Comparative study of lateral internal sphincterotomy versus local 0.2% glyceryl trinitrate ointment for the treatment of chronic anal fissure.

The gold standard surgical treatment of chronic anal fissure is lateral internal sphincterotomy which lowers the resting anal pressure and effectively heals the majority of fissures. Local application of 0.2% glyceryl trinitrate ointment has been used as an agent for chemical sphincterotomy, causing temporary alleviation of sphincter spasm and allowing the fissure to heal without compromising the anal continence. The aim of the present study was to compare the results of surgical sphincterotomy with that of local 0.2% glyceryl trinitrate ointment in the treatment of chronic anal fissure. Seventy adult patients between the age of 18 and 50 years with chronic anal fissure were randomized in a prospective trial to receive either surgical sphincterotomy or 0.2% glyceryl trinitrate ointment locally. Patients were followed up at 2 weeks' interval for 10 weeks. Symptom relief, fissure healing and continence scores were the outcomes assessed. Six patients were excluded for protocol violations. Surgical sphincterotomy was significantly more effective in providing pain relief and was associated with significantly better fissure healing rates at 6 weeks and 10 weeks (both p < 0.001). There were substantial problems with compliance in ointment group related to slow healing and longer time needed for symptomatic relief. Minor incontinence was 6% in sphincterotomy group and none in ointment group (p > 0.05). Considering early symptomatic relief, rapid fissure healing and better patient compliance surgical sphincterotomy is the treatment of choice for chronic anal fissure.

Major post-operative complications of thyroid surgery: preventable or not?

Factors responsible for major complications following thyroid surgery in 598 patients were studied. Patients with non toxic multinodular goiter involving both lobes of thyroid constituted the maximum bulk subjected to thyroidectomy. The most frequent procedure was bilateral subtotal thyroidectomy. Reactionary hemorrhage occurred in 6 patients, all following bilateral procedures and among them 5 patients developed tension hematoma with respiratory obstruction despite the presence of a drain. Temporary vocal cord palsy was observed in 7 patients whereas one patient subjected to total thyroidectomy with neck dissection for papillary carcinoma of thyroid developed permanent right vocal cord palsy. Temporary parathyroid insufficiency was seen in 51 patients and one patient developed permanent hypoparathyroidism. Incidence of parathyroid insufficiency was higher in bilateral procedures as compared to unilateral ones. There was no operation related death in this series, but complications like hemorrhage, vocal cord palsy and parathyroid insufficiency following thyroid surgery are still a deep concern.