Title: IS CHEMODENERVATION WITH INCOBOTULINUMTOXINA AN
ALTERNATIVE TO INVASIVE CHRONIC ANAL FISSURE TREATMENTS?
Version: 3 Date: 19 Jul 2024
Reviewer:  Michael Roblick
Reviewer's report:
Reviewer 3:
Personal Impact of this Article:
I personally wouldn´t change my current procedure for the cure of anal fissures.
Without a consistent, parallel improvement in stool consistency, there will be no long-term and
persistent healing, either after botox injection or surgery.
Further points:
small patient cohort
Different application quantities within the small group
In the article, stool consistency is identified as the initial triggering problem, but  it is not
consistently treated.
BT is neither in the USA nor in Germany. Appendix-Ostium first-line treatment
Lateral sphincterotomy is, due to high incontinence rates, in most European states no first-line
surgical treatment.
Possibility of fissurectomy after Gabriel (the highest number of surgical interventions for AF in
Germany) not even mentioned, good method, very little incontinence
What was the purpose of different quantities of BT (medical)?
Did the author continue with parallel conservative treatments during the investigation?
Page 7/Page 10: "Patients with both nitrates and Divertikel CCB presented headaches.“ Why
did they receive both medications? Only the nitrates are responsible for the headaches. CCB on
its own is quite often enough to cure the patient.
Manometry is an  good tool to measure the reducing or increasing pressure of the anal channel.
It is not good at measuring absolute numbers. The same anal manometry performed only half
an hour later will lead the same patient to different measurements.
Page 11.: „Sentinel hemorrhoid“ is the wrong description of the hypertrophe papilla, which
has anatomically nothing in common with a hemorroidal cushion. Using this term can lead to
misunderstandings.
All in all, the healing rate is a little over 50% after 3 years after the use of Botox. Botox, by the
way, is expansive. 50 units of Botox in Germany cost between 270 and 300 Euros. This should
be mentioned in an article concerning Botox.
I myself use Botox sometimes, in certain patients it is auseful therapy. But BT is not an
established therapy in Germany for the anal fissure; it needs prior to application the personal
signature of the doctor, and the procedure needs extra documentation of the use of Botox in
an area of therapy that is not officially approved by German health insurances. (F.i. overactive
bladder, therapy with Botox is no problem).
Title: IS CHEMODENERVATION WITH INCOBOTULINUMTOXINA AN
ALTERNATIVE TO INVASIVE CHRONIC ANAL FISSURE TREATMENTS?
Version: 3 Date: 19 Jul 2024
Reviewer:  Michael Roblick
Reviewer's report:
Reviewer 3:
Personal Impact of this Article:
I personally wouldn´t change my current procedure for the cure of anal fissures.
Without a consistent, parallel improvement in stool consistency, there will be no long-term and
persistent healing, either after botox injection or surgery.
Further points:
small patient cohort
Different application quantities within the small group
In the article, stool consistency is identified as the initial triggering problem, but  it is not
consistently treated.
BT is neither in the USA nor in Germany. Appendix-Ostium first-line treatment
Lateral sphincterotomy is, due to high incontinence rates, in most European states no first-line
surgical treatment.
Possibility of fissurectomy after Gabriel (the highest number of surgical interventions for AF in
Germany) not even mentioned, good method, very little incontinence
What was the purpose of different quantities of BT (medical)?
Did the author continue with parallel conservative treatments during the investigation?
Page 7/Page 10: "Patients with both nitrates and Divertikel CCB presented headaches.“ Why
did they receive both medications? Only the nitrates are responsible for the headaches. CCB on
its own is quite often enough to cure the patient.
Manometry is an  good tool to measure the reducing or increasing pressure of the anal channel.
It is not good at measuring absolute numbers. The same anal manometry performed only half
an hour later will lead the same patient to different measurements.
Page 11.: „Sentinel hemorrhoid“ is the wrong description of the hypertrophe papilla, which
has anatomically nothing in common with a hemorroidal cushion. Using this term can lead to
misunderstandings.
All in all, the healing rate is a little over 50% after 3 years after the use of Botox. Botox, by the
way, is expansive. 50 units of Botox in Germany cost between 270 and 300 Euros. This should
be mentioned in an article concerning Botox.
I myself use Botox sometimes, in certain patients it is auseful therapy. But BT is not an
established therapy in Germany for the anal fissure; it needs prior to application the personal
signature of the doctor, and the procedure needs extra documentation of the use of Botox in
an area of therapy that is not officially approved by German health insurances. (F.i. overactive
bladder, therapy with Botox is no problem).
Please review this paper.
user
Title: IS CHEMODENERVATION WITH INCOBOTULINUMTOXINA AN
ALTERNATIVE TO INVASIVE CHRONIC ANAL FISSURE TREATMENTS?
Version: 3 Date: 19 Jul 2024
Reviewer:  Michael Roblick
Reviewer's report:
Reviewer 3:
Personal Impact of this Article:
I personally wouldn´t change my current procedure for the cure of anal fissures.
Without a consistent, parallel improvement in stool consistency, there will be no long-term and
persistent healing, either after botox injection or surgery.
Further points:
small patient cohort
Different application quantities within the small group
In the article, stool consistency is identified as the initial triggering problem, but  it is not
consistently treated.
BT is neither in the USA nor in Germany. Appendix-Ostium first-line treatment
Lateral sphincterotomy is, due to high incontinence rates, in most European states no first-line
surgical treatment.
Possibility of fissurectomy after Gabriel (the highest number of surgical interventions for AF in
Germany) not even mentioned, good method, very little incontinence
What was the purpose of different quantities of BT (medical)?
Did the author continue with parallel conservative treatments during the investigation?
Page 7/Page 10: "Patients with both nitrates and Divertikel CCB presented headaches.“ Why
did they receive both medications? Only the nitrates are responsible for the headaches. CCB on
its own is quite often enough to cure the patient.
Manometry is an  good tool to measure the reducing or increasing pressure of the anal channel.
It is not good at measuring absolute numbers. The same anal manometry performed only half
an hour later will lead the same patient to different measurements.
Page 11.: „Sentinel hemorrhoid“ is the wrong description of the hypertrophe papilla, which
has anatomically nothing in common with a hemorroidal cushion. Using this term can lead to
misunderstandings.
All in all, the healing rate is a little over 50% after 3 years after the use of Botox. Botox, by the
way, is expansive. 50 units of Botox in Germany cost between 270 and 300 Euros. This should
be mentioned in an article concerning Botox.
I myself use Botox sometimes, in certain patients it is auseful therapy. But BT is not an
established therapy in Germany for the anal fissure; it needs prior to application the personal
signature of the doctor, and the procedure needs extra documentation of the use of Botox in
an area of therapy that is not officially approved by German health insurances. (F.i. overactive
bladder, therapy with Botox is no problem).
assistant