Background: In the treatment of chronic anal fissures (CAFs), surgical sphincterotomy is more commonly being replaced by chemical sphincterotomy. After the good results of our pilot study including 32 patients, we now describe the effect of botulinum toxin A (BT-A) in a consecutive series of 100 patients with isosorbide dinitrate (ISDN) ointment-resistant CAFs. Methods: From October 2002 until August 2005, 100 patients (52 males, 48 females) with a median age of 45 (20–79) years were treated with an injection of 40–100 IU BT-A (Dysport®, Ipsen, The Netherlands) in the internal anal sphincter. Results: After a median follow-up of 10 (4–38) months, 77 of the 100 CAFs (77%) were cured. 20 patients were given a second injection, 1 a third and 1 a fourth injection. In 11 patients a fissure recurred (14%). In 1 patient (1%) there was temporary incontinence due to flatus. Conclusion: With an early response rate of 77% and an overall success rate of 66%, BT-A injections appear to be effective in patients with ISDN ointment-resistant CAFs if initial non-responders are retreated. These results are in concordance with the results of our pilot study. It is a simple technique with little or no side effects, that does not compromise future treatments. Its place in the first-line treatment of CAFs should be investigated further.

Fissurectomy in combination with Botulinum Toxin A injection in the internal anal sphincter is an effective treatment for medically resistant CAFs.

A relatively new therapy in the treatment of hemorrhoids is transanal hemorrhoidal dearterialization (THD). We report a case of brain abscess caused by Streptococcus milleri following THD. Although a brain abscess after drainage of a perianal abscess has been described in the literature, no report exists of a brain abscess following treatment of hemorrhoids. A healthy 51-year-old man with hemorrhoids underwent THD. Two weeks later he presented with a headache, bradyphrenia, flattened behavior and a left hemiplegia. No perianal complaint and/or perianal abscess was present. A contrast CT scan of the cerebrum showed a right temporoparieto-occipital abscess, with edema and compression of the surrounding tissue and lateral ventricles. MRI showed an abscess with leakage in the right lateral ventricle. Treatment with dexamethasone and intravenous antibiotics was started. Because of progression of symptoms, 3 weeks later ventriculoscopy was performed and the abscess was drained. Culture of the punctuate showed S. milleri. Because of developing hydrocephalus 3 days after ventriculoscopy, first an external ventricle drain and later a ventriculoperitoneal drain was placed. Hereafter the hemiplegia and cognitive disorders improved. This case report describes a severe complication following treatment of hemorrhoids with THD which until now, to our knowledge, has never been described in the literature.

30 patients had epididymovasostomies procedures. The years post vasectomy were noted. Of these patients, the level of vasal occlusion was recorded for 150 of the vasovasostomies and 36 of the epididymovasostomies.RESULTS: 50% of the epididymovasostomies were performed on low vasectomy sites as compared to 34% of the vasovasostomies. In other words, 15% of patients with high vasectomy site required an epididymovasostomy, while 26% of patients with a low vasectomy site required an epididymovasostomy (p = 0.07). Furthermore, the mean years post vasectomy for vasovasostomies was 8.7 +/-5.5, while the mean number of years for epididymovasostomies was 15.1 +/-5.6 (p < 0.001).CONCLUSIONS: The palpable level of the vasectomy affected the type of vasectomy reversal procedure required with almost twice the incidence of patients with low sites requiring epididymovasostomy as compared to those with high occlusion sites. This difference approached statistical significance. This finding suggests that vasectomies should be performed high in the scrotum whenever possible to improve the success of possible later reversal. Also, in our series the years post vasectomy did statistically influence the required reversal procedure and does have predictive value.

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