Lateral Internal Sphincterotomy is Superior to Topical Nitroglycerin for Healing Chronic Anal Fissure and does not Compromise Long-Term Fecal Continence: Six-Year Follow-Up of a Multicenter, Randomized, Controlled Trial

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Purpose:Although there is enthusiasm for nonoperative management of anal fissures, most trials have been of short duration (6-8 weeks) and long-term outcome is unknown. The purpose of this study was to assess long-term outcome in two cohorts of patients who had participated in a randomized, controlled trial to compare the effectiveness of topical nitroglycerin with internal sphincterotomy in the treatment of chronic anal fissure.Methods:Between February 1997 and October 1998, 82 patients with chronic anal fissure were accrued and randomized to 0.25 percent nitroglycerin ointmentt.i.d.or lateral internal sphincterotomy. In 2004, a telephone survey of trial participants was conducted to determine symptom recurrence, the need for further medical and/or surgical treatment, and patient satisfaction. Furthermore, patients were assessed for symptoms of fecal incontinence using the Jorge and Wexner Fecal Incontinence Score and the Fecal Incontinence Quality of Life questionnaire.Results:Overall, 51 of the original 82 patients (62 percent, 27 nitroglycerin, 24 lateral internal sphincterotomy) completed our survey. Mean follow-up was 79 (±1) months. Sphincterotomy patients were less likely to have experienced fissure symptoms within the past year (0vs. 41 percent;P= 0.0004) and were less likely to require subsequent surgical treatment (0vs. 59 percent;P< 0.0001) than patients treated with nitroglycerin. Patients in the lateral internal sphincterotomy group were more likely to say that they were “very” or “moderately” satisfied with their treatment (100vs.56 percent;P= 0.04) and that they would choose the same treatment again (92vs.63 percent;P= 0.02) than patients in the nitroglycerin group. Finally, the fecal incontinence and fecal incontinence quality of life scores at six-year follow-up were similar in both groups.Conclusions:After six years of follow-up, it seems that lateral internal sphincterotomy is a more durable treatment for chronic anal fissure compared with topical nitroglycerin therapy and does not compromise long-term fecal continence. Thus, sphincterotomy continues to be a good treatment for patients with chronic anal fissure.

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