Topical Nitroglycerin versus Lateral fnternal Sphincterotomy in Treatment of Chronic Anal Fissure

Background

These cases were randomized in equal number into trvo groups: Group l: rvcre treated by chcmical Sphincterotomy.
Croup 2: rverc treated by lateral internal Sphincterotomy. The avcragc pcriod of follorv up aftcr complction of treatmcnt was 3 months for both groups.
Introduction:-Unlike acute anal fissure, chronic fissure in ano do not usually respond to dietary advice alone, the aim of treatment is to alleviate sphincter hypertonia and. improve blood flolv to the ulcerated area (".Lateral internal Sphincterotomy has replaced anal stretching as the main stay of treatment due to concerns over adverse effects on continence. Lateral Sphincterotomy permanently lowers resting anal pressure and in doing so aids the healing of anal fissures. It may, however,be associated with minor temporary or . permanent alterations in the control of gas, mucous and occasionally stool in up to35% of patients(2). This had led to alternative therapeutic approaches, in particular, pharmacological, reversible Sphincterotomy using topical agents such as butulinurn toxin, calcium channel blockers and glyceryl trinitrate(GTN).The most widely used topical agent is GTN.Thc latter is mobilized to nitric oxidc and leads to sphincter muscle relaxation and reduction in maxintttnt anal resting prcssurc. this rcsult in a rcvcrsiblc irnprovcmcnt in pcctin pcrlusion and clintinatc thc risk of pcrmancttt nnal incontincncc associatccl rvith surgcry(l).Dxistirrg data conccnr nrainly thc cflicacy of 0.2%C1'N pastc. Rccent evidcncc suggcsts tlrat nitric oxidc (NO) is thc ncurotranstnittcr rclcascd by irrhibitory cntcric ncurons ittttcrvatirtg tltc irttcrttal attal splrinctcr(IAS;(a).Endogctlous ancl cxogcltotls nitric oxidc(NO) in cotttact rvitlr thc IAS catrscs rclaxation of that tttusclc('r '5).Orgartic ttitratcs, such as tritroglyccrin, nrc clcgradcd by cclltrlar nrctabolisnt, liberating 0\O). Nitroglyccrine (NTC) applied topically to tltc arttts ltas been shorvn to cause a lorvering of IAS pressttre in nonnal human subj ects (7'8 At presentation, a pain score (0-10) was established as well as a symptom score (0)(1)(2)(3) with one point each for bleeding, discharge and itching. The patients were treated with GTN 0.2% ointment (prepared by pharmacist) which was applied digitally peri and internally 3 times daily, initially for 6 weeks. The amount applied was the smallest amount that could be rubbed into the anal area without leaving excess ointment. All patients were reviewed at 3,6and 12 weeks to assess pain and symptoms scores and to asses fissure healing complication and compliance. Patients that did not respond to treatment or rvho were unable to comply with the treatment were offered a lateral anal Sphincterotomy. Rcsults:-Thc results rvere recordcd as: l-Asyrnptomatic: lvhen thc main symptoms (pain, blceding, disclrarge and itching) were conrplctcly controllcd and ulcer hcalcd conrpletcly.
2-Residrral symptoms: rvltcn marked intprovcrtrcnt of the main syrnptoms but sorne rcsidual synrptonrs pcrsist and hcadachc (non cornpl iant) rvas occurrcd.    'fopical Gl-N should be the initial treatnrent in cltronic anal fissure. In patients rvith chronic fissure in ano chemical Sphincterotonry is a non-invasive and effective modality that can be considered as first line of treatment, especially in patients rvho tend to avoid or are tunfit for surgery, as it has no permanent side effects and is well tolerated. Lateral Sphincterotomy should be reserved for patients rvith severe disabling pain (because pain relief is much faster), and for patients not responding to at least 4lveeks of GTN therapy.

3-No irnprovcrncnt
Moreover, topical treatment proved to be si gn i fi cantly cost-effective.