JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 92 April 1999

Lateral internal sphincterotomy is not redundant in the era

of glyceryl trinitrate therapy for chronic anal fissure
M Jonas FRCS D N Lobo MS FRCS A M Gudgeon MS FRCS

J R Soc Med 1999;92:186-188

SUMMARY
Lateral internal sphincterotomy has been the standard treatment for chronic anal fissure, but fissure healing rates of
up to 80% with topical glyceryl trinitrate (GTN) treatment have suggested that this operation may become
redundant. We evaluated the results of topical treatment of chronic anal fissures with 0.2% GTN for 6 weeks in the
outpatient clinical setting, outside the confines of a randomized clinical trial. The role of lateral internal
sphincterotomy in the GTN era was also assessed.
GTN induced fissure healing in 21 of 49 consecutive patients. Fissures healed spontaneously in 2 patients who
discontinued GTN because of headache. Lateral internal sphincterotomy was performed in 26 patients who had
persistent symptoms after 6 weeks of GTN therapy. At the 6-week post-sphincterotomy review, all fissures had
healed and there were no complications.
In this study topical GTN for treatment of chronic anal fissure in the outpatient setting was not as effective as
demonstrated in controlled clinical trials. Lateral internal sphincterotomy is still a good therapeutic option,
especially in patients not responding to GTN.

INTRODUCTION 49 patients with chronic anal fissure

treated with 0.2% GTN for 6 weeks
Lateral internal sphincterotomy (LIS) is a well-established
treatment for chronic anal fissures and cure rates of over 22 (45%) 1 2 (4%0/)
cured at stopped GTN
95% have been reported1. However, the incidence of -

6 weeks = ferweeks
2
incontinence to faeces or flatus after this procedure ranges
from 0% to 35%2. Recent controlled studies have raised
resolution of
interest in the nitric oxide donor glyceryl trinitrate (GTN), symptoms
healing rates of up to 80% having been demonstrated after 26 (53%) underwent lateral internal
topical application for 6-8 weeks3'4. One commentator has sphincterotomy with complete relief
of symptoms
even proposed that topical GTN may make surgical
procedures for anal fissures obsolete5. Figure 1 Summary of results. GTN=glyceryl trinitrate
This study was undertaken to evaluate the efficacy of
0.2% GTN paste in the treatment of chronic anal fissure in
the outpatient clinic setting, outside the confines of a
clinical trial, and to determine whether LIS still has a role to the anal verge twice daily for 6 weeks. Patient satisfaction
play. with the treatment and fissure healing were assessed at 6
weeks. Patients with fissures that had not healed at 6 weeks
went on to have a closed short LIS limited to the length of
METHODS the fissure, performed under general anaesthesia as a day
case procedure by a consultant colorectal surgeon or by a
All patients with chronic anal fissures (symptoms for 8 supervised higher surgical trainee. Patients were reassessed
weeks or more) attending a single colorectal outpatient 6 weeks after LIS.
clinic over a 24-month period were included in the study.
Patients were advised to apply 0.2% GTN paste topically to
RESULTS
Department of Surgery, Derbyshire Royal Infirmary, Derby DE1 2QY, UK 49 consecutive patients (28 men, 21 women) were studied.
Correspondence to: Miss M Jonas, Department of Surgery, E Floor, West Block, Their median age was 35 years (range 20-72). 6 patients
186 University Hospital, Nottingham NG7 2UH, UK had anterior fissures, 43 posterior.
 JOURNAL OF THE ROYAL SOCIETY
Treatment outcome is summarized in Figure 1. GTN
induced fissure healing in 22 patients (45%): 21 (43%)
required no further treatment, but 1 relapsed and
subsequently underwent LIS. Spontaneous fissure healing
was noted in 2 (4%) patients who discontinued GTN
therapy after 2 weeks because of the onset of headache. LIS
was performed in 26 (53%) patients who had persistent
symptomatic fissures despite 6 weeks of GTN therapy. At
the 6-week post-sphincterotomy review, all fissures had
healed; all patients were satisfied with the operation and
none complained of incontinence to faeces or flatus.
DISCUSSION
In controlled clinical trials topical GTN has cured 68-80%
of chronic anal fissures3'4, whereas our cure rate with 0.2%
GTN paste for 6 weeks was only 43%. There may be
several reasons why GTN should be less effective outside
the confines of a clinical trial. In controlled studies patients
are reviewed more frequently than in the outpatient setting,
and this close follow-up may improve patient compliance.
One study included patients with acute as well as chronic
fissures6, though most acute fissures resolve with simple
measures such as dietary manipulation. The concentration
of the GTN preparation (0.2%) used in this study was
identical to that used in trials3'4'6, but the quantity of paste
applied each time is somewhat arbitrary: patients were
simply instructed to apply a 'thin film' to the anal verge,
and our patients may have been more economical in their
applications than their controlled trial counterparts. In
addition, one group reported that 15 of their 19 patients
required concentrations of GTN paste greater than 0.2% to
achieve significant reductions in anal pressure: 8 of the 9
patients with healed fissures required a concentration of
0.3% GTN or greater7. In this study, as in the trials cited,
twice daily dosage was chosen because of reports by Loder
et al.8 that resting pressure remained reduced for up to 9
hours after topical application of 0.2% GTN. This
prolonged action was demonstrated in only 2 patients,
however. In a more recent study anal pressures had
returned to pretreatment values in all 6 patients by 6 hours
after application of topical 0.2% GTN9. More frequent
dosage might give a more sustained reduction of anal
pressure and better healing, though possibly with more
side-effects.
Symptoms persisted in 53% of patients in this study
after completion of GTN therapy. Treatment options at this
stage included continued GTN therapy or LIS. Until
recently LIS was the mainstay of treatment for chronic anal
fissure. When the study was begun there were no clear
guidelines on appropriate duration of therapy. It is
noteworthy, however, that 9 patients who gained partial
symptomatic relief were advised to continue GTN for 2-A
OF MEDICINE Volume 92 April 1999
weeks while awaiting sphincterotomy and none of these
patients healed in this interval. We found that patients with
troublesome symptoms despite 6 weeks of GTN were
reluctant to persist with this treatment and opted for LIS
when given the choice. Furthermore, the results of LIS
were rewarding: there were no complications in the short
term and patients were well satisfied.
The likelihood of recurrent fissures in the long term
must also be considered. The primary pathology in most
chronic anal fissures is hypertonicity of the internal anal
sphincter, with subsequent compromise of the blood supply
to the distal anal canal as branches of the inferior rectal
arteries are compressed while traversing the sphincter.
Consequently, what begins as a superficial mucosal tear,
possibly as a result of stool trauma, becomes a non-healing
ischaemic ulcer. Although topical GTN relaxes the internal
sphincter, this so-called 'chemical sphincterotomy' is
completely reversed on cessation of treatment and sphincter
pressures return to pre-treatment values10. By contrast,
after LIS, anal pressures remain normal for at least one
year, probably much longer 1, and most recurrences appear
within the first four postoperative monthsl2. The
implication is that patients treated with GTN, although
initially spared an operation, are more prone to recurrent
fissures than those undergoing LIS.
It must be emphasized that GTN therapy is safe and only
2 (4%) patients in this study discontinued treatment because
of headaches. Interestingly, the fissures healed sponta-
neously in both these patients. This safety, coupled with a
fissure-healing rate of 43%, suggests that GTN should be
used as first-line therapy for chronic anal fissures, LIS being
reserved for fissures not responsive to GTN and recurrent
fissures.
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