EP473 - Botulinum Toxin Therapy in Ileal Pouch-Anal Anastomosis: Safe and Effective, or a Risk for Incontinence?

Purpose/Background: The use of botulinum toxin A (BTA) for the treatment of pelvic floor dysfunction and anal fissure is well established. However, the safety and efficacy of BTA in ileal pouch-anal anastomosis (IPAA) patients have not been reported. We aimed to describe our institutional experience in BTA therapy after IPAA. We hypothesized that BTA in IPAA patients would be effective and safe in the treatment of pelvic floor dysfunction and anal fissure.

Methods/Interventions: We performed a retrospective review of a prospectively maintained database for IPAA who underwent perianal BTA from 2010 - 2024. Demographics, indications for IPAA and BTA, diagnostic workup, and postoperative outcomes were recorded. Univariate analysis was used to compare efficacy of BTA, short-term, and long-term complications by indication.

Results/Outcomes: A total of 27 IPAA patients who underwent perianal BTA therapy were identified. Demographics are shown in Table 1. Median age was 48 (37 - 57) years old; 62.9% of patients were female. Most IPAA were performed open (74.1%), and in 3-stages (77.8%). The majority of patients underwent IPAA for ulcerative colitis (77.8%). Indications for BTA after IPAA (Table 2) included pelvic floor dysfunction (70.4%) or anal fissure(s) (29.6%). Twenty patients (74.1%) had a diagnostic workup with manometry and defecography. Perianal BTA therapy improved symptoms in 66.7%, did not affect symptoms in 22.2%, and caused temporary worsening of function in 11.1%. After initial BTA, 9 (33.3%) patients underwent repeat BTA therapy. Short-term (90 day) complications were observed in 5 patients (18.5%), including temporary fecal incontinence (n=2, 7.4%), spasms >30 days (n=1, 3.7%), perianal ulcer (n=1, 3.7%), and worsening anal fissure (n=1, 3.7%) associated with a new diagnosis of Crohn's disease. When efficacy was compared by indication (pelvic floor vs. fissure) for BTA (57.9% vs 87.5%, p=0.2), no statistically significant differences were found. No long-term complications due to perianal BTA therapy were observed. Short-term complication rate for BTA for anal fissure was 37.5% versus 10.5% in pelvic floor dysfunction (p=0.1). Overall, pouch failure was seen in 11 patients (40.7%) due to the following indications: fistula (7/11, 63.6%), anastomotic sinus (3/11, 27.3%), and chronic pouchitis (1/11, 9.1%).

Conclusion/Discussion: In our experience, Botulinum toxin A therapy for pelvic floor dysfunction and fissures in IPAA patients improved symptoms in most patients, with a low rate of adverse events, including temporary fecal incontinence, which was comparable to the literature on perianal BTA (6-10% complication rate). Our findings suggest BTA is safe and effective, and not contraindicated, in pouch patients.

Table 1. Demographic, operative and postoperative data on IPAA patients who have undergone perianal BTA, 2010 - 2024 (N=27).
Figures represent frequency (proportion) or median (IQR). IQR, interquartile range; BMI, body mass index; UC, ulcerative colitis; TPC, total proctocolectomy; UTI, urinary tract infection; GI, gastrointestinal.
Table 2. Indications, perioperative data, and outcomes of perianal BTA therapy in IPAA patients, 2010 - 2024 (N=27).
Figures represent frequency (proportion) or median (IQR).

*Phenotypic switching to Crohn's disease.