Perry, William R

BACKGROUND: Surgeons and ostomy nurses receive a high volume of stoma photos from patients. OBJECTIVE: This study aimed to develop and validate an automated and scalable artificial intelligence pipeline for identification and triage of patient-submitted intestinal ostomy photos. DESIGN: Retrospective derivation and validation study with stakeholder engagement to guide model design. Clinical teams reviewed photos in duplicate and categorized them into: (a) obstructed view, (b) healthy stoma, (c) suitable for conservative management, or (d) requiring in-person review. Pre-trained neural networks including MobileNetV4, ResNet50, ViT and CLIP-ViT were fine-tuned with 5-fold cross-validation. SETTINGS: Nine Mayo Clinic hospitals (2019–2022). PATIENTS: Adult patients (≥18 years) undergoing surgery who submitted images within 30 days after surgery. MAIN OUTCOME MEASURES: Model performance was evaluated with area under the receiver operator curve, precision, recall, and F1-scores. RESULTS: In this study, 538 photos of abdominal ostomies were sent in by 191 patients (median age 52 years, IQR 40–63; 60.4% female). Expert consensus triaged 236 (43.9%) photos as having an obstructed view, 30 (5.6%) as healthy, 177 (32.9%) for conservative management, and 95 (17.7%) for in-person review. All models achieved area under the receiver operator curve >0.97 for identifying stomas. The CLIP-ViT model performed best at triage (macro- area under the receiver operator curve 0.94 ± 0.06; F1 0.77 ± 0.10). End-to-end detection and triage using CLIP-ViT achieved area under the receiver operator curve of 0.99 ± 0.01, precision of 0.87 ± 0.08, recall of 0.93 ± 0.04, and F1 of 0.89 ± 0.07. Attention maps showed that models focused on stomas to determine classification. LIMITATIONS: Low sample size and lack of prospective validation. CONCLUSIONS: A vision language model pipeline accurately detected and triaged patient-submitted ostomy photos. Prospective evaluation is now needed to support integration into multidisciplinary digital workflows. See Video Abstract .

BACKGROUND: Surgical management of Crohn’s disease of the colon and rectum frequently requires total proctocolectomy with end ileostomy. There are limited data on the need for Crohn’s disease–directed therapy and the prevalence of recurrence after surgery. OBJECTIVE: To determine the risk of small-bowel Crohn’s disease recurrence and evaluate risk factors for postoperative recurrence after total proctocolectomy with end ileostomy. DESIGN: Retrospective cohort study. SETTINGS: Multistate tertiary health care system. PATIENTS: Adult patients with Crohn’s disease undergoing total proctocolectomy with end ileostomy between 2014 and 2023. MAIN OUTCOME MEASURES: The primary outcome was small-bowel Crohn’s disease recurrence. RESULTS: A total of 193 patients with a median age of 45 years (interquartile range, 34–61) were included. More than half of the patients (n = 102; 52.9%) had a history of small-bowel Crohn’s disease, and the majority (n = 134; 69.4%) received biologic therapy before surgery. The median follow-up time was 4.8 years (interquartile range, 2.0–7.6). Postoperatively, 30.6% of patients (n = 59) received biologic therapy. Thirty-five patients (18.1%) had small-bowel Crohn’s disease recurrence for an estimated 5-year recurrence-free rate of 80.2% (95% CI, 73.0–85.7). Seven patients (3.6%) developed small-bowel Crohn’s disease recurrence requiring surgery for an estimated 5-year surgical recurrence-free rate of 94.7% (95% CI, 89.0–97.5). On multivariable analysis, history of small-bowel Crohn’s disease (HR 2.17; 95% CI‚ 1.04–4.54) and diagnosis at age younger than 18 years (HR 2.31; 95% CI‚1.1–4.86) were associated with small-bowel Crohn’s disease recurrence. LIMITATIONS: Retrospective design and nonstandardized follow-up. CONCLUSIONS: Patients undergoing total proctocolectomy with end ileostomy for Crohn’s disease have approximately a 20% risk of small-bowel recurrence at 5 years but a low risk of requiring surgical intervention. Patients with a history of small-bowel Crohn’s disease and younger age at diagnosis have a higher risk of recurrence and may warrant consideration of more frequent surveillance and medical prophylaxis. See Video Abstract . FACTORES DE RIESGO DE RECURRENCIA DE LA ENFERMEDAD DE CROHN DEL INTESTINO DELGADO DESPUÉS DE UNA PROCTOCOLECTOMÍA TOTAL ANTECEDENTES: El tratamiento quirúrgico de la enfermedad de Crohn del colon y el recto frecuentemente requiere proctocolectomía total con ileostomía terminal. Existe información limitada sobre la necesidad de terapia dirigida a la enfermedad de Crohn y la prevalencia de recurrencia tras la cirugía. OBJETIVO: Determinar el riesgo de recurrencia de la enfermedad de Crohn del intestino delgado y evaluar los factores de riesgo de recurrencia posoperatoria tras proctocolectomía total con ileostomía terminal. DISEÑO: Estudio de cohorte retrospectivo. ÁMBITO: Sistema de atención médica terciaria multiestatal. PACIENTES: Pacientes adultos con enfermedad de Crohn sometidos a proctocolectomía total con ileostomía terminal entre 2014 y 2023. PRINCIPALES MEDIDAS DE RESULTADO: El resultado primario fue la recurrencia de la enfermedad de Crohn del intestino delgado. RESULTADOS: Se incluyeron un total de 193 pacientes con una mediana de edad de 45 años (RIC, 34-61). Más de la mitad de los pacientes (n = 102, 52,9 %) tenían antecedentes de enfermedad de Crohn del intestino delgado y la mayoría (n = 134, 69,4 %) recibieron terapia biológica antes de la cirugía. El tiempo medio de seguimiento fue de 4,8 años (RIC, 2,0-7,6). Después de la cirugía, el 30,6 % de los pacientes (n = 59) recibieron terapia biológica. Treinta y cinco pacientes (18,1 %) tuvieron recurrencia de la enfermedad de Crohn del intestino delgado para una tasa estimada libre de recurrencia a 5 años del 80,2 % (IC del 95 %, 73,0-85,7). Siete pacientes (3,6 %) desarrollaron recurrencia de la enfermedad de Crohn del intestino delgado que requirió cirugía para una tasa estimada libre de recurrencia quirúrgica a 5 años del 94,7 % (IC del 95 %, 89,0-97,5). En el análisis multivariable, los antecedentes de enfermedad de Crohn del intestino delgado (HR 2,17; IC del 95%: 1,04-4,54) y el diagnóstico antes de los 18 años (HR 2,31; IC del 95%: 1,1-4,86) se asociaron con la recurrencia de la enfermedad de Crohn del intestino delgado. LIMITACIONES: Diseño retrospectivo y seguimiento no estandarizado. CONCLUSIONES: Los pacientes sometidos a proctocolectomía total con ileostomía terminal por enfermedad de Crohn tienen aproximadamente un 20% de riesgo de recurrencia en el intestino delgado a los 5 años, pero un bajo riesgo de requerir intervención quirúrgica. Los pacientes con antecedentes de enfermedad de Crohn del intestino delgado y menor edad al diagnóstico tienen un mayor riesgo de recurrencia y podrían requerir una vigilancia más frecuente y profilaxis médica. (AI-generated translation )

Objective: To develop a predictive model for pathological complete response (pCR) after total neoadjuvant therapy (TNT) to inform selection for watch-and-wait (W/W). Summary Background Data: Patient selection for W/W after TNT for locally advanced rectal cancer remains challenging. Methods: An ensemble of tabular foundation models was fine-tuned in adults with clinical stage II or III microsatellite stable primary rectal adenocarcinoma undergoing TNT and total mesorectal excision (TNT+TME) from 2018-2023 to predict pCR, using pre-TNT, post-TNT and pre-TME variables. This model was externally validated on patients having TNT and W/W (TNT+W/W) to predict persistent clinical complete response (pcCR; the absence of local regrowth, distant metastases, or persistent near-cCR). Area under the receiver operator curve (AUROC), area under the precision-recall curve (AUPRC), and Brier score were calculated with 95% confidence intervals (CI). Results: Among 308 patients that underwent TNT+TME (median age 56; 40% female), the model predicted pCR with an AUROC 0.71 (95% CI 0.65-0.77), AUPRC 0.44 (95% CI 0.35-0.57), and was well calibrated with a Brier score of 0.17 (95% CI 0.15-0.20). At external validation in a cohort of 83 patients that are being managed with TNT+W/W (median age 57; 37% female), the model predicted pcCR with an AUROC 0.69 (95% CI 0.57-0.82), AUPRC 0.90 (95% CI 0.82-0.96), and Brier score of 0.30 (95% CI 0.26-0.33), improving to 0.17 with recalibration. Conclusions: This novel predictive model demonstrated good discrimination and calibration for pCR after TNT+TME with utility in TNT+W/W for pcCR after appropriate recalibration, supporting its application for W/W patient selection.

Abstract Background Presacral tumours are rare and heterogeneous lesions arising within a complex anatomical space, resulting in variability in diagnosis and management. Increasing incidental detection and evolving surgical and oncological strategies have highlighted the need for contemporary guidance. The aim of this study was to establish an international expert consensus on the optimal diagnosis and management of presacral tumours. Methods An international panel of colorectal surgeons from high-volume units was convened. Evidence- and practice-based statements were developed after domain-based literature reviews and refined through five online and two in-person meetings. Consensus was achieved using a modified Delphi process with anonymous voting. Results In total, 16 colorectal surgeons participated in the study. Ten domains were identified resulting in the development of 22 statements based on expert opinion and retrospective studies. After two rounds, unanimous (100%) agreement was achieved for all statements. High-resolution MRI with structured synoptic reporting is endorsed as central to risk stratification. Selective image-guided transperineal or parasacral biopsy is recommended for high-risk lesions where histology would alter management. Complete surgical resection is defined as the operative goal, with approach tailored to tumour biology and anatomy; minimally invasive surgery is considered appropriate in selected cases. Non-operative surveillance is supported for carefully selected asymptomatic, low-risk cystic lesions. Postoperative surveillance is recommended in a risk-adapted manner according to histopathology and margin status. Conclusion This international consensus provides a pragmatic, risk-stratified framework for the multidisciplinary diagnosis and management of presacral tumours. These recommendations aim to reduce practice variation, support decision-making in specialized centres, and inform future prospective collaborative research.

ABSTRACT Background Minimal‐invasive surgery (MIS) was proven beneficial in Crohn's Disease (CD). Intracorporeal anastomosis (ICA) represents a further improvement as it is associated with decreased complications and shorter hospitalization. Extracorporeal anastomosis (ECA) is preferred to ICA as it allows haptic feedback of the bowel and mesentery, which is historically required for bowel resection in CD to minimize recurrences. We compared ICA and ECA in terms of recurrences and complications. Methods All patients between 2016 and 2022 with Crohn's disease who underwent a MIS ileocecectomy were identified and divided into ICA and ECA groups. Exclusion criteria were open surgery, end ileostomies, follow‐up < 1 month, and ileocecectomy not due to CD. Results 107 patients were included in the ICA group (44.9% male, mean age of 40.2 [±16.6] years), while 270 patients were in the ECA group (46.7% male, mean age of 41.9 [±17.3] years). The rate of endoscopic recurrences with a Rutgeerts score > 2, clinical recurrence, and surgical recurrence were not statistically different between the two cohorts. On the multivariable analysis for endoscopic and clinical recurrences, the ICA/ECA approach was not significant. The ECA group revealed a higher overall complication rate (30.4% versus 15.9%, p = 0.004). The median length of stay was significantly reduced in the ICA group ( p < 0.001). Conclusion ICA seems to be safe in ileocecectomies for CD. The complication rate and length of stay were reduced while not affecting the endoscopic, clinical, and surgical recurrence rates. MIS technology provides enhanced visualization and haptic feedback, which could be used as surrogates for the tactile evaluation intra‐operatively.

BACKGROUND: Obstructed defecation syndrome and posterior compartment (rectal) prolapse significantly impact patients’ quality of life. Pelvic floor physical therapy is a critical part of multidisciplinary management for these conditions, yet there is little guidance or standardization to guide providers’ referral practices, diagnostic approaches, or treatment. OBJECTIVE: To develop multidisciplinary consensus-based recommendations for incorporating pelvic floor physical therapy into the treatment of obstructed defecation syndrome and posterior compartment prolapse. DATA SOURCES: MEDLINE, PubMed, Embase, and the Cochrane Database of Systematic Reviews were searched for English-language studies on pelvic floor physical therapy, obstructed defecation, diagnostic criteria, imaging, and pelvic organ prolapse. STUDY SELECTION: Studies identified in the literature search were reviewed by multidisciplinary expert subgroups, who formulated draft statements based on the available evidence. INTERVENTION: Consensus meetings were conducted and included experts from colorectal surgery, urogynecology, physical therapy, gastroenterology, radiology, and urology. Statements were evaluated via structured discussions and voting processes. Those reaching more than 70% consensus were adopted for inclusion. Statements underwent final review and editing by the leadership of the American Society of Colon and Rectal Surgeons and the International Urogynecological Association. MAIN OUTCOME MEASURES: Consensus statements addressed referral criteria, diagnostic evaluations, therapy protocols, timing, coordination with surgery, and management of anatomical abnormalities. RESULTS: Fifteen statements reached consensus. Key recommendations included prompt referral to pelvic floor physical therapy for patients without contraindications, individualized therapy based on appropriate diagnostic evaluation and patient goals, timing of pelvic floor physical therapy relative to surgery, and trauma-informed patient care. LIMITATIONS: Recommendations primarily reflect expert consensus due to limited high-quality evidence. Variability in practitioner expertise and geographic access to trained therapists are barriers to consistent implementation. CONCLUSIONS: These recommendations provide structured guidance for integrating pelvic floor physical therapy into the management of obstructed defecation syndrome and rectal prolapse. Additional research and standardized training are essential to optimize patient outcomes.

BACKGROUND: Stoma-free survival represents a key quality-of-life outcome after surgery for locally advanced rectal cancer. Despite advances in neoadjuvant and surgical management, up to 30% of patients ultimately require a permanent fecal diversion. OBJECTIVE: To evaluate stoma-free survival and identify factors associated with permanent stoma formation in patients with locally advanced rectal cancer undergoing coloanal anastomosis. DESIGN: Retrospective cohort study. SETTINGS: Single tertiary referral center (2017–2021). PATIENTS: A total of 126 patients with clinical stage II and III rectal adenocarcinoma who received neoadjuvant therapy and underwent curative-intent resection with coloanal anastomosis were included. INTERVENTION: Curative-intent resection with coloanal anastomosis. MAIN OUTCOME MEASURES: The primary outcome was stoma-free survival. Secondary analyses examined factors associated with permanent fecal diversion. RESULTS: The medical records of 126 patients were analyzed, comprising 62.5% men, with a mean age of 54 ± 10 years and a median BMI of 27.7 (interquartile range 24.5–31.4). At a median follow-up of 53.0 months, the 5-year stoma-free survival rate was 88.9%. Univariate Cox regression analysis showed that BMI ≥35 (HR 3.80; 95% CI, 1.04–13.91, p = 0.044) and handsewn coloanal anastomosis with mucosectomy compared to stapled coloanal anastomosis without mucosectomy (HR 5.58; 95% CI, 1.71–18.14, p = 0.004), as well as local recurrence (HR 6.51; 95% CI, 1.44–29.46), were associated with worse stoma-free survival. The 30-day major morbidity rate was 7.9% after the index surgery. Sixteen patients required permanent fecal diversion due to bowel dysfunction (n = 11), disease recurrence (n = 4), or bowel obstruction (n = 1). LIMITATIONS: Retrospective, single-institution design with limited generalizability. CONCLUSIONS: Coloanal anastomosis in the era of total neoadjuvant therapy resulted in favorable 5-year stoma-free survival. BMI ≥35, handsewn coloanal anastomosis with mucosectomy, and local recurrence were associated with worse stoma-free survival. See Video Abstract . SUPERVIVENCIA SIN ESTOMA TRAS UNA RESECCIÓN ANTERIOR BAJA CON ANASTOMOSIS COLOANAL PARA EL CÁNCER RECTAL EN ESTADIO II-III ANTECEDENTES: La supervivencia sin estoma representa un resultado clave para la calidad de vida tras la cirugía de cáncer rectal localmente avanzado. A pesar de los avances en el tratamiento neoadyuvante y quirúrgico, hasta un 30 % de los pacientes requieren finalmente una derivación fecal permanente. OBJETIVO: Evaluar la supervivencia sin estoma e identificar los factores asociados con la formación de un estoma permanente en pacientes con cáncer rectal localmente avanzado sometidos a anastomosis coloanal. DISEÑO: Estudio de cohorte retrospectivo. ENTORNO: Centro terciario de referencia único, 2017-2021. PACIENTES: Se incluyó a un total de 126 pacientes con adenocarcinoma rectal en estadio clínico II-III que recibieron terapia neoadyuvante y se sometieron a una resección con intención curativa con anastomosis coloanal. INTERVENCIÓN: Resección con intención curativa con anastomosis coloanal. PRINCIPALES MEDIDAS DE RESULTADO: El resultado principal fue la supervivencia sin estoma. Los análisis secundarios examinaron los factores asociados con la derivación fecal permanente. RESULTADOS: Se analizaron 126 pacientes, de los cuales el 62,5 % eran hombres, con una edad media de 54 ± 10 años y un índice de masa corporal medio de 27,7 kg/m 2 (rango intercuartílico: 24,5-31,4 kg/m 2 ). Con una mediana de seguimiento de 53,0 meses, la tasa de supervivencia sin estoma a 5 años fue del 88,9 %. El análisis de regresión de Cox univariante mostró que el índice de masa corporal ≥ 35 kg/m 2 (razón de riesgo = 3,80, intervalo de confianza del 95 %: 1,04-13,91, p = 0,044) y la anastomosis coloanal cosida a mano con mucosectomía, en comparación con la anastomosis coloanal grapada sin mucosectomía (razón de riesgo = 5,58, intervalo de confianza del 95 %: 1,71-18,14, p = 0,004), así como la recurrencia local (razón de riesgo = 6,51, intervalo de confianza del 95 %: 1,44-29,46) se asociaron con una peor supervivencia sin estoma. La tasa de morbilidad grave a los 30 días fue del 7,9 % tras la cirugía índice. Dieciséis pacientes requirieron una derivación fecal permanente debido a disfunción intestinal (n = 11), recurrencia de la enfermedad (n = 4) u obstrucción intestinal (n = 1). LIMITACIONES: Diseño retrospectivo, de una sola institución, con una generalización limitada. CONCLUSIONES: La anastomosis coloanal en la era de la terapia neoadyuvante total dio lugar a una supervivencia sin estoma favorable a los 5 años. El índice de masa corporal ≥ 35 kg/m2, la anastomosis coloanal cosida a mano con mucosectomía y la recurrencia local se asociaron con una peor supervivencia sin estoma. (AI-generated translation )

BACKGROUND: The Ventral Rectopexy International Expert Panel recently published a consensus update on ventral rectopexy. The ability of large language models to synthesize the literature on ventral rectopexy without an explicit knowledge base was studied before the publication of the consensus. OBJECTIVE: To compare the responses and citations of different large language models on ventral rectopexy using the expert panel consensus as the reference standard. DESIGN: ChatGPT-4o, Gemini 1.5 Pro, and OpenEvidence were compared on content appropriateness (1 = inappropriate to 5 = appropriate), readability (Flesch reading ease), response length, citation fabrication, and citation quality per Oxford Levels of Evidence. The most content-appropriate chatbot response selected by the expert panel was de-identified and presented alongside the consensus text to 15 colorectal surgeons who attempted to identify the chatbot-generated text. SETTINGS: Questions were submitted from September 18 to 19, 2024. Analysis was performed before the online publication of the consensus on January 30, 2025. MAIN OUTCOME MEASURES: The main outcome measures included content appropriateness, fabricated citation rate, citation quality, and the accuracy of identifying human versus chatbot text by colorectal surgeons. RESULTS: OpenEvidence ranked highest for content appropriateness (mean 3.5/5), above Gemini (3.0/5) and ChatGPT (2.8/5; p < 0.001). ChatGPT was most verbose with the highest readability scores ( p = 0.021). ChatGPT fabricated 53% of citations; Gemini fabricated 12%; OpenEvidence fabricated 0% ( p < 0.001). All OpenEvidence citations were peer reviewed, with 40 of 117 (34%) citing level I to III studies compared with 46 of 94 (49%) of the references cited in the consensus ( p = 0.043). Chatbot-generated responses were identified with 28 of 51 (55%) accuracy. LIMITATIONS: Reproducibility may be affected due to the nature of large language models and the availability of the consensus after publication. CONCLUSIONS: OpenEvidence outperformed Gemini 1.5 Pro and ChatGPT-4o in content appropriateness and peer-reviewed citation quantity and quality. Chatbot-generated text was indistinguishable from expert-authored consensus to subject matter experts. Large language models, as an early-stage research tool, may be viable for future consensus working groups, provided transparent disclosure and rigorous oversight. See Video Abstract . ¿PUEDEN LOS MODELOS LINGÜÍSTICOS DE GRAN TAMAÑO SER UNA HERRAMIENTA VIABLE PARA LOS GRUPOS DE TRABAJO DE CONSENSO? LA EXPERIENCIA DEL GRUPO DE CONSENSO DE EXPERTOS EN RECTOPEXIA VENTRAL ANTECEDENTES: El Panel Internacional de Expertos en Rectopexia Ventral publicó recientemente una actualización consensuada sobre la rectopexia ventral. Antes de la publicación del consenso, se estudió la capacidad de los grandes modelos lingüísticos para sintetizar la bibliografía sobre la rectopexia ventral sin una base de conocimientos explícita. Objetivo: Comparar las respuestas y citas de diferentes grandes modelos lingüísticos sobre la rectopexia ventral utilizando el consenso del panel de expertos como estándar de referencia. DISEÑO: Se compararon ChatGPT-4o, Gemini 1.5 Pro y OpenEvidence en cuanto a la idoneidad del contenido (1 = inadecuado a 5 = adecuado), la legibilidad (índice de legibilidad de Flesch), la longitud de la respuesta, la fabricación de citas y la calidad de las citas según los niveles de evidencia de Oxford. La respuesta del chatbot más adecuada en cuanto al contenido seleccionada por el panel de expertos se anonimizó y se presentó junto con el texto del consenso a 15 cirujanos colorrectales que intentaron identificar el texto generado por el chatbot. ENTORNO: Las preguntas se enviaron los días 18 y 19 de septiembre de 2024. El análisis se realizó antes de la publicación del consenso en línea el 30 de enero de 2025. PRINCIPALES MEDIDAS DE RESULTADOS: Adecuación del contenido, tasa de citas inventadas, calidad de las citas, precisión en la identificación del texto humano frente al del chatbot por parte de los cirujanos colorrectales. RESULTADOS: OpenEvidence obtuvo la puntuación más alta en cuanto a la adecuación del contenido (media de 3,5/5), por encima de Gemini (3,0/5) y ChatGPT (2,8/5) (p<0,001). ChatGPT fue el más prolijo, con las puntuaciones más altas en legibilidad (p = 0,021). ChatGPT inventó el 53% de las citas; Gemini inventó el 12 %; OpenEvidence inventó el 0 % (p < 0,001). Todas las citas de OpenEvidence fueron revisadas por pares, con 40/117 (34 %) que citaban estudios de nivel I-III frente a 46/94 (49 %) de las referencias citadas en el consenso (p = 0,043). Las respuestas generadas por el chatbot se identificaron con una precisión del 28/51 (55 %). LIMITACIONES: Reproducibilidad debido a la naturaleza de los modelos de lenguaje grandes y a la disponibilidad del consenso tras la publicación. CONCLUSIONES: OpenEvidence superó a Gemini 1.5 Pro y ChatGPT-4o en cuanto a la idoneidad del contenido y la cantidad y calidad de las citas revisadas por pares. El texto generado por el chatbot era indistinguible del consenso redactado por expertos para los expertos en la materia. Los modelos de lenguaje grandes como herramienta de investigación en fase inicial pueden ser viables para futuros grupos de trabajo de consenso, siempre que se garantice una divulgación transparente y una supervisión rigurosa. ( AI-generated translation )

BACKGROUND: Chronic anal fissures are a painful condition characterized by a tear in the anal mucosa. Botulinum toxin injection is a minimally invasive treatment option, but long-term effectiveness in recurrent or persistent cases remains unclear. OBJECTIVE: This study evaluates the long-term outcomes of botulinum toxin injections for the treatment of chronic anal fissures. DESIGN: This study is a retrospective review. SETTINGS: The study was conducted at a tertiary academic center. PATIENTS: Adults with chronic anal fissures treated with botulinum toxin between 2018 and 2023 were included. MAIN OUTCOME MEASURES: Short- and long-term healing, recurrence, or persistence after botulinum toxin injection. Persistent or recurrent fissure(s) were followed for outcomes after subsequent repeat injections or surgery (lateral internal sphincterotomy or fissurectomy). RESULTS: Among 161 patients, 45.3% (n = 73) experienced short-term healing after botulinum toxin as first-line therapy, but only 26% (n = 42) had sustained healing. Subsequent treatment patterns were similar for recurrent (n = 31) and persistent (n = 88) fissures: 35% versus 31% no further intervention, 55% versus 42% multiple subsequent injections, 10% versus 23% surgery, respectively. Sustained healing was achieved in 63% (n = 10/16) of patients who underwent surgery compared with 37% (n = 14/38) who had repeat botulinum toxin injections ( p = 0.06). Only 49% achieved sustained healing after a single injection, multiple injections, or injection(s) with surgery. Complications included 5 episodes of mild fecal incontinence in the botulinum toxin group and 2 instances of surgical site infection in the surgery group. LIMITATIONS: Limitations include a single-institution, retrospective study design and loss to follow-up. CONCLUSION: Botulinum toxin remains a valuable therapy for chronic anal fissures. Many patients have persistent or recurrent fissures after botulinum toxin injection and undergo additional interventions. Despite multiple interventions, only half of the patients achieved sustained healing, regardless of the treatment pattern. These data do not support the use of botulinum toxin over surgery for the treatment of chronic fissures, are helpful for counseling patients on the safety profile of each, and set expectations regarding the need for multiple interventions. See Video Abstract . RESULTADOS A LARGO PLAZO DEL USO DE TOXINA BOTULÍNICA EN EL TRATAMIENTO DE FISURAS ANALES CRÓNICAS: UN ENFOQUE GRADUAL PARA EL MANEJO DE CASOS RECURRENTES Y PERSISTENTES ANTECEDENTES: Las fisuras anales crónicas son una afección dolorosa caracterizada por un desgarro en la mucosa anal. La inyección de toxina botulínica es una opción de tratamiento mínimamente invasiva, pero su eficacia a largo plazo en casos recurrentes o persistentes sigue sin estar clara. OBJETIVO: Evaluar los resultados a largo plazo de las inyecciones de toxina botulínica para el tratamiento de las fisuras. DISEÑO: Revisión retrospectiva. ENTORNO: Centro académico terciario. PACIENTES: Adultos con fisuras crónicas tratados con toxina botulínica entre 2018 y 2023. PRINCIPALES MEDIDAS DE RESULTADO: Curación a corto y largo plazo, recurrencia o persistencia después de la inyección de toxina botulínica. Se realizó un seguimiento de las fisuras persistentes o recurrentes para evaluar los resultados después de repetidas inyecciones o cirugía (esfinterotomía interna lateral o fisurectomía). RESULTADOS: Entre los 161 pacientes, el 45,3 % (n = 73) experimentó una curación a corto plazo tras la toxina botulínica como terapia de primera línea, pero solo el 26 % (n = 42) tuvo una curación sostenida. Los patrones de tratamiento posteriores fueron similares para las fisuras recurrentes (n = 31) o persistentes (n = 88): 35 % frente a 31 % sin intervención adicional, 55 % frente a 42 % con múltiples inyecciones posteriores, 10 % frente a 23 % con cirugía, respectivamente. Se logró una curación sostenida en el 63 % (n = 10/16) de los pacientes que se sometieron a cirugía, en comparación con el 37 % (n = 14/38) que recibió inyecciones repetidas de toxina botulínica ( p = 0,06). Solo el 49 % logró una curación sostenida después de una sola inyección, múltiples inyecciones o inyecciones con cirugía. Las complicaciones incluyeron 5 episodios de incontinencia fecal leve en el grupo de la toxina botulínica y dos casos de infección en el sitio quirúrgico en el grupo de la cirugía. LIMITACIONES: Estudio retrospectivo de una sola institución y pérdida de seguimiento. CONCLUSIÓN: La toxina botulínica sigue siendo una terapia valiosa para las fisuras anales crónicas. Muchos pacientes presentan fisuras persistentes o recurrentes tras la inyección de toxina botulínica y se someten a intervenciones adicionales. A pesar de las múltiples intervenciones, solo la mitad de los pacientes lograron una curación sostenida, independientemente del patrón de tratamiento. Estos datos no respaldan el uso de la toxina botulínica frente a la cirugía para el tratamiento de las fisuras crónicas, pero son útiles para asesorar a los pacientes sobre el perfil de seguridad de cada una y establecer expectativas con respecto a la necesidad de múltiples intervenciones. ( AI-generated translation )