Title: Comparision of Lateral Sphincterotomy with Glyceral Nitrate 0.2% / Diltiazem 2%Local Application in Chronic Fissure in Ano
Authors: Rajeev.N (MS), Raghunandan (MS)
DOI: http://dx.doi.org/10.18535/jmscr/v3i9.38
Abstract
Background and Objectives: Anal fissures are commonly encountered in routine general surgical practice. Developments in understanding of anatomy,physiology and itsresponse to GNT/Diltiazemhas resulted in new conservative approach.In this study we compare the two modalities of treatment in chronic fissure in ano.
Methods: In the study 80 patients of chronic fissure in ano was treated conservatively with0. 2% GTN/2% Diltiazem and lateral sphincterotomy based on the patient preference.The patients were followed up for 5 to 6 weeks for symptomatic relief and healing of fissure and the results compared.
Results: 1. The fissure healed completely in 46 patients with Diltiazem 2%/NTG0.2% application twice daily with Sitz bath.2. In 25 patients treated with surgery (Internal Lateral Anal Sphincterotomy), the fissure healed completely.3. The mean duration required for healing of fissure was 5.37weeks in Diltiazem/NTG group and 4 weeks in Internal sphincterotomy group.4.There were no side effects after Diltiazem/NTG therapy, 8 patients treated with sphincterotomy had pain in immediate post-op periods subsided with analgegics.
Conclusion: Comparision between Diltiazem/NTG gel and Internal sphincterotomy did not show any difference in pain relief and fissure healing. But the time taken for healing was less in surgical group compared to conservatively managed group. Conservative treatment is equally efficacious as surgical treatment in this study.
References
1. Jonas Marion, Scholefield J.H., Anal fissure and chemical sphincterotomy. Taylor I., Johnson C.D., Recent advances in Surgery. Churchill Livingstone, 24th Edition,2001, pg. 115.
2. John Goligher, Anal Fissure, John Goligher, Surgery of the Anus, Rectum & Colon. AITBS, 5th Edition, 1992, pg.150.
3. J. S. Knight, M. Birks, R. Farouk, Topical Diltiazem ointment in the treatment of chronic anal fissure. British Journal of Surgery.2001; 88 (4): pg. 553-556.
4. R. Dasgupta, I. Franklin, J. Pitt, P. M. Dawson, Successful treatment of chronic anal fissure with Diltiazem gel. Colorectal Disease; 4: pg. 20-22.
5. Marion Jonas, William Speake, John H. Scholefield, Diltiazem heals Glyceryltrinitrate resistant chronic anal fissures: a prospective study. Diseases of the colon and Rectum. 2002; 45 (8): pg. 1091-1095.
6. U. K. Srivastava, B. K. Jain, Praveen Kumar, Yusuf Saifee, A comparison of the effects of Diltiazem and Glyceryltrinitrate ointment in the treatment of chronic anal fissure: a randomized clinical trial. Surgery Today. 2007; 37 (6): pg. 482-485.
7. E. Carapeti, M. Kamm, B. Evans, R. Phillips, Topical Diltiazem and Bethanechol decrease anal sphincter pressure and heal anal fissures without side effects. Diseases of the Colon and Rectum. 1999; 43 (10): pg. 1359-1362.
8. I. T. Khubchandani, J. F. Reed, Sequelae of internal sphincterotomy for chronic fissure in ano. British Journal of Surgery. 1989; 76 (5): pg. 431-434.
9. John Goligher, Surgical Anatomy and Physiology of the Anus, Rectum and Colon, John Goligher.
10. Surgery of the Anus, Rectum and Colon, AITBS, 5th Edition, 1992,pg. 7.Bannister H.L., Muscle System, Soames R. Gray’s Anatomy
11. Lee McGregor, The Large Bowel and Anal Canal, Synopsis of Surgical Anatomy, Decker G.A.G. Varghese Publishing House, 1999, pg. 48.
12. Peter J. Lunniss, The anus and anal canal, Norman S. Williams, Christopher J.K.Bulstrode& P. Roman O’Connell. Bailey & Love’s Short Practice of Surgery, Hodder Arnold, 25th edition, 2008, pg. 1251-1253.
13. Heidi Nelson, Robert R. Cima, Anus, Courtney M. Townsend, R. Daniel Beauchamp, B. Mark Evers, Kenneth L. Mattox. Sabiston Textbook of Surgery, Elsevier, 18th edition, 2003, pg.1443.
14. Jennifer K. Lowney& James W. Fleshman, Jr., Benign disorders of the anorectum, Michael J. Zinner& Stanley W. Ashley. Maingot’s Abdominal Operations, Tata Mc Graw Hill, 11th edition, 2007, pg. 680-684.
15. Harry T. Papa Constantinou, Philip Huber, Jr., & Clifford L. Simmang, Fissure-in ano, Charles J. Yea, Daniel T. Dempsey, Andrew S. Klein, John H. Pemberton, Jeffrey H. Peters. Shackelford’s Surgery of the Alimentary Tract, Elsevier, 6thedition, 2007, pg. 2038-2044.
16. Kelli M. Bullard & David A. Rothenberger, Colon, Rectum & Anus, F. CharlesBrunicardi, Dana K. Anderson, Timothy R. Billiar, David L. Dunn, John G.Hunter, Raphael E. Pollock. Schwartz’s Principles of Surgery, Tata Mc Graw Hill, 8th edition, 2005, pg. 1103-1104.
17. R. Bhardwaj, M. C. Parker, Modern perspectives in the treatment of chronic anal fissures.Annals of the Royal College of Surgeons of England. 2007; 89 (5): pg.472-478.
18. BikashMedhi, RamyaSankarnarayanRao, Ajay Prakash, Om Prakash, Lileswar Kaman, PromilaPandhi, Recent advances in the pharmacotherapy of chronic anal fissure
19. I. Lindsey, O. M. Jones, C. Cunningham, N. J. Mc C. Mortensen, Chronic anal fissure.The British journal of surgery. 2004; 91 (3): pg. 270-279.
20. Richard Nelson, A systematic review of medical therapy for anal fissure. Diseases of the colon and rectum. 2004; 47 (4): pg. 422-431.
21. Z. Haq, M. Rahman, R. A. Chowdhury, M. A. Baten, M. Khatun, Chemical sphincterotomy – first line of treatment for chronic anal fissure.Mymensingh Medical Journal. 2005; 14(1): pg. 88-90.
22. E. E. Collins, J. N. Lund, A review of chronic anal fissure management: Techniques in Coloproctology. 2007; 11(3): pg. 209-223.
23. Eveline B. Boeker, M. J. P. MarjanKruijer, Paul C. M. Verbeek, Treatment of chronic anal fissures: Diltiazem or Isosorbide-dinitrate as first choice? Nederlands Tijdschrift VoorGeneeskunde. 2011; 155: pg. A2594.
24. K. Bielecki, M. Kolodziejczak, A prospective randomized trial of Diltiazem and Glyceryltrinitrate ointment in the treatment of chronic anal fissure. Colorectal disease the official journal of the Association of Coloproctology of Great Britain and Ireland. 2003; 5(3): pg. 256-257.
25. MasoodJawaid, ZubiaMasood, Manzar Salim, Topical Diltiazem hydrochloride and Glyceryltrinitrate in the treatment of chronic anal fissure. Journal of the College of Physicians and Surgeons Pakistan. 2009; 19(10): pg. 614-617.
26. M. S. Sajid, J. Rimple, E. Cheek, M. K. Baig, The efficacy of Diltiazem and glyceryltrinitrate for the medical management of chronic anal fissure: a meta analysis. International Journal of Colorectal Disease. 2008; 23(1): pg. 1-6.
27. G. F. Nash, K. Kapoor, K. Saeb-Parsy, T. Kunanadam, P. M. Dawson, The long term results of Diltiazem treatment for anal fissure. International Journal of Clinical Practice. 2006; 60(11): pg. 1411-1413.
28. M. S. Sajid, S. Hunte, S. Hippolyte, V. A. Kiri, C. Maringe, M. K. Baig, Comparison of surgical vs chemical sphincterotomy using botulinum toxin for the treatment of chronic anal fissure: a meta analysis. Colorectal disease the official journal of the Association of Coloproctology of Great Britain and Ireland. 2008; 10(6): pg. 547-552.
29. D. Simkovic, K. Smejkal, J. Folvarsky, L. Repasky, Treatment of chronic anal fissure with lateral sphincterotomy. Bratislavske LekarskeListy. 1999; 100(2): pg. 89-91.
30. A. M. Saad, A. Omer, Surgical treatment of chronic fissure in ano: a prospective randomized study. East African Medical Journal. 1992; 69(11): pg. 613-615.
31. P. R. Hawley, The treatment of chronic fissure in ano: a trial of methods. The British Journal of Surgery. 1969; 56(12): pg. 915-918.
32. Notaras M.J., The treatment of anal fissure by lateral subcutaneous internal sphinct-erotomy – A technique and results. British Journal of Surgery. 1971; 58: pg. 96-99.
33. Marvin L. Corman, Anal Fissure, Sydor A. M., McAllister L. Colon and Rectal Surgery. Lippincott Raven, 4th Edition, 1998, pg. 206.
34. Boulos P. B., Araujo J. G. C., Adequate internal sphincterotomy for chronic anal fissure: subcutaneous or open technique? British Journal of Surgery. 1984; 71 (5): pg. 360-362.
35. Udwadia T.E., The prophylaxis of fissure in ano. Indian Journal of Surgery. 1978
36. Scouten W.R. et al., Ischemic nature of anal fissure. British Journal of Surgery. 1996; 83: pg. 63-65.
37. Adriano Tocchi, GianlucaMazzoni, Michelangelo Miccini, Diletta Cassini, EliaBettelli, StefaniaBrozzetti, Total lateral sphincterotomy for anal fissure International Journal of Colorectal Disease. 2004; 19(3): pg. 245-249.