Is Topical Nitroglycerin Superior to Internal Sphincterotomy in the Management of Chronic Anal Fissure (original) (raw)
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Local Glyceryl Trinitrate Versus Lateral Internal Sphincterotomy in Management of Anal Fissure
World Journal of Colorectal Surgery, 2010
Introduction: Anal fissure is a common benign condition that can cause severe anal pain after defecation and bleeding. Symptoms from fissure cause considerable morbidity and reduction in quality of life. The aim of treatment is to reduce anal hvpertonia, which may improve anodermal blood flow and heal the fissure. Aim of the work: This study 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: In our present study we compared topical application of GTN on lipsomal base with the surgical procedure i.e. internal lateral sphincterotomy and according to the method of treatment the patients were divided into two groups; group 1 which included 40 patients with anal fissure and agreed to have the medical treatment with topical GTN 0.2% applied to the anoderm twice daily. Group 2 also included 40 patients and treated with lateral internal sphincterotomy. Results: In group1, healing of fissures occurred in 85% of patients after 8 weeks therapy. Headache as a side effect developed in 65% of patients but no patient ceased to apply the ointment due to headache. 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 and there was no gross incontinence and one patient with wound infection. The improvement in group 2 faster than group 1 but at the end of 8 weeks both groups become equal in pain score. The main anal resting pressure (MARP) assessment changes in the two groups were nearly equal. Conclusion: We concluded that topical application of nitroglycerin represents a new easily handled and effective alternative in the treatment of anal fissure.
ANZ Journal of Surgery, 2005
Introduction: Topical nitroglycerin (GTN) is one of the medical treatments of choice in chronic anal fissure. The present prospective, randomized, clinical trial was conducted to study the symptomatic relief, healing, and changes in the maximum anal resting pressure (MARP) in patients with chronic anal fissure comparing topical GTN and lateral sphincterotomy. Methods: Forty consecutive patients with chronic anal fissure were randomized for treatment with either topical GTN or internal sphincterotomy (20 patients in each group). Anal manometry was done before treatment in all patients, and 1 h after application of GTN or sphincterotomy. Patients were followed at 2-weekly intervals for 6 weeks for symptomatic relief and healing. Results: Both GTN and sphincterotomy brought about a highly significant, but comparable drop in the MARP after treatment ( P < 0.0001 in both groups). Sphincterotomy relieved pain much earlier compared to GTN (70% vs 40% at 2 weeks, P = 0.0032); but after 4 weeks of treatment, pain relief in both groups was comparable. Healing in the sphincterotomy group was also earlier than with GTN (55% vs 0% at 2 weeks, P < 0.0001; and 85% vs 30% at 4 weeks, P < 0.0001); but after 6 weeks, healing in both groups was comparable. Sphincterotomy had a significant incidence of minor, short-term complications; it also required surgical expertise, theatre time, and day-care beds. Nitroglycerin is safe, with mild and tolerable side-effects of headache and local burning sensation. Conclusion: Topical GTN should be the initial treatment in chronic anal fissure. Lateral sphincterotomy should be reserved for patients with severe disabling pain (because pain relief is much faster), and for patients not responding to at least 4 weeks of GTN therapy.
Surgery: Current Research, 2012
Aim: Lateral Internal Sphincteromy (LIS) is considered as gold standard in the treatment of chronic anal fissure. However, LIS has complications such as gas and stool incontinence. The aim of the present study was to compare the results of LIS and 0.4% topical nitroglicerin treatment in patients with chronic anal fissure. Method: 150 patients with Chronic Anal Fissure were prospectively randomised into two Groups of 75 subjects in each. Group I underwent LIS and Group 2 was administered topical nitroglicerin. All patients were given high fibre diet and phsyllium diet before and after the treatment. After follow up period, two Groups were compared in terms of postoperative complications, recurrence rates, loss of work days and patient satisfaction. Results: Two Groups were similar in terms of demographic data and anal fissures. Recurrence was seen in 4 patients in Group I and 8 patients in Group II. Gas incontinence under stress developed in 7 patients in Group I, in no patient Group II. Anal itching and soiling occurred in 8 patients in Group I, in no patient Group II. In Group II, headache occurred in 12 patients during treatment. Duration of time to return to work and normal activity was longer in Group I. Conclusion: It is our suggestion that topical nitroglicerin is as effective as surgery in the treatment of chronic anal fissure with absence of incontinence.
Techniques in Coloproctology, 2001
Several treatments for anal fissure offer different responses and risks for complications. Reversible chemical sphincterotomy with topical nitroglycerin is an alternative to surgical sphincterotomy. The aim of this observational prospective study was to compare the effectiveness of topical nitroglycerin with the conventional medical treatment. Forty-three patients with anal fissure were treated: 22 (16 chronic and 6 acute) received 0.25% nitroglycerin topically, and 21 (16 chronic and 5 acute) received conventional treatment. Nitroglycerin or placebo was administered in two daily applications for two weeks. Median follow-up was 39 weeks. Healing rate with NTG was 75% for chronic and 83% for acute fissures, but recurrence rate for chronic fissures at 9 months was 67%. Healing rate with placebo for chronic fissures was only anecdotical (1 out of 16 patients). Headache as side effect occurred in 17 cases (77%). In conclusion, both treatments were effective for acute fissures, whereas for chronic ones NTG had a high healing rate but also a high recurrence rate.
Comparative Study of Glyceryl Trinitrate Ointment Versus Surgical Management of Chronic Anal Fissure
Indian Journal of …, 2011
Chronic Anal Fissure (CAF) is common perineal condition and well-known painful entity. Standard surgical treatment even though available, may require long hospital stay and sometimes have worrying complications like anal incontinence. So non-surgical treatment, Glyceryl Trinitrate has been shown to be an effective for chronic anal fissure. It decreases anal tone and ultimately heals the anal fissure. The present study is the attempt to know the efficacy of 0.2% Glyceryl Trinitrate ointment in the treatment of chronic anal fissure and to compare the effectiveness of 0.2% Glyceryl Trinitrate ointment (GTN) versus fissurectomy with lateral internal sphincterotomy (LIS) and fissurectomy with posterior internal sphincterotomy (PIS) in the management of chronic anal fissure. This is a prospective comparative study of management of chronic anal fissure done in our hospital during the period of one and half year from October 2005 to March 2007. Thirty patients treated with 0.2% Glyceryl Trinitrate ointment and 30 patients treated with fissurectomy and lateral internal sphincterotomy and 30 patients treated with posterior internal sphincterotomy, for chronic anal fissure were selected for study. A single brand of 0.2% Glyceryl Trinitrate ointment (Nitrogesic) used for trial arm. Dose of administration was 1.5 cm to 2 cm in the anal canal with device provided by manufacturers of the proprietary preparation and applied twice a daily for 12 weeks. Patients were followed up for 12 weeks and thereafter evaluated for relief of symptoms in all three groups. Observations were recorded at 2 weeks; 6 weeks and 12 weeks of follow up period, regarding symptoms like pain and bleeding during defecation, healing of CAF and also for side effects like headache in GTN group and flatus, fecal incontinence in surgical groups. Data collected in proforma and analyzed. Study revealed CAF was more in male 59 patients (66%) than the female 31 patients (34%), the ratio being 1: 0.52. The maximum number of patients was encountered in the age group of 20 to 40 years with mean duration of age 34.14 years. In all three groups symptoms like pain, bleeding, constipation and sphincter spasm were present. Sentinel pile was present in 56% of the patients. Common site of fissure was found to be posterior in 94% of patients. Observations with respect to relief of pain, no bleeding and healing were recorded at 2, 6 and 12 weeks of duration. Lateral sphincterotomy remains effective but should be reserved for the patients who fail to respond to initial chemical sphincterotomy or GTN therapy. GTN is good alternative mode of therapy for patients who refuse surgery and prefer medical line of treatment.
Aims and Objectives: To prospectively evaluate and compare effectiveness of topical 0.2% glyceryl trinitrate ointment vs lateral internal sphincterotomy in treatment of patients with chronic anal fissure. Material and Methods: The study included a total of 50 patients presented with chronic anal fissure, divided into two groups by computer generated randomization. Group A included 25 patients with chronic anal fissure treated with local glyceryl trinitrate ointment 0.2% whereas Group B included 25 patients managed by lateral internal sphincterotomy.
Glyceryl trinitrate is an effective treatment for anal fissure
Diseases of the Colon & Rectum, 1997
It has been suggested that chronic anal fissure is ischemic in origin because of poor blood supply and spasm of the internal anal sphincter. Nitric oxide donors such as glyceryl trinitrate (GTN) cause a chemical sphincterotomy leading to healing of the fissure. This study addresses the hypothesis that topical GTN ointment may be an effective nonsurgical treatment for chronic anal fissure. Thirty-nine consecutive patients (23 women; median age, 34 (range, 16-54) years) with chronic anal fissure presenting to the surgical outpatient department were treated for four to six weeks with 0.2 percent GTN ointment applied twice daily to the anoderm. Maximum anal resting pressure was measured at steady state before and after application of the ointment at the first visit. Patients were assessed at two weekly intervals. Previous surgery for fissure had been performed in seven patients. There were 30 posterior and 9 anterior fissures. Resting maximum anal resting pressure fell from 122.1 +/- 44 to 72.5 +/- 33.3 cm of water (mean +/- standard deviation) by 20 minutes after application of ointment (P < 0.0001; paired t-test). Healing was complete in 14 patients at four weeks and in 33 patients at six weeks. Fissures recurred in five patients after treatment had been stopped. Four recurrences were successfully treated by further GTN ointment and one by sphincterotomy. This study shows that most anal fissures can be treated nonsurgically with topically applied 0.2 percent GTN ointment. Prospective, randomized controlled trials are now needed, because nonsurgical treatment of anal fissure avoids permanent division of part of the sphincter and the consequent disturbance of continence mechanisms.
Local nitroglycerin for treatment of anal fissures
Diseases of the Colon & Rectum, 1997
PURPOSE: Nitric oxide is an important neurotransmitter mediating internal anal sphincter relaxation. Patients suffering from fissure-in-ano were treated with topical nitroglycerine. The clinical evidence for therapeutic adequacy was examined in a prospective, randomized study. METHODS: The study included 35 patients with acute and chronic anal fissures. In Group A, including 20 patients with the clinical diagnosis of acute (12 patients) and chronic (8 patients) anal fissures, treatment consisted of topical nitroglycerine. Group B, consisting of 15 patients (10 acute and 5 chronic fissures), received topical anesthetic gel during therapy. Manometry was performed before and on days 14 and 28 in the course of topical application of either 0.2 percent glyceryl trinitrate ointment or anesthetic gel (lignocaine). Anal pressures were documented by recording the maximum resting and squeeze pressures. RESULTS: In 60 percent of cases treated with topical nitroglycerine (Group A, 11 acute (91.6 percenO and 1 chronic (12.5 percent)), anal fissure healed within 14 days, in contrast to Group B in which no healing was observed. The healing rate after one month was 80 percent (11 acute (91.6 percent); 5 chronic (62.5 percent)) in Group A and was significantly superior to Group B (healing rate, 40 percent: 5 acute (50 percent); 1 chronic (20 percent)). DISCUSSION: Previously increased maximum resting pressures decreased from a mean value of 110 to 87 cm H20. This represents a mean reduction of 20 percent (P = 0.0022). We also noted a significant decrease in squeeze pressures (from 177.8 to 157.9 cm HzO (11 percent)). However, anal pressures did not decrease significantly in the four chronic fissure patients from Group A, whose fissures only healed after 28 days. Similarly to these Group A chronic fissure patients, no significant anal pressure reduction was observed in any Group B patients. Except for mild headache (20 percent), no side effects of treatment were reported. CONCLUSIONS: Topical application of nitroglycerine represents a new, easily handled, and effective alternative in the treatment of anal fissures. All of our patients reported a dramatic reduction in acute anal pain. However, it should be noted that a lack of sphincter tone reduction is a likely reason for the great tendency of chronic anal fissures to recur.
Niger J Clin Pract . , 2020
Background: Anal fissure which is defined as a longitudinal tear in anoderm below the dentate line is one of the most common benign diseases of anorectal area. Severe pain during the defecation and emotional stress that it causes may reduce people's quality of life. Aims: In this randomized clinical trial, we aimed to compare the efficiency of the topical ointment with medical treatment and surgical lateral internal sphincterotomy. Method: This is a randomized clinical trial of 550 patients who were treated for chronic anal fissure. Patients were randomly divided into 4 groups according to the treatment type they received. Results: In a vast majority of the patients, the primary complaint was pain (92.3%) and bleeding during defecation (62%). Both pain relief and healing of the fissure, which are the components of response to treatment, had not been observed in 56 (37.3%) patients of topical nitroglycerin ointment group until the second month. Among the recalcitrant patients in both topical nitroglycerin (56) and topical diltiazem ointment (47) groups, 27 (48.2%), and 36 (76.5%) patients underwent surgery, respectively. The best response to treatment was also obtained in lateral internal sphincterotomy group. Conclusion: LIS is still the gold standard for the treatment of chronic anal fissure when the physicians would like to avoid recurrence and obtain the best pain relief.