Systematic Reviews
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Pharmacol Ther. Aug 6, 2016; 7(3): 453-462
Published online Aug 6, 2016. doi: 10.4292/wjgpt.v7.i3.453
Efficacy and safety of botulinum toxin in treatment of anismus: A systematic review
Sameh Hany Emile, Hossam Ayman Elfeki, Hosam Ghazy Elbanna, Mohamed Youssef, Waleed Thabet, Tito M Abd El-Hamed, Basem Said, Ahmed Lotfy
Sameh Hany Emile, Hossam Ayman Elfeki, Hosam Ghazy Elbanna, Mohamed Youssef, Waleed Thabet, Tito M Abd El-Hamed, Basem Said, Ahmed Lotfy, General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University, Mansoura City 35516, Dakahlia Providence, Egypt
Author contributions: Emile SH designed the review; Emile SH and Elfeki HA conducted the search and acquisition and analysis of data; Emile SH, Elfeki HA and Youssef M wrote the manuscript; Elbanna HG, Abd El-Hamed TM and Said B contributed to data interpretation, writing and critical revision of the manuscript; Thabet W, Said B and Lotfy A shared in data analysis, drafting and critical revision of the manuscript; all authors approved the final version of the manuscript.
Conflict-of-interest statement: All the authors declare that they have no competing interests.
Data sharing statement: Technical appendix, statistical code, and dataset are available from the corresponding author at sameh200@hotmail.com. Informed consents of patients were obtained by the original studies included in the review.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Sameh Hany Emile, MD, Lecturer of General Surgery, General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University, Elgomhuoria Street, Mansoura City 35516, Dakahlia Providence, Egypt. sameh200@hotmail.com
Telephone: +20-100-6267150 Fax: +20-50-239733
Received: February 29, 2016
Peer-review started: February 29, 2016
First decision: June 16, 2016
Revised: June 20, 2016
Accepted: July 11, 2016
Article in press: July 13, 2016
Published online: August 6, 2016
Processing time: 154 Days and 7.3 Hours
Abstract

AIM: To evaluate the efficacy and safety of botulinum toxin type A (BTX-A) in the management of patients with anismus.

METHODS: An organized search of published literature was conducted using electronic databases including: PubMed/MEDLINE, and Cochrane Central Register of Controlled Trials, also an internet-based search using “Google Scholar” service was conducted. Both comparative and observational studies were included. We excluded irrelevant articles, editorials, case reports, reviews, and meta-analyses. The studies that followed the patients less than 6 mo were excluded. Variables collected were demographic data of the patients, technique of BTX-A injection and number of sessions, short-term and long-term clinical improvement, post-injection changes in electromyography (EMG), defecography, manometry, and balloon expulsion test, and complications recorded after BTX-A injection.

RESULTS: Seven studies comprising 189 patients were included in the review. The median age of the patients was 41.2 years and female-to-male ratio was 1.3:1. The median dose of BTX-A injected per procedure was 100 IU (range, 20-100 IU). Lateral injection was done in five trails and combined lateral and posterior injections in two trials. Three studies used endorectal ultrasonography-guided technique, one study used EMG-guided technique, whereas the remaining three studies used manual palpation with the index finger. The median percentage of patients who reported initial improvement of symptoms was 77.4% (range 37.5%-86.7%), this percentage declined to a median of 46% (range 25%-100%) at 4 mo after injection of BTX-A. Rates of improvement evaluated by balloon expulsion test, EMG, and defecography ranged between (37.5%-80%), (54%-86.7%), and (25%-86.6%), respectively. Fourteen (7.4%) patients developed complications after injection of BTX-A. Complication rates across the studies ranged from 0% to 22.6%.

CONCLUSION: Initial satisfactory improvement of symptoms after BTX-A injection remarkably deteriorated after 3 mo of the procedure. However, repeated injection may provide better sustained results with no additional morbidities. Further analysis of more patients is necessary to conclude the safety of BTX-A for the treatment of anismus.

Keywords: Botulinum toxin; Botulinum toxin type A; Botox; Anismus; Puborectalis syndrome; Efficacy

Core tip: Injection of botulinum toxin type A (BTX-A) is a simple, technically feasible outpatient procedure. The initial satisfactory improvement of symptoms after BTX-A injection remarkably deteriorates after three months of the procedure from a median rate of 77.4% to 46%. However, repeated injections may provide better sustained results with no additional morbidities. The endorectal ultrasonography- and electromyography-guided techniques do not add significant value regarding both initial and long-term improvement. Combined lateral and posterior injections do not offer better results than lateral injection alone, on the contrary they can lead to higher complication rates. Although most of the studies reported very low complication rates after BTX-A injection; further studies on a larger number of patients are necessary to conclude the safety of this treatment.