10 - World Journal of Gastroenterology

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and high dose (50 IU). The patients received different doses of botulinum toxin to test which dose may have a lower complication rate and higher healing rate. Statistical analysis Data have been analyzed with statistical standard methods. At the outset, we performed a univariate analysis with all the factors potentially influencing the course of disease using the χ 2 test or Fisher’s exact test for categorical data and the ANOVA test for continuous data divided in more than two groups. Subsequently, we executed a logistic multivariate regression, constructing models with the factors potentially influencing the course of disease, which by univariate analysis had a P value < 0.25. Additionally, we inserted age and sex into our multivariate analysis. Data were processed using GraphPad ® Prism Software (GraphPad, San Diego, CA, United States). P < 0.05 was considered statistically significant, regardless of the test used. RESULTS Demographic data and parameters registered at the first observation are reported in Table 1. Specifically, we observed 21 (35.6%) male patients and 38 (64.4%) females, aged between 21 years and 61 years (average: 40.49 ± 10.63 years). We did not observe prevalence of the considered disease in patients of a particular age: we observed 12 (20.3%) patients aged ≤ 30 years, 19 (32.2%) aged 31-40 years, 15 (25.4%) aged 41-50 years, and 13 (22.0%) aged > 50 years. The anal fissure was localized posteriorly in 91.5% and anteriorly in 5.1% of the patients. In 31 (52.5%) patients, symptoms started in the 7 mo before the clinical observation and treatment with botulinum toxin. 98.3% of cases (58 patients) were referred with post-defecatory pain, which tended to persist independently from the evacuation in 22 patients (37.3%) and during the night in 17 (28.8%). Bleeding, even mild, was reported in 44 patients (74.6%), and 22.0% complained of mucorrhea. The relaxation of puborectal muscle was documentable at the physical examination in almost all patients (98.3%). Associated anal or systemic pathology due to obesity was observed in only 11.9% and 39.0% of patients, respectively. As regards defecation characteristics, 50 patients (84.7%) were referred for diarrhea and evacuation of feces with decreased consistency. In 89.8% of cases, the number of weekly evacuations was > 7. Only three patients (5.1%) were referred for forced evacuations, a sense of incomplete evacuation, and continuous utilization of laxatives and evacuative enemas. In almost all patients, botulinum toxin was injected into the internal anal sphincter, at the anterior midline (56 cases). No patients received local anesthesia and/or systemic sedation, and in all patients, the internal sphincter was easily identified with digital palpation alone (Table 2). Healing after treatment with botulinum toxin We observed 45 and 26 patients at 1 mo and 2 mo, re- WJG|www.wjgnet.com Vanella S et al . Botulinum toxin after bariatric surgery Table 1 Parameters considered in the analysis of 59 patients who were treated with botulinum toxin for chronic anal fissure and had previously undergone biliopancreatic diversion Age (yr) Frequency Percent (%) ≤ 30 12 20.3 31-40 19 32.2 41-50 15 25.4 > 50 13 22.0 Sex Female 38 64.4 Male 21 35.6 Duration of symptoms (mo) ≤ 7 31 52.5 > 7 28 47.5 Postdefecatory anal pain Present 58 98.3 Absent 1 1.7 Nocturnal anal pain Present 17 28.8 Absent 42 71.2 Anal pain unrelated to defecation Present 22 37.3 Absent 37 62.7 Bleeding Present 44 74.6 Absent 15 25.4 Mucorrhea Present 13 22.0 Absent 46 78.0 Other anal pathologies Present 7 11.9 Absent 52 88.1 Extra-anal pathologies Present 23 39.0 Absent 36 61.0 Defecation pattern Normal 5 8.5 Diarrhea 50 84.7 Constipation 4 6.8 Stool consistency Formed 5 8.5 Soft 50 84.7 Hard 4 6.8 Number of evacuations per week ≤ 7 6 10.2 > 7 53 89.8 Straining Present 3 5.1 Absent 56 94.9 Incomplete evacuations Present 3 5.1 Absent 56 94.9 Laxative use Yes 3 5.1 No 56 94.9 Enemas/suppositories use Yes 3 5.1 No 56 94.9 Location of fissure Posterior midline 54 91.5 Anterior midline 3 5.1 Others 2 3.4 spectively. One month after treatment with botulinum toxin, healing was observed in 68.9% of patients. Only one patient developed mild incontinence to flatus that 1023 March 14, 2012|Volume 18|Issue 10|
Vanella S et al . Botulinum toxin after bariatric surgery Table 2 Results of treatment with botulinum toxin A lasted 3 wk after treatment but disappeared spontaneously. Two months after treatment, no patient had incontinence. At the same time, the complete cicatrization of the fissure, with no residual specific symptoms, was evident in 65.4% of patients. Healing persisted for a period of 32.2 ± 33.9 mo (range: 0-141 mo). Manometric results At the first observation, before treatment, resting anal pressure was 107.1 ± 20.0 mmHg and maximal voluntary squeezing was 78.2 ± 17.0 mmHg. One month after treatment with botulinum toxin, the mean resting pressure and maximum voluntary squeeze pressure were 21.2% (84.4 ± 23.6 mmHg, P < 0.0001) and 9.3% (70.9 ± 18.3 mmHg, P = 0.03) lower, respectively, than the respective baseline values. Two months after treatment, the mean resting anal pressure was similar to the 1-mo value (P = 0.7) and was 23.2% lower than the baseline value (82.3 ± 22.7 mmHg, P < 0.0001). The maximum voluntary squeeze pressure did not differ significantly from the 1-mo value (P = 0.9) and was 10.4% lower than the baseline value (70.1 ± 19.2 mmHg, P = 0.05) (Table 3). Univariate analysis The considered parameters were compared with the healing rate at 1 mo and 2 mo after treatment with botulinum WJG|www.wjgnet.com Frequency Percent (%) Botox dose 20 IU 3 5.1 30 IU 11 18.6 50 IU 45 76.3 Site of injection Unspecified - internal sphincter 1 1.7 Posterior side internal sphincter 2 3.4 Anterior side internal sphincter 56 94.9 Resting anal tone Normal 1 1.7 Increased 58 98.3 Maximal voluntary anal squeeze Normal 4 6.8 Increased 53 89.8 Decreased 2 3.4 Pubo-rectal muscle relaxation Present 58 98.3 Absent 1 1.7 Table 3 Manometric data before, and 1 and 2 mo after botulinum toxin treatment (mean ± SD) Time Resting anal pressure (mmHg) Maximum voluntary anal squeeze pressure (mmHg) Baseline 107.1 ± 20.0 78.2 ± 17.0 1 mo 84.4 ± 23.6 b 70.9 ± 18.3 a 2 mo 82.3 ± 22.7 b 70.1 ± 19.2 All patients were included in all evaluations. a P = 0.036, b P < 0.001 vs baseline. Table 4 Univariate analysis of parameters registered 1 and 2 mo after treatment Risk factor P value 1 toxin. No demographic parameter had a direct influence on healing rate (Table 4). Both age and sex did not show a statistically significant difference (P = 0.42 and P = 0.11, respectively). None of the clinical parameters had an influence on the results. Dose and site of injection did not have a significant effect on healing rate. Multivariate analysis One month after treatment (Table 5), no significant relationship was revealed with any parameter. Two months after treatment, sex (P = 0.01), baseline resting anal pressure (P = 0.02) and resting anal pressure 2 mo after treatment (P < 0.0001) were significantly related to healing rate (Table 6). DISCUSSION P value 2 Age 0.4275 0.4034 Sex 0.1147 0.4128 Duration of symptoms 0.4566 0.4018 Post-defecatory anal pain 0.6889 NA Nocturnal anal pain 0.1008 0.1039 Anal pain unrelated to defecation 0.1507 0.1039 Bleeding 0.4669 0.1585 Mucorrhea 0.5826 0.2081 Other anal pathologies 0.1656 0.1591 Extra-anal associated pathologies 0.3223 0.133 Defecation pattern 0.3825 0.3972 Stool consistency 0.3825 0.3291 Number of evacuations/wk 0.1656 0.4197 Straining 0.2244 0.2615 Sensation of incomplete evacuation 0.2244 0.7323 Laxative use 0.2244 0.2615 Enemas/ suppositories use 0.2244 0.7323 Botulinum toxin dose 0.8151 0.1635 Resting anal tone 0.6889 NA Maximal voluntary anal squeeze 0.2094 0.6179 Puborectal muscle relaxation 0.3111 NA MVAS 0 (mmHg) 0.2457 0.7281 MVAS 1 (mmHg) 0.5292 0.4133 MVAS 2 NA 0.8272 RAP 0 (mmHg) 0.284 0.1322 RAP 1 (mmHg) 0.3513 0.0985 RAP 2 NA 0.172 Site of injection 0.0818 0.5815 MVAS 0: Maximal voluntary anal squeeze (pretreatment); MVAS 1: Maximal voluntary anal squeeze (1 mo after the treatment); MVAS 2: Maximal voluntary anal squeeze (2 mo after the treatment); RAP 0: Resting anal pressure (pretreatment); RAP 1: Resting anal pressure (1 mo after treatment); RAP 2: Resting anal pressure (2 mo after treatment). NA: Not applicable. 1: 1 mo after treatment; 2: 2 mo after treatment. It has been shown that the more aggressive a bariatric technique is, the better are the results in terms of fat loss and maintenance of that fat loss over time. and although there is an improvement in comorbidity, the price paid by the patient, in relation to undesirable and adverse side effects and associated illnesses derived from these aggres- 1024 March 14, 2012|Volume 18|Issue 10|
Page 1 and 2: World Journal of Gastroenterology W
Page 3 and 4: Phillip S Oates, Perth Ross C Smith
Page 5 and 6: Deepak N Amarapurkar, Mumbai Abhiji
Page 7 and 8: Trine Olsen, Tromsø Eyvind J Pauls
Page 9 and 10: Conor P Delaney, Cleveland Sharon D
Page 11 and 12: S Contents EDITORIAL ORIGINAL ARTIC
Page 13 and 14: Contents ACKNOWLEDGMENTS APPENDIX A
Page 16 and 17: (Table 1). Seven hundred and forty-
Page 18 and 19: 23 Yoon HM, Kim JH, Shin YM, Won HJ
Page 20 and 21: Online Submissions: http://www.wjgn
Page 22 and 23: Location known Resection Primary tu
Page 24 and 25: pathologic classification of neuroe
Page 28 and 29: Table 1 Diagnosis of definitive and
Page 30 and 31: Figure 3 Endoscopic retrograde chol
Page 38 and 39: of bariatric surgery on improvement
Page 40: © 2012 Baishideng. All rights rese
Page 43: 692 bp 501 bp 331 bp 242 bp M 1 2 3
Page 46 and 47: 750 bp 250 bp 692 bp 501 bp 331 bp
Page 48 and 49: of poor survival associated with en
Page 50 and 51: tobacillus in the AGT group (7.83
Page 52 and 53: Survival distribution function 1.00
Page 54: Endotoxin (ng/L) TNF-α (pg/mL) IL-
Page 57 and 58: Jiang JW et al . Chronic graft dysf
Page 62 and 63: certain markers including alpha-smo
Page 64 and 65: Intravenous injection Intrahepatic
Page 66 and 67: A B C D 1.4 1.2 1.0 0.8 0.6 0.4 0.2
Page 68 and 69: the host immune response by increas
Page 72 and 73: with care to prevent injury to the
Page 74 and 75: MPO activities (U/g) MDA contents (
Page 76 and 77: teers. In addition, rebamipide was
Page 80 and 81: Sterol 27-hydroxylase deficiency (C
Page 82 and 83: Table 2 Electrospray ionization-tan
Page 84 and 85:
Control Intensity, cps Intensity, c
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scribed, one presenting with biliar
Page 88 and 89:
Online Submissions: http://www.wjgn
Page 90 and 91:
ARFI-SWV (m/s) 5.00 4.00 3.00 2.00
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A ARFI-SWV (m/s) 4.5 4 3.5 3 2.5 2
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eases [16] . In the above-mentioned
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access to care, which were practica
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Hospitalization Hospitalization Ind
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has been one of the main focuses in
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Table 2 The HP- and CagA-positivity
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tala G. Is there anything to the re
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copy in children. World J Gastroent
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Table 3 Gastroscopic findings accor
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ence. Laryngoscope 2006; 116: 1422-
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cer, and significant advances have
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Park LC et al . Efficacy of bevaciz
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Law ST et al . Hepatic neoplasm-rel
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Table 5 Summary of multivariate log
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Law ST et al . Hepatic neoplasm-rel
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Zhang LH et al . TBX21 gene polymor
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compared with the wild-type mice. B
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Enzyme-linked immunosorbent assay T
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cer cells was easily observed in hu
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24 Chelouche-Lev D, Miller CP, Tell
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Shen ZW, Cao Z, You KZ, Yang ZX, Xi
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Table 1 Summary of data quality rel
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such as the concentration and relax
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ized by stem cell disorders, multi-
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SUBMISSION OF MANUSCRIPTS Manuscrip
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ic effect of Jianpi Yishen decoctio
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World Journal of Gastroenterology V
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10 - World Journal of Gastroenterology

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