646 Correspondence

for needle catheter jejunostomy2,3; ourown experience has demonstrated com-plication rates of much lower than thosereported in the study.

We are concerned about the mecha-nism of re-insertion of the nasoduodenaltube if it becomes dislodged, as com-monly occurs. Blind insertion with aguidewire past the cervical anastomosisintroduces the possibility of damage tothe anastomosis, with significant associ-ated morbidity and mortality.

In this study, patients with naso-duodenal tubes had the tubes removedbefore discharge. Our experience hasshown that patients may require recom-mencement of enteral feeding followingdischarge; this is made easier with afeeding jejunostomy tube still in situ.

H. C. Rodgers and K. MoorthyDepartment of Upper GI Surgery,University Hospital Birmingham,

Birmingham, UKDOI: 10.1002/bjs.5875

1 Jenkinson AD, Lim J, Agrawal N,Menzies D. Laparascopic feedingjejunostomy in esophagogastric cancer.Surg Endosc 2007; 21: 299–302.

2 Sica GS, Sujendran V, Wheeler J,Soin B, Maynard N. Needle catheterjejunostomy at esophagectomy forcancer. J Surg Oncol 2005; 91:276–279.

3 Yagi M, Hashimoto T, Nezuka H,Tani T, Shimizu K, Miwa K.Complications associated with enteralnutrition using catheter jejunostomyafter esophagectomy. Surg Today 1999;29: 214–218.

Authors’ reply: Randomized clinicaltrial comparing feeding jejunostomywith nasoduodenal tube placementin patients undergoingoesophagectomy (Br J Surg 2007;94: 31–35)

SirWe would like to thank Rodgers andMoorthy for their interesting response.We congratulate them on their good

results with the needle catheter jejunos-tomy. We do not think that the tech-nique we used contributes to the com-plication rate as it is a frequently usedand well described technique. Althoughwe have not had any problems with blindreinsertion of the tube, we do share theirconcerns regarding possible damage tothe anastomosis. It is probably safestto reposition under direct vision withthe aid of an endoscope. Indeed, thereare some patients who would possiblybenefit from at-home adjuvant feed-ing. However, as this is only a verysmall minority, we chose to not intro-duce a risk factor for all patients for thebenefit of a few. Furthermore recent lit-erature has demonstrated that adjuvantout-patient feeding is successful whengiven by nasoduodenal tube.

I. HanDepartment of Surgery, Erasmus Medical

Centre, 3015 GD Rotterdam,The Netherlands

DOI: 10.1002/bjs.5876

Randomized clinical trial comparingbotulinum toxin injections with0·2 per cent nitroglycerin ointmentfor chronic anal fissure (Br J Surg2007; 94: 162–167)

SirWe applaud the efforts of Brisinda et al.in this RCT comparing botulinum toxininjections with 0·2 per cent nitroglyc-erin (GTN) ointment for chronic analfissure. We found the results interestingand they will certainly provide usefuldata for further trials.

The authors reported a significantsuperior benefit in healing at 2 monthsafter treatment with botulinum toxincompared with GTN ointment. How-ever, it would also be interesting to knowthe proportion of subjects who hadsymptomatic improvement at 2 months,as there was no statistical differenceat 1 month between treatment groups(P = 0·262). Furthermore, complianceas a cause of failure rates for the GTNgroup was not assessed and this has con-founded the results. The 12 patientsin the GTN group who later had

botulinum toxin injection were foundto have no change in the mean analtone before and after treatment withGTN. One could speculate that this is aresult of poor compliance with GTNtreatment. Perhaps the technique ofusing a gloved finger to apply the GTNointment, which is a proven methodto reduce side effects, could have beenintroduced1.

We also question the authors’ use ofthe Student’s t test for comparing thedifference in rectal tone pre- and post-treatment. The paired t test is usuallypreferred when measurements are takenfrom the same sample before and afterintervention.

T. Kelly, M. Ballal and G. KheraDepartment of Surgery, Whiston Hospital,

Merseyside L355DR, UKDOI: 10.1002/bjs.5877

1 Minguez M, Herreros B, Benages A.Chronic Anal Fissure. Curr TreatmOptions Gastroenterol 2003; 6: 257–262.

Authors’ reply: Randomized clinicaltrial comparing botulinum toxininjections with 0·2 per centnitroglycerin ointment for chronicanal fissure (Br J Surg 2007; 94:162–167)

SirWe thank Dr Kelly and colleagues fortheir interest in our article. Resultsof recent reports confirm that themanagement of chronic anal fissurehas undergone extensive re-evaluation.There is a growing interest in phar-macological approaches of sphinctero-tomy to produce reversible reductionof sphincter pressure and obtain fissurehealing, minimizing the incontinencerisk. Of these pharmacological options,botulinum toxin has achieved healingrates approaching 90 per cent in somestudies1. Particularly, 82 per cent heal-ing rate was detected at 3 month follow-up using intrasphincteric injections of2·5–5 U2 and, moreover, healing ratesup to 96–100 per cent were obtained2 months after the injection of higherdoses of toxin (up to 50 U)3.

Copyright 2007 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2007; 94: 642–648Published by John Wiley & Sons Ltd