Abstract
ABSTRACT

Objective
To evaluate the efficacy of lateral internal sphincterotomy versus chemical (topical 0.2% glycerltrinitrate ointment) sphincterotomy for the treatment of anal fissure.
Methods
This was a comparative, prospective study of 342 patients of acute and chronic anal fissure, conducted at Ghulam Muhammad Mahar Medical College Hospital Sukkur, during a period of three years from July 2007 to June 2010. Chemical sphinterotomy was advised to 233 patients with 0.2% glyceryltrinitrate ointment applied at fissure site twice or thrice a day for eight weeks. 109 patients were in urgency due to severe pain or refused topical treatment and underwent surgical sphincterotomy. The lateral internal sphincterotomy was done in 272 patients, including the failure/persistent fissures treated by glyceryltrinitrate. The patients were followed and the extent of improvement in presenting symptoms, side effects and complication of both modalities were recorded.
Results
Chemical sphincterotomy relieved symptoms in only 70 (30.04%) patients while laternal internal sphincterotomy in all 272 (100%) patients. In the former, the recurrence/persistence of fissure was found in 163 (69.95%) patients while none of the patients treated by surgical sphincterotomy suffered from the recurrence/persistence of the fissure. Except for bleeding in 4.77%, hematoma in 1.47%, faecal soiling in 6.98% and transient flatus incontinence in 2.57%, no failure or longterm complications like faecal incontinence were observed in patients treated by lateral internal sphincterotomy after mean follow up of 24 months.
Conclusion
Chemical sphincterotomy is a non-invasive, cost-effective and first line of treatment for anal fissure but lateral internal sphincterotomy was superior, more effective and curative than the chemical sphincterotomy. (Rawal Med J 2010;35: ).
Key words
Anal fissure, chemical sphincterotomy, lateral internal sphincterotomy.
INTRODUCTION
An anal fissure is a painful linear tear or split in the long axis of the distal anal canal1 below the level of the dentate line and extending to the anal verge.2,3 Possible causes include infection and trauma to the anal canal such as passage of hard stool or severe diarrhea. It is associated with increased tone of internal anal sphincter and poor perfusion of anterior and posterior anoderm. More than 90% of fissures are acute and resolve spontaneously. Acute anal fissures progress to chronic if not treated properly.4 About 90% of anal fissures occur in posterior midline.5
Chemical sphincterotomy (topical application of 0.2% glyceryltrinitrate (GTN) ointment) is emerging as first line treatment as it relaxes the sphincter.6-9 It is economical and cost-effective, but takes longer time for the healing and causes headache.9,10 Surgery is invasive, expensive and associated with postoperative pain7,11 but is now considered the treatment of choice for anal fissure, as it addresses the pathologically raised pressure withi

Key words: Anal fissure, chemical sphincterotomy, lateral internal sphincterotomy.