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BACKGROUND: The best surgical technique for sacrococcygeal pilonidal disease is still controversial. The aim of this randomized prospective trial was to compare both the results of Limberg flap procedure and primary closure. METHODS: A total of 260 patients with sacrococcygeal pilonidal disease were assigned randomly to undergo Limberg flap procedure or tension-free primary closure. RESULTS: Success of surgery was achieved in 84.62% of Limberg flap patients versus 77.69% of primary closure (P = .0793). Surgical time for primary closure was shorter. Wound infection was more frequent in the primary closure group (P = .0254), which experienced less postoperative pain (P < .0001). No significant difference was found in time off from work (P = .672) and wound dehiscence. Recurrence was observed in 3.84% versus 0% in the primary closure versus Limberg flap group (P = .153). CONCLUSIONS: Our results do not show a clear benefit for surgical management by Limberg flap or primary closure. Limberg flap showed less convalescence and wound infection; our technique of tension-free primary closure was a day case procedure, less painful, and shorter than Limberg flap.

Background The purpose of this study was to assess our colorectal surgical training program experience with the Delorme procedure for complete rectal prolapse. Methods Consecutive patients were identified from a surgical database and evaluated by chart review. Results Seventy-six patients with a mean follow-up period of 3.6 years were included. Outcomes included a recurrence rate of 14.5%, an overall complication rate of 25%, and a surgical site-specific complication rate of 8%. For patients younger than 50 years old (mean age, 36 y; range, 19–49 y), the recurrence rate was 8% with a mean follow-up period of 4.1 years. Their total complication rate was 15%, with no surgery site-specific complications. Conclusions Our results are consistent with previously published experiences in that most preoperative evacuatory symptoms resolve with repair of the prolapse, and serious complications are uncommon. The observation that recurrence and complication rates may be lower in younger medically fit patients suggests the Delorme repair need not be restricted specifically to older, medically unfit patients.

Functional results following surgery for obstructed defecation (OD) have been widely investigated, but there are few reports aimed to analyze postoperative complications and re-interventions. This study investigates the adverse events requiring retreatment for obstructed defecation.We retrospectively analyzed the records of 203 patients operated on by a single surgeon, 20 transabdominally and 183 transperineally (159 manual and 24 stapled). Postoperative complications requiring retreatment and outcome of reinterventions were analyzed.Adverse events requiring retreatment occurred in 14.3% more frequently after abdominal than after perineal procedures (20% vs. 13.7%), but the sample size of the two arms is different. Rectal bleeding and strictures were the most common adverse events (6.9%). Major complications, i.e., ischemic colitis requiring hemicolectomy and pelvic sepsis requiring colostomy also occurred (1%). The overall reintervention rate was 7.5%, (5% after abdominal and 7.6% after perineal surgery). Overall, 59% of the reoperated patients were still constipated at a median follow up of 2 years.Complications requiring retreatment are not uncommon after surgery for OD and reinterventions are often unsuccessful. A careful preoperative evaluation and selection of patients should be undertaken in order to minimize adverse events.

Aim of the present study was to assess, in a pair-matched analysis design, risk factors for post-transplant diabetes mellitus (PTDM) in renal transplant recipients (KTx). The incidence of PTDM was evaluated in 538 consecutive KTx in relation to their baseline immunosuppression. PTDM was defined according to the 2003 American Diabetes Association and World Health Organization experts committee definition. As risk factors for PTDM development were considered: age, family history of diabetes, body mass index (BMI), baseline immunosuppression, doses and blood levels of the immunosuppressive agents used. Baseline immunosuppression consisted of CSA, TAC and SRL + CNI. Thirty-two pair-matched controls were identified among the 538 KTx and included in the risk analysis. Significant risk factors for the development of PTDM were identified in the family history of diabetes (P < 0.02) and BMI (P < 0.05). Higher BMI and positive family history for diabetes mellitus were significant risk factors for the development of PTDM, regardless of the immunosuppressive agent used.

Summary Background : Botulinum neurotoxin induces healing in patients with idiopathic fissure. The optimal dosage is not well established. Aim : To compare the efficacy and tolerability of two different formulations of type A botulinum neurotoxin, and to provide more evidence with regard to the choice of dosage regimens. Methods : Symptomatic adults with chronic anal fissure were enrolled in a randomized study. The outcome of each group was evaluated clinically, and by comparing the pressure of the anal sphincters before and after treatment. Results : Fifty patients received injections of 50 units of Botox formulation (group I), and 50 patients received injections of 150 units of Dysport toxin (group II). One month after injection, 11 patients in group I and eight in group II had mild incontinence of flatus. At the 2-month evaluation point, 46 patients in group I and 47 patients in group II had a healing scar. In group I patients, the mean resting anal pressure was 41.8% lower, and the maximum voluntary squeeze pressure was 20.2% lower, than the baseline value. In group II patients, the resting anal pressure and maximum voluntary squeeze pressure were 60.0 ± 12.0 mmHg and 71.0 ± 30.0 mmHg, respectively. There were no relapses during an average of about 21 months of follow-up. Conclusions : Botulinum neurotoxin may be considered an effective treatment in patients with chronic anal fissure. The efficacy and tolerability of the two different formulations of botulinum neurotoxin were indistinguishable.

Early and late results of surgical palliation for unresectable periampullary neoplasms were evaluated in 24 patients older than 70 years and compared with the same results obtained from 33 younger patients. The two groups of patients were comparable, except for age. Biliary bypass associated to gastric bypass was the most common performed procedure.No significant differences in the results (morbidity, mortality, and outcome) were found in the two groups of patients. In addition, the results of palliative surgery in the elderly were compared with those obtained from a comparable group of 35 patients palliated with endoscopic stent insertion: surgical palliation resulted in better long-term results.This study provides evidence that the chronologic age is not a contra-indication for surgical palliation of periampullary neoplasms and that surgery provides a better quality of residual life.

Anal fistula is a common proctological problem to both patient and physician throughout surgical history. Several surgical and sphincter-sparing approaches have been described for the management of fistula-in-ano, aimed to minimize the recurrence and to preserve the continence. We aimed to systematically review the available studies relating to the surgical management of anal fistulas. A Medline search was performed using the PubMed, Ovid, Embase, and Cochrane databases to identify articles reporting on fistula-in-ano management, aimed to find out the current techniques available, the new technologies, and their effectiveness in order to delineate a gold standard treatment algorithm. The management of low anal fistulas is usually straightforward, given that fistulotomy is quite effective, and if the fistula has been properly evaluated, continence disturbance is minimal. On the contrary, high complex fistulas are challenging, because cure and continence are directly competing priorities. Conventional fistula surgery techniques have their place, but new technologies such as fibrin glues, dermal collagen injection, the anal fistula plugs, and stem cell injection offer alternative approaches whose long-term efficacy needs to be further clarified in large long-term randomized trials.

TO THE EDITOR: Endosponge is a minimally invasive method to treat anastomotic leak endoscopically accessible in the low rectal area (B. Braun, Melsungen, Germany). We report the case of a 70-yr-old patient with an anastomotic leak following low anterior resection for rectal cancer successfully treated with the Endosponge.

Chronic constipation is a common self-reported gastrointestinal problem that affects between 2% and 34% of adults in various populations studied [1].

A rectocele is a herniation of the rectum through the rectovaginal fascia and posterior vaginal wall causing a protrusion into the vaginal lumen. It is a common disorder in women with a history of multiple vaginal deliveries, and it is asymptomatic in 80% of cases [1]. Symptomatic rectocele is less common, usually affects postmenopausal females, and results in obstructed defecation and constipation (Table 18.1) [2, 3].

Gastroesophageal reflux disease (GERD) represents a real social problem in the western world. About 20% of population has at least once a week, typical symptoms of this disease (heartburn and acid regurgitation); this incidence is probably underestimated because many patients have symptoms referable to extra-esofageal locations (asthma, cough, hoarseness, , non cardiogenic chest pain). The Montreal consensus conference defined GERD as “a condition which develops when the reflux of gastric contents causes troublesome symptoms and/or complications” (Vakil et al.,2006) But this definition does not take into account all possible pathogenetic causes and their therapeutic implications. Therefore seems more relevant to the definition of Brazilian consensus conference who considered GERD to be “a chronic disorder related to the retrograde flow of gastro-duodenal contents into the esophagus and/or adjacent organs, resulting in a spectrum of symptoms, with or without tissue damage”(Moraes-Filho et al.,2002). This definition recognizes the chronic character of the disease, and acknowledges that the refluxate can be gastric and duodenal in origin, with important implications for the treatment of this disease (Herbella & Patti, 2010).

Anal stenosis is a rare but serious complication of anorectal surgery, most commonly seen after hemorrhoidectomy. Anal stenosis represents a technical challenge in terms of surgical management. A Medline search of studies relevant to the management of anal stenosis was undertaken. The etiology, pathophysiology and classification of anal stenosis were reviewed. An overview of surgical and non-surgical therapeutic options was developed. Ninety percent of anal stenosis is caused by overzealous hemorrhoidectomy. Treatment, both medical and surgical, should be modulated based on stenosis severity. Mild stenosis can be managed conservatively with stool softeners or fiber supplements. Sphincterotomy may be quite adequate for a patient with a mild degree of narrowing. For more severe stenosis, a formal anoplasty should be performed to treat the loss of anal canal tissue. Anal stenosis may be anatomic or functional. Anal stricture is most often a preventable complication. Many techniques have been used for the treatment of anal stenosis with variable healing rates. It is extremely difficult to interpret the results of the various anaplastic procedures described in the literature as prospective trials have not been performed. However, almost any approach will at least improve patient symptoms.

Background and Aims Sphincter-saving procedures for resection of mid and, in some cases, of distal rectal tumors have become prevalent as their safety have been established. Increased anastomotic leak rate, associated with the type of anastomosis and the distance from the anal verge, has been reported. To compare surgical outcomes of end-to-end and end-to-side anastomosis after anterior resection for T1–T2 rectal cancer. Methods During the study period, a total of 298 rectal cancer patients were treated. Patients with T1–T2 rectal cancer (i.e., tumor level ≤15 cm from the anal verge) fit for surgery were asked to participate in the study. Patients were randomized to receive either an end-to-end anastomosis or an end-to-side anastomosis using the left colon. Surgical results and complications were recorded. Results Seventy-seven patients were randomized. Thirty-seven end-to-end anastomoses and 40 end-to-side anastomoses were performed. Anastomotic leakage after end-to-end anastomosis was 29.2%, while after end-to-side anastomosis was 5% (P = 0.005). In the end-to-end group 11 patients had anastomotic leaks: nine patients needed a re-intervention with colostomy creation subsequently closed in seven cases. Two patients of the end-to-side group experienced anastomotic leakage and were successfully treated conservatively. Conclusions Regarding postoperative surgical complications, end-to-side anastomosis is a safe procedure. J. Surg. Oncol. 2009;99:75–79. © 2008 Wiley-Liss, Inc.

The liver is the most commonly injured intra-abdominal organ. Liver mass is the key factor in determining the extent of the inertial force and consequently of damage in the case of sudden deceleration. In this respect, high-speed accidents usually produce characteristic lesions where the III-IV segments tear at the level of the hepatic ligament causing grade I-III liver injuries. The pathophysiology of such traumas is the subject of the present contribution. All trauma patients who sustained a blunt abdominal injury from January 1 to December 31 2004 were identified by the trauma registry at the Policlinico di Tor Vergata In order to select high-speed and sudden deceleration traumas, clinical records were reviewed for demographics, severity of injury, severity of liver injury, associated concomitant injuries, and management scheme. The grade of liver injury was determined on the basis of the initial CT or the intraoperative findings. A total of 159 patients who incurred abdominal injuries due to blunt trauma were identified. In 14 (8.8 percent) one or more liver lesions were associated. Among the low-grade injuries, 3 were grade I, and 8 grade II. Forty percent were high-grade injuries consisting in 6 grade III and 1 grade IV. We observed no grade V or grade VI injuries in this series. The most frequent occurrence was a tear between hepatic segments III and IV caused by the acute impact of the liver on the hepatic ligament. A hepatic injury caused by the round ligament was diagnosed intraoperatively in 1 out of 5 liver trauma patients (20 percent) and preoperatively in 4 out of 5 (80 percent) in our one-year abdominal blunt trauma series. Our clinical contribution underlines the high frequency of such lesions that seems to be related to, and characteristic of, high-speed trauma. In these cases immediate deceleration due to the impact may be a relevant factor in the pathophysiology of the lesion.

Objectives To present a comprehensive experience with intraprostatic botulinum toxin (BT) injection in men with symptomatic benign prostatic hyperplasia (BPH). Methods In this open-label study using an outpatient setting, 77 men with BPH received 200 intraprostatic BT A units (Botox) using an ultrasound-guided transperineal approach. We evaluated the American Urological Association (AUA) score, serum prostate-specific antigen (PSA), prostatic volume, residual volume, and peak urinary flow rates. The primary endpoint was symptomatic improvement after treatment, as measured by means of AUA score and peak urinary flow rates. The secondary endpoint was the evaluation of prostatic volume, serum PSA, and residual urinary volume. Results No significant local effects occurred. At their 1-month evaluation, 41 patients had subjective symptomatic relief. Compared with baseline values, AUA score was reduced from 24.1 ± 4.6 to 12.6 ± 2.9 (P = .00001), and serum PSA from 6.2 ± 1.7 to 4.8 ± 1.0 ng/mL (P = .03). At the same time, prostatic volume and residual urine volume were reduced by 12.7% and 12.8%, respectively, and mean peak urinary flow rate increased (P = .01). At 2 months' evaluation, 55 patients had subjective symptomatic relief. AUA score was reduced by 63.9% (P = .00001) compared with baseline values. In the same patients, serum PSA, prostatic volume, and residual urine volume were reduced by 51.6% (P = .00001), 42.8% (P = .00001), and 55.9% (P = .002), respectively, and mean peak urinary flow rate increased significantly. Conclusions Intraprostatic BT seems to be a promising approach to the treatment of BPH. It is safe, effective, well-tolerated, and not related to the patient's willingness to complete treatment.

Background The long-term prognosis of patients with colon cancer is dependent on many factors. To investigate the influence of a series of clinical, laboratory and morphological variables on prognosis of colon carcinoma we conducted a retrospective analysis of our data. Methods Ninety-two patients with colon cancer, who underwent surgical resection between January 1999 and December 2001, were analyzed. On survival analysis, demographics, clinical, laboratory and pathomorphological parameters were tested for their potential prognostic value. Furthermore, univariate and multivariate analysis of the above mentioned data were performed considering the depth of tumour invasion into the bowel wall as independent variable. Results On survival analysis we found that depth of tumour invasion (P < 0.001; F-ratio 2.11), type of operation (P < 0.001; F-ratio 3.51) and CT scanning (P < 0.001; F-ratio 5.21) were predictors of survival. Considering the degree of mural invasion as independent variable, on univariate analysis, we observed that mucorrhea, anismus, hematocrit, WBC count, fibrinogen value and CT scanning were significantly related to the degree of mural invasion of the cancer. On the multivariate analysis, fibrinogen value was the most statistically significant variable (P < 0.001) with the highest F-ratio (F-ratio 5.86). Finally, in the present study, the tumour site was significantly related neither to the survival nor to the mural invasion of the tumour. Conclusion The various clinical, laboratory and patho-morphological parameters showed different prognostic value for colon carcinoma. In the future, preoperative prognostic markers will probably gain relevance in order to make a proper choice between surgery, chemotherapy and radiotherapy. Nevertheless, current data do not provide sufficient evidence for preoperative stratification of high and low risk patients. Further assessments in prospective large studies are warranted.

OBJECTIVES:: To enhance the knowledge on the long-term efficacy and safety of tetrabenazine (TBZ) in managing chorea. METHODS:: We analyzed 68 Huntington disease patients (mean disease duration, 55.8 +/- 34.7 months) who had been treated with TBZ for a mean period of 34.4 +/- 25.2 months (median, 34 months; mode, 48 months; range, 3-104 months). We measured the variation from pretreatment of the motor score of Unified Huntington's Disease Rating Scale at the first follow-up visit and at the latest. RESULTS:: Mean Unified Huntington's Disease Rating Scale-chorea underscore at the time of the pretreatment visit was 10.4 +/- 4.1 (range, 0-28). At the first follow-up, 9.7 +/- 7.8 months after the prescription of TBZ (mean dose, 35.3 +/- 14.7 mg), mean score of chorea was 8.2 +/- 4.1 (-21% compared with baseline), whereas at the latest follow-up visit (mean dose, 57.5 +/- 14.7 mg), it was 9.5 +/- 5.0 (9%). During the follow-up, the clinical benefit persisted, but the magnitude was reduced despite a progressive increase of the doses (up to 60%). Motor improvement was not influenced by sex, or doses or duration of therapy; age at onset was the only predictor of a good outcome. Five patients (7%) did not gain any improvement, and TBZ was discontinued. There were 2 withdrawals because of side effects; 34 patients reported at least 1 side effect. CONCLUSIONS:: Tetrabenazine was well tolerated and produced long-term improvement of motor symptoms in Huntington disease patients, although a slight reduction of benefit occurred during the course of treatment.

BACKGROUND Puborectalis syndrome remains a therapeutic challenge for today's physicians. Traditional approaches include use of fiber, laxatives, enemas, biofeedback training, and surgery. These often were tried sequentially and had conflicting or even disappointing results. We investigated the efficacy of injections of botulinum toxin in improving rectal emptying in patients with defecatory disorders involving spastic pelvic-floor muscles. METHODS Twenty-four consecutive patients with chronic outlet obstruction constipation resulting from puborectalis syndrome were included in the study. The patients were treated with 60 units of type A botulinum toxin, injected into two sites on either side of the puborectalis muscle under ultrasonographic guidance. RESULTS At 2 months, evaluation inspection revealed a symptomatic improvement in 19 patients. Anorectal manometry demonstrated decreased tone during straining from 98 +/- 24 to 56 +/- 20 mmHg at a 1-month evaluation (p < 0.01) and 56 +/- 29 mmHg at a 2-month follow-up (p < 0.01). Pressure during straining was lower than resting anal pressure at the same time in all patients. Defecography after the treatment showed improvement in anorectal angle during straining, which increased from 98 +/- 9 degrees to 121 +/- 15 degrees (p < 0.01). CONCLUSIONS Botulinum toxin injections should be considered as a simple therapeutic approach in patients with obstructed defecation. The treatment is safe and effective, especially with the use of the ultrasonographic guidance that accounts for a more precise injection and consequently better long-term results. Otherwise, given the limited effect of the toxin, repeated injections may be necessary to maintain the clinical improvement.

Since its introduction in the late 1970s for the treatment of strabismus and blepharospasm, botulinum toxin (BoNT) has been increasingly used in the interventional treatment of several other disorders characterized by excessive or inappropriate muscle contractions. Over the years, the number of primary clinical publications has grown exponentially, and still continues to increase. It has been shown that BoNT blocks cholinergic nerve endings in the autonomic nervous system but does not block non-adrenergic non-cholinergic responses mediated by nitric oxide (NO). The present paper reviews a number of recent clinical indications for urological and pelvic floor dysfunctions, such as overactive and neurogenic bladder, non-bacterial prostatitis, benign prostatic hyperplasia, chronic anal fissure, or conditions associated to hyperactivity of the puborectalis muscle during straining. These indications provide a new promising palette of indications for future usage of BoNT in clinical practice.

Since its introduction in the late 1970s for the treatment of strabismus and blepharospasm, botulinum toxin (BoNT) has been increasingly used in the interventional treatment of several other disorders characterized by excessive or inappropriate muscle contractions. The use of this pluripotential agent has extended to a plethora of conditions including: focal dystonia; spasticity; inappropriate contraction in most sphincters of the body such as those associated with spasmodic dysphonia, esophageal achalasia, chronic anal fissure, and vaginismus; eye movement disorders; other hyperkinetic disorders including tics and tremors; autonomic disorders such as hyperhidrosis; genitourinary disorders such as overactive and neurogenic bladder, non-bacterial prostatitis and benign prostatic hyperplasia; and aesthetically undesirable hyperfunctional facial lines. In addition, BoNT is being investigated for the control of the pain, and for the management of tension or migraine headaches and myofascial pain syndrome. BoNT injections have several advantages over drugs and surgical therapies in the management of intractable or chronic disease. Systemic pharmacologic effects are rare; permanent destruction of tissue does not occur. Graded degrees of relaxation may be achieved by varying the dose injected; most adverse effects are transient. Finally, patient acceptance is high. In this paper, clinical experience over the last years with BoNT in urological impaired patients will be illustrated. Moreover, this paper presents current data on the use of BoNT to treat pelvic floor disorders.

A series of 84 patients with unresectable periampullary neoplasms, observed during an eight-year period (1992-1999), is reviewed for a critical analysis of modalities of treatment and clinical outcome. Two different approaches, a preference for "non-surgical" palliation and a preference for "surgical" palliation, in two consecutive periods, are compared.In the first period (1992-1995) endoscopic retrograde cholangiopancreatography with endoprosthesis insertion was performed routinely and, after diagnostic assessment, patients were divided into two groups: those with apparently resectable neoplasms, candidates for surgery, in whom the decision to perform a surgical palliation by biliary bypass was taken intraoperatively, and those with unresectable neoplasms, in whom the endoprosthesis insertion was considered as definitive palliation. Since January 1996, a different approach was started; surgical bypass was considered the palliation of choice and only patients unfit for surgery underwent endoscopic stenting.Evaluation of the results showed that the first strategy was associated with a high incidence of complications and unsatisfactory long-term results, with frequent hospital readmissions, poor quality of residual life and therefore failure of palliation. On the contrary, the latter approach with preference for surgical palliation was associated with lower morbidity and mortality, with persistent relief of symptoms and better quality of life in a larger percentage of patients.This study provides evidence that, in patients with unresectable periampullary carcinoma, surgical palliation provides better long-term results than endoscopic palliation. The results were also consistent with the advantage of associating a gastric bypass to the biliary bypass, also in the absence of gastric outlet obstruction.

Recent reports confirm that the management of chronic anal fissure has undergone extensive re-evaluation during the past few years. This rejuvenation of interest is attributable to the application of neurochemical treatment, which has contributed to the tendency to treat the disease on an outpatient basis. The use of botulinum neurotoxin seems to be a promising and safe approach for the treatment of chronic anal fissure, particularly in patients at high risk for incontinence. Indeed, botulinum neurotoxin has been successfully used selectively to weaken the internal anal sphincter as a treatment for chronic anal fissure. It is also more efficacious than nitrate therapy, and is not related to the patient's willingness to complete treatment.

Background Dermoid cyst of the pancreas is a benign, well-differentiated, extremely rare germ cell neoplasm. Published data indicate that differential diagnosis of cystic lesions of the pancreas is challenging and although ultrasonography, computed tomography and magnetic resonance may be useful, radiological findings are often inconclusive and the diagnosis is intraoperative. We report a case of a dermoid cyst of the tail of the pancreas intraoperatively diagnosed and successfully treated with left pancreatectomy. Further, characteristics, preoperative detection and differential diagnosis of this rare pathology are also discussed. Case presentation This report documents the findings of a 64-year-old male presenting with a well defined echogenic pancreatic mass on ultrasonography. Computerized Tomography (CT) showed a 5 cm cystic tumor arising from pancreatic tail and Magnetic Resonance Imaging (MRI) suggested a tumor extension to the middle side of the stomach without defined margins. A left pancreatectomy was performed. On surgical specimen, histological evaluation revealed a dermoid cyst of the tail of the pancreas measuring 8.5 × 3.0 cm. Conclusion Given the benign nature of the dermoid cyst, surgical resection most likely represents the definitive treatment and cure. In addition, resection is indicated in consideration of the difficulty in diagnosing dermoid cyst preoperatively. However, endoscopic ultrasound and fine needle aspiration cytology have recently been shown to be effective, safe, reliable and cost-saving preoperative diagnostic tools. Therefore, until more cases of dermoid cyst are identified to further elucidate its natural history and improve the reliability of the preoperative diagnostic tools, surgical resection should be considered the standard therapy in order to exclude malignancy.

Background In recent years treatment of chronic anal fissure has shifted from surgical to medical. This study compared the ability of two non-surgical treatments—botulinum toxin injections and nitroglycerin ointment—to induce healing in patients with idiopathic anal fissure. Methods One hundred adults were assigned randomly to receive treatment with either type A botulinum toxin (30 units Botox® or 90 units Dysport®) injected into the internal anal sphincter or 0·2 per cent nitroglycerin ointment applied three times daily for 8 weeks. Results After 2 months, the fissures were healed in 46 (92 per cent) of 50 patients in the botulinum toxin group and in 35 (70 per cent) of 50 in the nitroglycerin group (P = 0·009). Three patients in the botulinum toxin group and 17 in the nitroglycerin group reported adverse effects (P < 0·001). Those treated with botulinum toxin had mild incontinence to flatus that lasted 3 weeks after treatment but disappeared spontaneously, whereas nitroglycerin treatment was associated with transient, moderate-to-severe headaches. Nineteen patients who did not have a response to the assigned treatment crossed over to the other therapy. Conclusion Although treatment with either topical nitroglycerin or botulinum toxin is effective as an alternative to surgery for patients with chronic anal fissure, botulinum toxin is the more effective option.