Local Glyceryl Trinitrate Versus Lateral Internal Sphincterotomy In Management Of Anal Fissure

摘要

Aim of the work: We aimed to evaluate the effectiveness of local glyceryl trinitrate (GTN) versus surgical lateral internal sphincterotomy in the management of acute and chronic anal fissure.Patients and methods: We divided our patients into two groups; group 1 included 40 patients with anal fissure treated with topical GTN 0.2% and group 2 also included 40 patients, treated with lateral internal sphincterotomy. Results: In group 1, healing of fissures occurred in 85% of patients after 8 weeks therapy. Headache as a side effect developed in 65% of patients. In group 2, healing occurred in 97.5% of patients after 8 weeks. Incontinence to flatus occurred in 3 patients (7.5%) and mild soiling occurred in 2 patients (5%), but all were temporary. The improvement in group 2 was faster than in group 1 but at the end of 8 weeks both groups became equal in pain score. The main anal resting pressure (MARP) assessment changes in the two groups were nearly equal.Conclusion: We conclude that topical application of nitroglycerin represents a new, easily handled and effective alternative in the treatment of anal fissure. Introduction Anal fissure is one of the most painful conditions encountered in surgical practice, and causes considerable morbidity and reduction in quality of life.(1) Anal fissure is a linear tear in the lining of the distal anal canal below the dentate line. It is a common condition affecting all age groups, but is seen particularly in young and otherwise healthy adults, with equal incidence across the sexes. The classical symptom is anal pain during or after defecation accompanied by the passage of bright red stool. In addition, pruritus ani may accompany up to 50% of anal fissures.(2) Subcutaneous lateral sphincterotomy remains the gold standard for management of chronic anal fissure because of its simplicity, rapid healing and low recurrence rate. However, disadvantages of lateral sphincterotomy including disturbance of continence, bleeding, fistula, abscess, persistent wound pain, cost and time of recovery (3) have led to search for a mode of therapy or pharmacological way to create a temporary or reversible sphincterotomy, one that would lower sphincter pressure only until the fissure had healed.(4) Local GTN can reduce the increased anal canal pressure caused by a hypertonic internal anal sphincter and improve anodermal blood flow, as surgical lateral sphincterotomy. Reversible chemical sphincterotomy produced by local GTN has been used successfully for healing in anal fissure, with minimal side effects and avoiding the need for operative intervention.(5) Topical GTN can be used with liposomal base as a delivery system, liposomes are most useful to transfer and deliver active ingredients to application sites, which leads to more efficacy of the drug. In view of this and the fact that the optimal therapeutic strength of GTN is still to be determined, we aimed to evaluate the use of topical GTN versus surgical lateral internal sphincterotomy in the management of anal fissure.(6) Patients And Methods The study is a clinical prospective randomized controlled study, hospital-based, and was carried out on patients who were diagnosed clinically with anal fissure and attended to in the outpatient clinic of the surgical department of Suez Canal University Hospital.The study was carried out on male and female patients aged 18-60 years who were diagnosed clinically with acute and chronic anal fissures. Patients with complicated anal fissures, with other anal problems (as piles), with previous anal surgery, with systemic diseases (diabetes mellitus, chronic liver disease and collagen diseases), and patients under treatment with nitrates for other diseases, e.g. ischemic heart diseases were excluded from the study. Pregnant women and children were also excluded.Methods and proceduresFull detailed history, especially about symptoms of anal fissure including anal pain during and after defecation, bleeding, discharge and itching an