Surgical versus nonsurgical treatment of infected pancreatic necrosis: more arguments to change the paradigm.

OBJECTIVES: This study aimed to compare primary surgical versus nonsurgical treatment in a series of patients with infected pancreatic necrosis (IPN) and to investigate whether the success of nonsurgical approach is related to a less severe disease. METHODS: Thirty-nine consecutive patients with IPN have been included and further subdivided into two groups: primary surgical (n = 21) versus nonsurgical (n = 18). Outcome measures were the differences in mortality, morbidity, and pancreatic function. Comorbidity, organ failure, and other severity indexes were compared between the two groups. RESULTS: Mortality occurred in 16.7% of cases in the nonsurgical group versus 42.9% in the surgical group. In the primary nonsurgical group, seven were operated on due to failure of initial conservative treatment. In this latter group, mortality was 28.6% and was performed significantly later than in the primary surgical group. The group of primary surgical treatment was associated with a significant higher rate of multiple organ failure (MOF) at IPN diagnosis, new onset or worsening of organ failure, and MOF and nosocomial infection after surgery. CONCLUSIONS: Initial nonsurgical approach in IPN is associated with better results both in cases which respond to this treatment as well as in those who, failing this conservative approach, have to be operated on after a delayed period. Primary surgically treated patients had a more severe disease at the time of IPN.

Malondialdehyde in early phase of acute pancreatitis.

AIMS: to assess oxidative stress in acute pancreatitis, its evolution over time and its relationship with the severity of the disease. METHODS: during a two-year period, patients with acute pancreatitis with less than 24 hours of pain were evaluated. Serum was obtained the first, second and fourth day from admittance, if complications were detected, and after recovery. Malondialdehyde was determined by high performance liquid chromatography. Twenty healthy volunteers constituted the control group. Malondialdehyde between groups was compared with Mann-Whitney and Kruskal-Wallis tests; malondialdehyde evolution was studied with Wilcoxon test. RESULTS: one hundred and sixty-nine patients were included (91 women, median age 67 years, range 20-95); 33 suffered a severe episode. Malondialdehyde decreased from first to fourth day (0.600 vs. 0.451 vs. 0.343 M, respectively, p < 0.05). When complications were detected, malondialdehyde level was similar to that of first and second day (0.473 M, p > 0.05). In severe attacks malondialdehyde was higher than in control group at day 2 (severe: 0.514; mild: 0.440; control: 0.347 M, p < 0.05 severe vs. control). CONCLUSIONS: an early oxidative stress is observed in acute pancreatitis. In severe attacks, oxidative stress remains high longer than in mild episodes. The onset of complications is associated with high malondialdehyde concentration.

Malondialdehído en la fase inicial de la pancreatitis aguda / Malondialdehyde in early phase of acute pancreatitis

Objetivos: valorar el estrés oxidativo en la pancreatitis aguda, su evolución a lo largo del tiempo y su relación con la gravedad de la enfermedad. Métodos: durante un periodo de dos años, se estudiaron los pacientes ingresados por pancreatitis aguda con dolor abdominal de menos de 24 horas de evolución. Se obtuvo suero de los pacientes el primer, segundo y cuarto día de ingreso, en el momento en que se detectaban complicaciones y tras la recuperación. La concentración de malondialdehído fue determinada utilizando cromatografía líquida de alta resolución. Veinte voluntarios sanos conformaron el grupo control. La concentración de malondialdehído entre los diferentes grupos se comparó utilizando el test de Mann-Whitney y el test de Kruskal-Wallis; la evolución de malondialdehído se valoró mediante el test de Wilcoxon. Resultados: se incluyeron 169 pacientes (91 mujeres, edad mediana 67 años, rango 20-95); 33 sufrieron un episodio grave. La concentración de malondialdehído descendió desde el primer al cuarto día (0,600 vs. 0,451 vs. 0,343 M, respectivamente, p < 0,05). Cuando se detectaban complicaciones, los niveles de malondialdehído eran similares a los del primer y segundo día (0,473 μM, p > 0,05). En los episodios graves la concentración de malondialdehído fue superior que en el grupo control en el día 2 (grave: 0,514; leve: 0,440; control: 0.347 μM, p < 0,05 grave vs. control). Conclusiones: en la pancreatitis aguda existe un estrés oxidativo precoz. En los episodios graves, el estrés oxidativo permanece elevado durante más tiempo que en los episodios leves. El desarrollo de complicaciones se asocia a una elevada concentración de malondialdehído(AU)

Aims: to assess oxidative stress in acute pancreatitis, its evolution over time and its relationship with the severity of the disease. Methods: during a two-year period, patients with acute pancreatitis with less than 24 hours of pain were evaluated. Serum was obtained the first, second and fourth day from admittance, if complications were detected, and after recovery. Malondialdehyde was determined by high performance liquid chromatography. Twenty healthy volunteers constituted the control group. Malondialdehyde between groups was compared with Mann-Whitney and Kruskal-Wallis tests; malondialdehyde evolution was studied with Wilcoxon test. Results: one hundred and sixty-nine patients were included (91 women, median age 67 years, range 20-95); 33 suffered a severe episode. Malondialdehyde decreased from first to fourth day (0.600 vs. 0.451 vs. 0.343 μM, respectively, p < 0.05). When complications were detected, malondialdehyde level was similar to that of first and second day (0.473 M, p > 0.05). In severe attacks malondialdehyde was higher than in control group at day 2 (severe: 0.514; mild: 0.440; control: 0.347 μM, p < 0.05 severe vs. control). Conclusions: an early oxidative stress is observed in acute pancreatitis. In severe attacks, oxidative stress remains high longer than in mild episodes. The onset of complications is associated with high malondialdehyde concentration(AU)

Methotrexate induced sprue-like syndrome.

A 52 year-old male patient diagnosed of ankylosing spondylitis presented with an iron deficiency anemia after a ten-month treatment of methotrexate. He did not respond to treatment with oral iron not a proton pump inhibitor and an upper endoscopy was performed. The histological study of the duodenal biopsies showed villus atrophy. After removing the methotrexate, administering intramuscular iron and undertaking a gluten-free diet, the histological and analytical alterations progressively resolved.

Morphological and functional evaluation of the pancreatic duct with secretin-stimulated magnetic resonance cholangiopancreatography in alcoholic pancreatitis patients.

OBJECTIVES: The aim of this investigation was to evaluate the pancreatographic findings and dynamics of pancreatic duct diameter, as determined by secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP), in patients with acute alcoholic pancreatitis or chronic alcoholic pancreatitis and in a control group. METHODS: S-MRCP was performed in patients with acute alcoholic pancreatitis who did not manifest the functional and radiological (ultrasonography and computed tomography) criteria of chronic pancreatitis (n = 21), in patients with chronic alcoholic pancreatitis (n = 28) and in a control group (n = 16). The diameter of the main pancreatic duct (MPD) was monitored before secretin administration and at 3 and 10 min after secretin administration. Morphological features were also assessed before and after the administration of secretin. RESULTS: All ductal diameters were significantly larger in chronic alcoholic pancreatitis (P < 0.0001). There were no differences in MPD caliber between patients with acute alcoholic pancreatitis and the control group. The percentage of variation between basal MPD diameter and at 3 min post-secretin administration was lower in patients with chronic (35.5%) pancreatitis than in those with acute alcoholic pancreatitis (52.3%) and the control group (52.5%). There were no significant differences between patients with acute alcoholic pancreatitis and the control group in terms of the frequency of visualization of side branches, ductal narrowing, intraluminal filling defects, and ductal irregularity. One patient with acute alcoholic pancreatitis presented ductal criteria of chronic pancreatitis following the administration of secretin. CONCLUSIONS: The dynamics of MPD visualized on S-MRCP in patients with acute alcoholic pancreatitis is similar to that observed in the control group and different from that observed in patients with chronic alcoholic pancreatitis. There were no significant differences between patients with acute alcoholic pancreatitis and the control group in terms of morphological pancreatographic features.

Eradication of Helicobacter pylori for the prevention of peptic ulcer rebleeding.

AIM: To evaluate the effect of Helicobacter pylori eradication on ulcer bleeding recurrence in a prospective, long-term study including more than 400 patients. METHODS: Patients with peptic ulcer bleeding were prospectively included. H. pylori infection was confirmed by rapid urease test, histology or (13)C-urea breath test. Several eradication regimens were used. Ranitidine 150 mg was administered daily until eradication was confirmed by breath test 8 weeks after completing eradication therapy. Patients with therapy failure received a second or third course of therapy. Patients with eradication success did not receive maintenance anti-ulcer therapy, and were controlled yearly with a repeated breath test. RESULTS: Four hundred and twenty-two patients were followed up for at least 12 months, with a total of 906 patient-years of follow up. Mean age was 59 years, and 35% were previous nonsteroidal anti-inflammatory drug (NSAID) users. Sixty-nine percent had duodenal, 24% gastric, and 7% pyloric ulcer. Recurrence of bleeding was demonstrated in two patients at 1 year (incidence: 0.22% per patient-year of follow up), which occurred after NSAID use in both cases. CONCLUSION: Peptic ulcer rebleeding does not occur in patients with complicated ulcers after H. pylori eradication. Maintenance anti-ulcer (antisecretory) therapy is not necessary if eradication is achieved.

Factors predicting poor prognosis in ischemic colitis.

AIM: To determine the clinical, analytical and endoscopic factors related to ischemic colitis (IC) severity. METHODS: A total of 85 patients were enrolled in a retrospective study from January 1996 to May 2004. There were 53 females and 32 males (age 74.6+/-9.4 years, range 45-89 years). The patients were diagnosed as IC. The following variables were analyzed including age, sex, period of time from the appearance of symptoms to admission, medical history, medication, stool frequency, clinical symptoms and signs, blood tests (hemogram and basic biochemical profile), and endoscopic findings. Patients were divided in mild IC group and severe IC group (surgery and/or death). Qualitative variables were analyzed using chi-square test and parametric data were analyzed using Student's t test (P<0.05). RESULTS: The mild IC group was consisted of 69 patients (42 females and 27 males, average age 74.7+/-12.4 years). The severe IC group was composed of 16 patients (11 females and 5 males, average age of 73.8+/-12.4 years). One patient died because of failure of medical treatment (no surgery), 15 patients underwent surgery (6 after endoscopic diagnosis and 9 after peroperatory diagnosis). Eight of 85 patients (9.6%) died and the others were followed up as out-patients for 9.6+/-3.5 mo. Demographic data, medical history, medication and stool frequency were similar in both groups (P>0.05). Seriously ill patients had less hematochezia than slightly ill patients (37.5% vs 86.9%, P = 0.000). More tachycardia (45.4% vs 10.1%, P = 0.011) and a higher prevalence of peritonism signs (75% vs 5.7%, P = 0.000) were observed in the severe IC group while the presence and intensity of abdominal pain were similar between two groups. Two patients with severe IC had shock when admitted. Regarding analytical data, more seriously ill patients were found to have anemia and hyponatremia than the mildly ill patients (37.5% vs 10.1%, P = 0.014 and 46.6% vs 14.9%, P = 0.012, respectively). Stenosis was the only endoscopic finding that appeared more frequently in seriously ill patients than in slightly ill patients (66.6% vs 17.3%, P = 0.017). CONCLUSION: The factors that can predict poor prognosis of IC are the absence of hematochezia, tachycardia and peritonism, anemia and hyponatremia and stenosis.

Congenital splenic cyst treated with percutaneous sclerosis using alcohol.

We report a case of successful percutaneous treatment of a congenital splenic cyst using alcohol as the sclerosing agent. A 14-year-old female adolescent presented with a nonsymptomatic cystic mass located in the spleen that was believed to be congenital. After ultrasonography, a drainage catheter was placed in the cavity. About 250 ml of serous liquid was extracted and sent for microbiologic and pathologic studies to rule out an infectious or malignant origin. Immediately afterwards, complete drainage and local sclerotherapy with alcohol was performed. This therapy was repeated 8 days later, after having observed 60 ml of fluid in the drainage bag. One year after treatment the cyst has practically disappeared. We believe that treatment of splenic cyst with percutaneous puncture, ethanolization, and drainage is a valid option and it does not rule out surgery if the conservative treatment fails.

Angiodisplasia intestinal asociada a estenosis subaórtica hipertrófica: ¿una variante del síndrome de Heyde? / Intestinal angiodysplasia and hypertrophic subaortic stenosis: is it a Heyde’s syndrome variant?

No disponible

MRI evaluation of inflammatory activity in Crohn's disease.

OBJECTIVE: We wanted to assess the capability of MRI to quantitatively evaluate the therapeutic response to Crohn's disease (CD) relapse. SUBJECTS AND METHODS: Twenty patients with histologically proven CD were prospectively evaluated with MRI and ileocolonoscopy over a 2-year period. The MRI protocol included axial and coronal T2-weighted and contrast-enhanced T1-weighted sequences. MRI examinations were performed twice, once during an acute relapse of CD and the other at clinical remission. The terminal ileum and colon were divided into six segments/patient, and the endoscopy and histology findings were considered the standard of reference. These were compared on a segmental basis with the quantitative MRI findings regarding wall thickness and contrast enhancement. The results obtained in active and remission CD phases were likewise compared with the findings in 10 control subjects who underwent complete ileocolonoscopy for other reasons and had no pathological findings on ileocolonoscopy. RESULTS: Fifty three of 120 (44.2%) bowel segments showed pathologic changes on endoscopy and histology consistent with CD in active phase. On changing from the active disease phase to clinical remission, a significant decrease was observed in the wall thickness and contrast enhancement of the affected bowel wall. In the active phase of CD, the pathologic bowel segments presented with significantly greater contrast enhancement and wall thickness values compared with the healthy segments of CD and controls. On converting clinically into remission, contrast enhancement tended to normalize, whereas bowel wall thickness remained increased compared with the controls. CONCLUSION: MRI is able to detect pathologic bowel segments in CD, as it allows the measurement of significant variations in wall thickness and contrast enhancement on changing from the active phase of the disease to remission.

Recurrence of acute gallstone pancreatitis and relationship with cholecystectomy or endoscopic sphincterotomy.

OBJECTIVES: To determine the prevalence of recurrence of gallstone pancreatitis, its clinical features, and the presence of prognostic factors of recurrence. METHODS: From January 1, 2000 to August 31, 2003, 233 patients admitted with acute gallstone pancreatitis (AGP) were prospectively studied. Patients were divided into two groups: recurrent and nonrecurrent group. Clinical, analytical, radiological, prognostic parameters, and severity (Atlanta criteria) were assessed, along with the performance of cholecystectomy or endoscopic sphincterotomy (ES). Clinical features of recurrence were analyzed. Univariate (chi(2), Student's t-test) and multivariate tests were performed. Statistical significance was assumed if p < 0.05. RESULTS: Two hundred and eighty-six attacks were identified. Forty-two patients (18.2%) recurred, suffering 53 recurrent attacks, which took place within 30 days in 23.3%. Patients who did not undergo surgery after the first attack had 31-fold risk of recurrence (OR = 31.5%, CI = 95%[7.22-137.84], p < 0.001). In patients not operated, recurrence was more frequent if ES was not performed (37.04%vs 0%, p= 0.019). Among patients with surgical risk, none who recurred underwent ES, compared with 27.9% of those who did not recur. Patients in the nonrecurrent group underwent cholecystectomy within the first 30 days or ES more frequently (31.2%vs 7.3%, p= 0.001). CONCLUSIONS: Recurrence of gallstone pancreatitis is a frequent event. Delay of cholecystectomy implies an increased risk of recurrence. ES could be an acceptable option to prevent recurrence in patients who are not candidates for surgery or who do not desire to undergo cholecystectomy.

Outcome of esophageal function and 24-hour esophageal pH monitoring after vertical banded gastroplasty and Roux-en-Y gastric bypass.

BACKGROUND: One of the co-morbidities frequently associated with morbid obesity is gastro-esophageal reflux disease (GERD), present in >50 % of morbidly obese individuals. We compared the anti-reflux effect of vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass (RYGBP), and their effect on esophageal function. METHODS: 10 patients underwent VBG and 40 patients underwent RYGBP. Anthropometric parameters, symptomatology of GERD, esophageal manometry (EM), isotopic esophageal emptying (IEE) and 24 hr esophageal pH monitoring were recorded in all patients preoperatively, and at 3 months and 1 year postoperatively. RESULTS: Preoperatively, there was a high prevalence of GERD, symptomatic and pH-metric in both groups (57% and 80% respectively). The preoperative values of EM and IEE parameters were within the normal range in most patients. After surgery, there was an improvement at 3 months postoperatively in both groups. 1 year after surgery, the VBG group presented symptomatic GERD in 30% and pH-metric reflux in 60% of patients while the RYGBP group presented symptomatic GERD and pH-metric reflux in 12.5% and 15% of patients, respectively. There was an increase in postoperative sensation of dysphagia in both groups (70% VBG, 30% RYGBP) one year after operation. After surgery, differences in all EM parameters were minimal, and never reached statistical significance for any group (VBG and RYGBP). The IEE showed a significantly higher percentage of esophageal retention after surgery, but this retention was always within the normal range. Both groups had an improvement in anthropometric parameters, but 1 year after surgery the results were significantly better in RYGBP patients (70% excess weight loss) than in VBG patients (46% excess weight loss). CONCLUSION: >50% of morbidly obese individuals suffer from GERD. We did not find changes in esophageal function of morbidly obese patients to explain their gastroesophageal reflux preoperatively and postoperatively. EM and IEE studies are not indicated as standard preoperative tests, except in patients with significant symptoms of gastroesophageal reflux. RYGBP is significantly better than VBG as an anti-reflux procedure, and had better weight loss.

A risk score system for identification of patients with upper-GI bleeding suitable for outpatient management.

BACKGROUND: The aim of this study was to develop a risk score system for identification of patients with upper-GI hemorrhage who are suitable for outpatient management. METHODS: From a prospective cohort of 983 consecutive patients with upper-GI hemorrhage not associated with portal hypertension, 581 cases that did not meet pre-established criteria for admission were selected, and a logistic regression analysis was performed to identify factors associated with two adverse outcomes: recurrent bleeding and/or the need for emergency surgery. The risk score system was developed by using the beta coefficients of the logistic model, and its performance was evaluated. The results of this model were combined with pre-established criteria for admission to build a simplified scoring system for identification of patients who can be managed safely on an outpatient basis. RESULTS: Chronic alcoholism, active malignancy, prior upper digestive tract surgery, wasting syndrome, hemodynamic compromise, duodenal ulcer as the cause of upper-GI hemorrhage, and hemorrhage of unknown cause were independently associated with a greater risk of unfavorable outcomes in the group that did not meet pre-established criteria for admission. The logistic model showed a high capacity for discrimination (C statistic: 0.87) and good calibration (p value for Hosmer-Lemeshow goodness-of-fit test, 0.62), with a sensitivity of 100% and specificity of 64%. The simplified score had a sensitivity of 100% and specificity of 29% for adverse outcomes, and sensitivity of 78% and specificity of 38% for mortality. CONCLUSIONS: The score system developed in this study may be helpful in deciding between hospitalization and outpatient management for patients with upper-GI hemorrhage, but it remains to be validated in patient groups other than those used for its development.

Predictive value of the balloon expulsion test for excluding the diagnosis of pelvic floor dyssynergia in constipation.

BACKGROUND AND AIMS: The aim of this study was to establish a simple method to exclude the possibility of pelvic floor dyssynergia (PFD) in constipated patients and thus avoid unnecessary expensive physiologic studies. METHODS: Patients with suspicion of functional constipation (FC) were studied prospectively between 1994 and 2002, excluding those with severe systemic, psychological, or symptomatic anorectal/colonic disorders or taking medications that might modify symptoms or results of studies. Diagnosis of PFD was established retrospectively by manometric plus defecographic findings according to Rome II criteria. Two groups of patients were identified: FC without PFD (FC group) and PFD group. A 30-day symptom diary and balloon expulsion test results were evaluated in all patients. Clinical differences and results of the expulsion test were statistically compared between groups. RESULTS: Of 359 patients evaluated, 130 were included (FC group, 106; PFD group, 24). According to data from the diary, only anal pain was more frequent in the PFD group compared with the FC group (anal pain in >25% of defecations, 70.8% vs. 40.6%; P < 0.05, chi(2) test). The expulsion test was pathologic in 21 of 24 patients with PFD and 12 of 106 without PFD. The specificity and negative predictive value of the test for excluding PFD were 89% and 97%, respectively. CONCLUSIONS: The balloon expulsion test is a simple and useful screening procedure to identify constipated patients who do not have PFD. Symptoms are not enough to differentiate between subtypes of constipation.

Chronic Anal Fissure.

Diagnosis of chronic anal fissure is easy and common in clinical practice. Little is known about the etiology and pathogenesis of this disorder. Current investigations consider anal sphincteric hypertonia and ischemia as primary factors in the appearance and maintenance of this lesion. Recurrence rate after healing is high, so anal fissure may be a chronic disease that evolves depending on sphincteric features. Conservative measures to avoid constipation, including fiber intake, are useful to improve symptomatology, achieve healing, and reduce recurrence. Surgical treatment is the most effective procedure for chronic anal fissure. Lateral internal sphincterotomy achieves healing in most cases (more than 95%) and the recurrence rate is low (1% to 3%). However, permanent fecal incontinence may appear after surgery and available data about this complication are controversial. In recent years, chemical sphincterotomy has been developed as an option in the treatment of chronic anal fissure. This medical option aims to achieve the effectiveness of surgery without side effects, by means of a temporary decrease of anal pressures that allows fissures to heal. Local injection of botulinum toxin into the anal sphincter is the most successful medical option, nearly as effective as surgery and without significant adverse effects (transitory episodes of mild fecal incontinence). Although more studies are needed to establish the method of administering this treatment, in our opinion botulinum toxin is an effective option in a high percentage of cases, especially in patients who risk developing incontinence. Compared with botulinum toxin, topical nitroglycerine ointments, which produce a transitory sphincteric relaxation, have the advantage of being a simple and accessible procedure. However, we think that this option should not be a first choice because its effectiveness is lower compared with surgery (about 60% to 70%), its compliance with the application could be poor, and it has a greater percentage of side effects (eg, headache). Other topical treatments (eg, calcium channel antagonist or cholinergic agonists agents) appear to be as effective as nitroglycerine agents and do not have significant adverse effects, but little data exist about these options. In our opinion, treatment of chronic anal fissure must be individualized, depending on the clinical profile of patients. Medical treatment, especially injection of botulinum toxin, should be taken into account if risk for developing incontinence is suspected.

Elevated serum eotaxin levels in patients with inflammatory bowel disease.

OBJECTIVE: Eotaxin is a recently characterized chemokine with potent and selective chemotactic activity for eosinophils. Previous studies indicating that eosinophils accumulate and become activated in inflammatory bowel disease (IBD) led us to hypothesize that eotaxin is potentially involved in the pathophysiology of IBD and, therefore, that eotaxin would be increased in the serum of patients with IBD. The objective of this study was to test those assumptions. METHODS: We investigated 72 patients with IBD, 35 with ulcerative colitis, and 37 with Crohn's disease. A total of 27 patients had active and 45 inactive disease; 26 were receiving corticosteroids. Eotaxin serum levels were determined by solid phase sandwich ELISA. Lymphocytes, monocytes, and granulocyte subpopulations were determined in fresh blood samples with an automated autoanalyzer. RESULTS: Serum eotaxin levels were significantly higher in patients with Crohn's disease and in those with ulcerative colitis than in the control subjects (p < 0.0001). Patients with inactive Crohn's disease had significantly higher levels of eotaxin than patients with inactive ulcerative colitis (p < 0.05). We did not find significant differences for activity or inactivity of disease, nor for treatment with prednisone. A negative correlation (p < 0.05) was found between eotaxin serum level and eosinophil counts in peripheral blood in patients with Crohn's disease. CONCLUSIONS: There is an increased expression of eotaxin in IBD patients, suggesting that eotaxin may be involved in the pathogenesis of IBD. This increase is more accentuated in Crohn's disease and negatively correlates with the eosinophil number in peripheral blood. Our data support the increasing evidence that eosinophil are functionally involved in the pathophysiology of IBD.

Long-term follow-up (42 months) of chronic anal fissure after healing with botulinum toxin.

BACKGROUND & AIMS: Botulinum toxin is an effective treatment in idiopathic chronic anal fissure, but the long-term outcome after healing is not well documented. We analyzed the long-term outcome of patients in whom an anal fissure had healed after botulinum toxin injection and the factors contributing to recurrence. METHODS: Fifty-seven patients who had completely healed 6 months after injection of botulinum toxin were reassessed every 6 months. The follow-up was 42 months in all patients. Clinical and manometric differences between the permanently healed and the relapsed group were statistically analyzed. RESULTS: Four patients were lost to follow-up. A fissure recurrence was shown in 22 patients (41.5%). Statistical differences between the permanently healed and the relapsed group were detected when analyzing the anterior location of the fissure (6% vs. 45%), a longer duration of the disease (38% vs. 68%), the need for reinjection (26% vs. 59%), a higher total dose injected to achieve definitive healing (13% vs. 45%), and the percentage decrease of maximum squeeze pressure after injection (-28% vs. -13%; P < 0.05). CONCLUSIONS: The late recurrence rate of chronic anal fissure is high when the effect of botulinum toxin disappears. The highest risk of recurrence is associated with anterior location of the anal fissure, prolonged illness, the need for reinjection and for high doses to achieve healing, and a lower decrease of maximum squeeze pressure after treatment.