxin as firstline therapy, but only 26% (n = 42) had sustained healing. Subsequent treatment patterns were similar for recurrent (n = 31) or persistent (n = 88) fissures: 35% vs 31% no further intervention, 55% vs 42% multiple subsequent injections, 10% vs 23% surgery, respectively. Sustained healing was achieved in 63% (n = 10/16) of patients who underwent surgery compared to 37% (n=14/38) who had repeat botulinum toxin injections ( p = 0.06). Only 49% achieved sustained healing after either a single injection, multiple injections, or injection(s) with surgery. Complications included 5 episodes of mild fecal incontinence in the botulinum toxin group, and two instances of surgical site infection in the surgery group. LIMITATIONS: Single institution, retrospective study, and loss to follow up. CONCLUSION: Botulinum toxin remains a valuable therapy for chronic anal fissures. Many patients have persistent or recurrent fissures after botulinum toxin injection and undergo additional interventions. Despite multiple interventions, only half of patients achieved sustained healing, regardless of treatment pattern. These data do not support the use of botulinum toxin over surgery for treatment of chronic fissures, are helpful for counseling patients about the safety profile of each and sets expectations regarding the need for multiple interventions. See Video Abstract .
Aboelmaaty et al. (Mon,) studied this question.