P103 - Botulinum Toxin Versus Lateral Internal Sphincterotomy Quality (BLINQ) Project

Author(s)

• 

  Racquel S. Gaetani, MD (she/her/hers)

  General Surgery Resident/Colorectal Research Fellow
  LAHEY HOSPITAL AND MEDICAL CENTER
  Lahey Hospital and Medical Center
  Burlington, MA, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no financial relationships with ineligible companies.
• CM

  Cody W. Munroe, MS

  Coordinator
  Lahey Hospital and Medical Center
  Burlington, Massachusetts, United States

  Disclosure information not submitted.
• KK

  Kameron Ky, BS

  Clinical Research Coordinator
  Beth Israel Lahey Health Burlington
  Lynn, Massachusetts, United States

  Disclosure information not submitted.
• 

  Jonathan S. Abelson, MD MS (he/him/his)

  Staff Surgeon
  Lahey Hospital and Medical Center
  Tufts Medical Center
  Arlington, MA, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no financial relationships with ineligible companies.
• 

  Tess H. Aulet, MD (she/her/hers)

  Colorectal Surgeon
  UMass Memorial Medical Center
  UMass Memorial Medical Center
  Worcester, Massachusetts, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no relevant relationships with ineligible companies.
• 

  Vanessa Marie Baratta, MD, MHS

  Colon and Rectal Surgeon
  Colon and Rectal Surgeons of Greater Hartford
  Ivoryton, Connecticut, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no financial relationships with ineligible companies.
• 

  Olga Beresneva, MD

  Colorectal surgeon. Assistant professor.
  Boston University/Boston Medical Center
  Boston, Massachusetts, United States

  Disclosure information not submitted.
• 

  Liliana Bordeianou, MD, MPHFASCRS

  Professor of Surgery
  Harvard Medical School; Mass General Brigham Division Colon and Rectal Surgery
  Harvard
  Boston, MA, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no relevant relationships with ineligible companies.
• 

  Marcella Bradway, MD (she/her/hers)

  Chair, Department of Surgery
  Berkshire Medical Center
  Pittsfield, MA, United States

  Disclosure information not submitted.
• EB

  Elizabeth Breen, MD

  Retired surgeon. Clinical resesrcher
  Lahey Hospital and Medical Center
  Cambridge, Massachusetts, United States

  Disclosure information not submitted.
• JC

  Jonathan J. Canete, MD

  Associate Professor of Surgery
  Albany Medical Center
  Albany, New York, United States

  Disclosure information not submitted.
• 

  Christy Cauley, MD, MPH (she/her/hers)

  Associate Professor
  Mass General Brigham
  Massachusetts General Brigham; Harvard Medical School
  Winchester, Massachusetts, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no relevant relationships with ineligible companies.
• AC

  Alexandra Columbus, MD MPH

  Staff Surgeon
  Emerson Hospital
  Concord, Massachusetts, United States

  Disclosure information not submitted.
• JD

  Jeremy Dressler, MD

  Assistant Professor
  University of Vermont Department of Surgery
  Burlington, Vermont, United States

  Disclosure information not submitted.
• 

  Robert N. Goldstone, MD

  Assistant Professor of Surgery
  Massachusetts General Hospital
  Harvard Medical School
  Boston, MA, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no relevant relationships with ineligible companies.
• 

  David A. Kleiman, MD, MSc, FACS, FASCRS (he/him/his)

  Staff Surgeon
  Lahey Hospital & Medical Center
  Lahey Hospital & Medical Center
  Melrose, MA, United States

  Disclosure information not submitted.
• AK

  Angela H. Kuhnen, MD, MPH (she/her/hers)

  Attending
  Lahey Hospital and Medical Center
  Tufts University School of Medicine
  Burlington, Massachusetts, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no relevant relationships with ineligible companies.
• 

  Grace C. Lee, MD

  Assistant Professor of Surgery
  Massachusetts General Hospital
  Harvard Medical School
  Boston, MA, United States

  Disclosure information not submitted.
• 

  Ira L. Leeds, MD

  Asst Prof of Surgery
  Yale School of Medicine
  New Haven, CT, United States

  Disclosure information not submitted.
• RL

  Robert T. Lewis, MD (he/him/his)

  Program Director, Saint Francis Hospital
  Colon and Rectal Surgeons of Greater Hartford
  Saint Francis Hospital and Medical Center
  Bloomfield, CT, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no financial relationships with ineligible companies.
• JM

  Joseph Mack, MD

  Colorectal Surgeon
  Maine Medical Center
  Portland, Maine, United States

  Disclosure information not submitted.
• 

  Peter W. Marcello, MD, FACS, FASCRS (he/him/his)

  Chair, Division of Colon & Rectal Surgery
  Lahey Hospital & Medical Center
  Burlington, Massachusetts, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no relevant relationships with ineligible companies.
• DM

  Daniel Mullins, M.D.

  Colon and Rectal Surgeon
  Saint Francis Hospital
  Hartford, Connecticut, United States

  Disclosure information not submitted.
• MM

  Melissa Murphy, MD

  Executive Chief of Surgery
  Brigham and Women's Hospital
  Boston, Massachusetts, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no financial relationships with ineligible companies.
• 

  Haddon J. Pantel, MD

  Assistant Professor
  Yale School of Medicine
  Yale School of Medicine
  New Haven, CT, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no relevant relationships with ineligible companies.
• AR

  Andrew C. Raissis, MD

  Colorectal Surgeon faculty
  Andrew Raissis
  West Hartford, Connecticut, United States

  Disclosure information not submitted.
• RS

  Rachel B. Scott, DO (she/her/hers)

  Chief of Colon and Rectal Surgery St. Francis Hospital
  Colon and Rectal Surgeons of Greater Hartford
  St. Francis Hospital and Medical Center
  West Hartford, CT, United States

  Disclosure information not submitted.

Abstract Podium Presenter(s)

• JS

  Julia Saraidaridis, MD

  Burlington, MA

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no financial relationships with ineligible companies.

Purpose/Background: The current American Society of Colon and Rectal Surgeons clinical practice guidelines for chronic anal fissure provide no consensus on the use of botulinum toxin type A versus lateral internal sphincterotomy (LIS) resulting in wide variation in practice. This quality improvement project aimed to clarify the current practice patterns among New England colorectal surgeons using botulinum toxin injection and LIS for treatment of chronic anal fissure and report associated patient outcomes.

Methods/Interventions: This was a prospective, quality-improvement registry of surgeon-reported data open to all colon and rectal surgeons in New England performing botulinum toxin injection or LIS for treatment of chronic anal fissure. Collected variables included patient demographics, presenting symptoms, preoperative functional assessment, physical exam findings, operative findings, postoperative functional assessment, and postoperative satisfaction.

Results/Outcomes: 201 patient records were submitted from 23 providers across 13 centers. 158 underwent botulinum toxin injection and 41 LIS. There was no difference in demographic characteristics between the groups. Patients who underwent LIS had higher mean preoperative pain scores (7 vs. 5;p < 0.01).
Most (85%) botulinum toxin procedures were performed in the operating room. 60% were done under monitored anesthesia care, 21% under general anesthesia, and 10% with no anesthesia. Median botulinum toxin unit injection was 100 units (range 50-200 units). The median concentration was 33 units/mL (range 25-200 units/mL). Injection techniques varied with 51% into the internal sphincter and 37% into the inter-sphincteric groove. 45% underwent concomitant procedures along with botulinum injection including tag excision, fissure debridement, hemorrhoidectomy, and hemorrhoid banding. The majority of LIS were performed in a tailored fashion (90%) and 56% were performed open.
Median follow-up time was 31 days (IQR 28 - 41 days). The LIS group had superior resolution of bleeding (68% vs. 45%;p =0.02) and a decreased need for further procedures (2% vs. 24%;p < 0.01) in comparison to botulinum injection. LIS also had a greater reduction in pain scores post-operatively (5 vs. 3;p < 0.01) and higher mean satisfaction with treatment score (9 vs. 7;p < 0.001). Postoperative mean Vaizey incontinence scores improved in the LIS group (mean change -0.9) but worsened slightly in the botulinum toxin group (mean change 0.7;p = 0.05).

Conclusion/Discussion: While both LIS and botulinum toxin provided symptom relief for chronic anal fissure, LIS was associated with superior symptom resolution, greater pain reduction, and higher patient satisfaction. Both techniques had minimal change to continence. These results support the use of LIS in appropriately selected patients. Importantly, this initiative demonstrates the strength of a regional, multi-institutional quality collaborative in generating meaningful, real-world data to inform practice.

Figure 1: Change in Mean Pain Scores Before and After Treatment Specified by Treatment Type