Lund J N, Scholefield J H
Department of Surgery, University Hospital, Nottingham, United Kingdom.
Dis Colon Rectum. 1997 Apr;40(4):468-70. doi: 10.1007/BF02258394.
It has been suggested that chronic anal fissure is ischemic in origin because of poor blood supply and spasm of the internal anal sphincter. Nitric oxide donors such as glyceryl trinitrate (GTN) cause a chemical sphincterotomy leading to healing of the fissure. This study addresses the hypothesis that topical GTN ointment may be an effective nonsurgical treatment for chronic anal fissure.
Thirty-nine consecutive patients (23 women; median age, 34 (range, 16-54) years) with chronic anal fissure presenting to the surgical outpatient department were treated for four to six weeks with 0.2 percent GTN ointment applied twice daily to the anoderm. Maximum anal resting pressure was measured at steady state before and after application of the ointment at the first visit. Patients were assessed at two weekly intervals.
Previous surgery for fissure had been performed in seven patients. There were 30 posterior and 9 anterior fissures. Resting maximum anal resting pressure fell from 122.1 +/- 44 to 72.5 +/- 33.3 cm of water (mean +/- standard deviation) by 20 minutes after application of ointment (P < 0.0001; paired t-test). Healing was complete in 14 patients at four weeks and in 33 patients at six weeks. Fissures recurred in five patients after treatment had been stopped. Four recurrences were successfully treated by further GTN ointment and one by sphincterotomy.
This study shows that most anal fissures can be treated nonsurgically with topically applied 0.2 percent GTN ointment. Prospective, randomized controlled trials are now needed, because nonsurgical treatment of anal fissure avoids permanent division of part of the sphincter and the consequent disturbance of continence mechanisms.
有人提出慢性肛裂起源于缺血，原因是血液供应不足和肛门内括约肌痉挛。硝酸甘油（GTN）等一氧化氮供体可导致化学性括约肌切开术，从而使肛裂愈合。本研究探讨局部应用GTN软膏可能是慢性肛裂有效非手术治疗方法这一假说。
39例连续就诊于外科门诊的慢性肛裂患者（23例女性；中位年龄34岁（范围16 - 54岁）），使用0.2% GTN软膏每日两次涂抹于肛管皮肤，治疗4至6周。首次就诊时，在涂抹软膏前后的稳定状态下测量最大肛门静息压。每隔两周对患者进行评估。
7例患者曾因肛裂接受过手术。有30例后位肛裂和9例前位肛裂。涂抹软膏20分钟后，最大肛门静息压从122.1±44降至72.5±33.3厘米水柱（均值±标准差）（P < 0.0001；配对t检验）。4周时14例患者肛裂完全愈合，6周时33例患者肛裂完全愈合。5例患者在停药后肛裂复发。4例复发患者通过进一步使用GTN软膏成功治愈，1例通过括约肌切开术治愈。
本研究表明，大多数肛裂可用局部涂抹0.2% GTN软膏进行非手术治疗。现在需要进行前瞻性、随机对照试验，因为肛裂的非手术治疗可避免永久性切断部分括约肌及其对控便机制的后续干扰。
