title: Randomized clinical trial of botulinum toxin plus glyceryl trinitrate vs. botulinum toxin alone for medically resistant chronic anal fissure: overall poor healing rates.
abstract: OBJECTIVE
  This study was designed to assess whether addition of glyceryl trinitrate to botulinum toxin improves the healing rate of glyceryl trinitrate-resistant fissures over that achieved with botulinum toxin alone.
  
  
  METHODS
  Patients were randomized between botulinum toxin plus glyceryl trinitrate (Group A) and botulinum toxin plus placebo paste (Group B). Patients were seen at baseline, four and eight weeks, and six months. The primary end point was fissure healing at eight weeks. Secondary end points were symptomatic relief, need for surgery, side effects, and reduction in maximum resting and squeeze pressures.
  
  
  RESULTS
  Thirty patients were randomized. Two-thirds of patients had maximum anal resting pressures below or within the normal range at entry to the study. Healing rates in both treatment groups were disappointing. There was a nonsignificant trend to better outcomes in Group A compared with Group B in terms of fissure healing (47 vs. 27 percent), symptomatic improvement (87 vs. 67 percent), and resort to surgery (27 vs. 47 percent).
  
  
  CONCLUSIONS
  There is some evidence to suggest that combining glyceryl trinitrate with botulinum toxin is superior to the use of botulinum toxin alone for glyceryl trinitrate-resistant anal fissure. The poor healing rate may reflect the fact that many of the patients did not have significant anal spasm at trial entry.
authors.affiliation: Department of Colorectal Surgery, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, United Kingdom.
authors.forename: O M
authors.initials: OM
authors.lastname: Jones
authors.forename: T
authors.initials: T
authors.lastname: Ramalingam
authors.forename: A
authors.initials: A
authors.lastname: Merrie
authors.forename: C
authors.initials: C
authors.lastname: Cunningham
authors.forename: B D
authors.initials: BD
authors.lastname: George
authors.forename: N J McC
authors.initials: NJ
authors.lastname: Mortensen
authors.forename: I
authors.initials: I
authors.lastname: Lindsey
mesh_terms: D000328:Adult; D000368:Aged; D001905:Botulinum Toxins / Q000627:therapeutic use*; D004359:Drug Therapy, Combination; D005260:Female; D005401:Fissure in Ano / Q000188:drug therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D020030:Nitric Oxide Donors / Q000627:therapeutic use*; D005996:Nitroglycerin / Q000627:therapeutic use*; D011042:Poisons / Q000627:therapeutic use*; D011312:Pressure; D013997:Time Factors; D014945:Wound Healing / Q000187:drug effects*
chemical_list: D020030:Nitric Oxide Donors; D011042:Poisons; D001905:Botulinum Toxins; D005996:Nitroglycerin