Preop Diagnosis: Anal Fissure Anal Stenosis

on 6/1/10 2:48 am
Finally broke down literally in such severe pain this morning and called Colon Rectal people. I begged them to squeeze me in somehow today.  I heard the words that I suspected, but DID NOT Want to hear.

You have a chronic anal fissure, my dear. 

Scheduled for:  Proctoplasty and repair to anal fissure and anal stenosis. 

I knew this was worse than roids.  Had roids when I was pregnant and they hurt, but his is EXCRUTIATING.  I wanted to beg him to put me under general anestheti****il it healed it hurt so badly. 

Good news is that he is familiar with Dr. Buchwald, wrote his own academic books on ******** and did not have a glazed look on his face when I said, "Duodenal Switch".  He knew what it was.  AND, he was positive about the weight that I've lost.....

Oh you guys; I so did not need this...........  I've got so much on my plate already in my life with my son's, my mom, and I also have a hernia that is growing and needs repair.



Body by God; alterations by Buchwald.  I love Jesus.  I so so so appreciate my DS.

on 6/1/10 3:04 am

Surgical treatment. The Standard Task Force of the American Society of Colon and Rectal Surgeons has recommended a surgical procedure called partial lateral internal sphincterotomy as the technique of choice for the treatment of anal fissures. In this procedure, the internal anal sphincter is cut starting at its distal most end at the anal verge and extending into the anal canal for a distance equal to that of the fissure. The cut may extend to the dentate line, but not farther. The sphincter can be divided in a closed (percutaneous ) fashion by tunneling under the anoderm or in an open fashion by cutting through the anoderm. The cut is made on the left or right side of the anus, hence the name "partial lateral internal sphincterotomy." The posterior midline, where the fissure usually is located, is avoided for fear of accentuating the posterior weakness of the muscle surrounding the anal canal. (Additional weakness posteriorly can lead to what is called a keyhole deformity, so called because the resulting anal canal resembles an old fashioned skeleton key. This deformity promotes soilage and leakage of stool.)

Although many surgeons decline to cut out the fissure itself during lateral sphincterotomy, this author feels that this reluctance to remove the fissure is not always appropriate, and characteristics of the fissure itself should be taken into account. If the fissure is hard and irregular, suggesting anal cancer, the fissure should be biopsied. If the edges and base of the fissure are heavily scarred, there may be a problem after surgery with anal stenosis, a condition in which additional scarring narrows the anal canal and interferes with the passage of stool. In this case, it may be better to cut out the scarred fissure so that there is a chance for the wound to heal with less scarring and chance of stenosis. Finally, an associated large anal papilla or a large hemorrhoidal tag may interfere physically with wound healing, and removing them may promote healing.

Following surgery, 93-97% of fissures heal. In one representative study, healing following surgery occurred in 98% of patients by two months. At 42 months following surgery, 94% of patients were still healed. Recurrence rates after this type of surgery are low, 0-3%.

Failure to heal following surgery often is attributed to reluctance on the part of the surgeon to adequately divide the internal anal sphincter; however, other reasons for failure to heal, such as Crohn's disease should be considered as well. The risk of incontinence (leakage) of stool following surgery is low. It is important to distinguish between short-term and long-term incontinence. In the short-term (under six weeks), the sphincter is weakened by the surgery, so leakage of stool is not unexpected. Long-term incontinence should not occur after partial lateral internal sphincterotomy because the internal sphincter is less important than the external sphincter (which is not cut) in controlling the passage of stool. It is important to distinguish between incontinence to gas, a minimal amount of stool that, at most, stains the underwear (soiling), and loss of stool that requires an immediate change in underwear. In a large series of patients followed for a mean of five years after surgery, 6% were incontinent of gas, 8% had minor soiling, and 1% experienced loss of stool.

Anal surgical stretch. Several surgeons have described procedures that stretch and tear the anal sphincters for the treatment of anal fissures. Though anal stretching often is successful in alleviating pain and healing the fissure, it is a traumatic, uncontrolled disruption of the sphincter. Ultrasonograms of the anal sphincters following stretching demonstrate trauma that extends beyond the desired area. Because only 72% of fissures heal and there is a 20% incidence of incontinence of stool, stretching has fallen out of favor.

Anal Fissures At A Glance
  • Anal fissures are cracks or tears in the anus and anal canal. They may be acute or chronic.
  • Anal fissures are caused primarily by trauma, but several non-traumatic diseases are associated with anal fissures and should be suspected if fissures occur in unusual locations.
  • The primary symptom of anal fissures is pain during and following bowel movements. Bleeding, itching, and a malodorous discharge also may occur.
  • Anal fissures are diagnosed and evaluated by visual inspection of the anus and anal canal. Endoscopy and, less commonly, gastrointestinal x-rays may be necessary.
  • Anal fissures are initially treated conservatively by adding bulk to the stool, softening the stool, consuming a high fiber diet, avoiding "sharp" or poorly digested foods, and utilizing sitz baths.
  • Ointments containing anesthetics, steroids, nitroglycerin, and calcium channel blocking drugs are used for treating anal fissures that fail to heal with less conservative management.
  • Injections of botulinum toxin may be effective when ointments are not effective. (The cost of treatment would be substantially reduced if the toxin were packaged in smaller doses.)
  • Surgery by lateral sphincterotomy is the gold standard for curing anal fissures. Because of complications, however, it is reserved for patients who are intolerant of non-surgical treatments or in whom non-surgical treatments have proven to be ineffective.



Body by God; alterations by Buchwald.  I love Jesus.  I so so so appreciate my DS.

on 6/1/10 3:06 am - Canada
Aww I'm so sorry to hear you are going through this and it must be compounded if you have family stresses in your life too.

Focus on teh fact that you are scheduled for something to take care of this once and for all!  I recently had surgery for an anal fistula so I can empathize with your pain in this region.

Please keep us posted and you know your DS family is always here for you!



(deactivated member)
on 6/1/10 3:09 am
Sorry to hear this. I just got through treating two anal fissures...SO painful.

In my case, the medication and colace worked and I won't need surgery. Is it due to the stenosis or the severity that they're jumping straight to surgery for you?

Anyway, good luck.
on 6/1/10 3:14 am
I don't know.  I was SO overwhelmingly mortified having my ass up in the air and two people looking at it and in so much severe pain that I didn't care what he said, as long as he said he could fix it.  :( 

I've been having pain off and on for 1 year or so.  I can control my BM's with my diet.  And, this helps, but doesn't fix it.  This AM was horrific.  I begged to get into to see somebody.  NOTHING helps the pain.  Not pain meds, not topical steriods.  I even bought sun burn spray the 20% benzocaine and spray it every 2 seconds on my ass, and it still hurts. 

This just sucks.  I knew it was more than roids.  I just didn't want to hear it.  :( 

I wonder if he is going to remove the damn thing or what the hell.........    OH, how miserable.  :(

And, I was going to start working on a more positive attitude this week. 




Body by God; alterations by Buchwald.  I love Jesus.  I so so so appreciate my DS.

on 6/1/10 4:04 am
And, I am so not constipated.  So, maybe that's it.  Don't need stool softners or anything, so that wouldn't help.....  Dunno.  I'm just feeling miserable and a cloud of depression is coming over me.  :(



Body by God; alterations by Buchwald.  I love Jesus.  I so so so appreciate my DS.

(deactivated member)
on 6/1/10 4:19 am
I am so sorry, Kathy. :-(

It sounds like you really have a lot going on and this is the last thing you need. Although the surgery doesn't sound like fun, I hope at least it resolves the problem and the pain for you for good.

And yes, my fissures were caused by severe constipation which I did not stay on top of and let get out of hand. Never again.
on 6/1/10 10:24 am
Ann Surg. 2005 August; 242(2): 208–211. doi: 10.1097/01.sla.0000171036.39886.fa. PMCID: PMC1357726
Copyright © 2005 Lippincott Williams & Wilkins, Inc. Internal Anal Sphincter Function Following Lateral Internal Sphincterotomy for Anal Fissure A Long-term Manometric Study Edward Ram, MD,* Dan Alper, MD,* Gideon Y. Stein, MD, Zachar Bramnik, MD,* and Zeev Dreznik, MD* From the *Division of General Surgery and †Department of Internal Medicine ‘B,’ Rabin Medical Center and Tel-Aviv University Sackler School of Medicine, Israel.
  Small right arrow pointing to: This article has been cited by other articles in PMC. Abstract Background: Anal fissure is a common and painful disorder. Its relation to hypertonic anal sphincter is controversial. The most common surgical treatment of chronic anal fissure is lateral internal sphincterotomy. Objective: The aim of this study was to evaluate long-term manometric results of sphincter healing following lateral internal sphincterotomy. Patients and Methods: Between 2000 and 2003, 50 patients with anal fissure were included in this study and underwent sphincterotomy; 12 healthy patients served as controls. All patients with anal fissure underwent manometric evaluation using a 6-channel perfusion catheter. All patients were examined 1 month before surgery and 1, 3, 6, and 12 months following surgery. The control group had 3 manometric evaluations 6 months apart. Results: The mean basal resting pressure before surgery was 138 ± 28 mm Hg. One month after surgery, the pressure dropped to 86 ± 15 mm Hg (P < 0.0001) and gradually rose to a plateau at 12 months (110 ± 18 mm Hg, P < 0.0001). At 12 months, the manometric pressure was significantly lower than the baseline (P < 0.0001). However, manometric measurements in the fissure group were still significantly higher than in the control group (110 ± 18 versus 73 ± 4.8 mm Hg, P < 0.0001). All patients were free of symptoms at the 12-month follow-up. Conclusion: Lateral internal sphincterotomy caused a significant decline in the resting anal pressure. During the first year following surgery, the tone of the internal anal sphincter gradually increased, indicating recovery, but still remained significantly lower than before surgery. However, postoperative resting pressures were higher than those in the control, and no patient suffered any permanent problems with incontinence, so this decrease may not be clinically significant.   Anal fissure is a linear crack or tear in the squamous epithelium of the lower half of the anal canal, usually extending from below the dentate line to the anal verge. Fissures occur in all age groups, with equal prevalence in men and women. Because of sensory innervations to this area, the fissure is a painful condition. The pathophysiology of chronic anal fissures has not been clearly established. Possible causes include infections and traumatic injury to the anal canal such as passage of a hard stool or severe diarrhea.1 Its relationship to hypertonic anal sphincter is controversial. The majority of investigators have found significantly elevated resting anal pressures in patients with fissure.2–7 Other studies have found no significant difference in resting pressures.8,9 Since the introduction of lateral internal sphincterotomy by Eisenhammer in 1951,10 this procedure has been used with increasing frequency and is now considered the treatment of choice for anal fissure. The procedure reduces the pathologically raised pressure profile within the anal canal. The main purpose of this study was to evaluate long-term manometric results of sphincter healing following left lateral internal sphincterotomy during 1 year of follow-up. MATERIALS AND METHODS This prospective study, conducted at the Division of General Surgery in Rabin Medical Center between the years 2000 to 2003, included all patients with chronic anal fissure requiring surgery. The study was approved by the hospital's ethics committee. Manometric evaluations were performed at the Pelvic Floor Physiologic Laboratory Unit. Exclusion criteria were: acute anal fissure, coexisting Crohn's disease or ulcerative colitis, prior history of anorectal surgery, chronic diarrheal illness, and pelvic radiotherapy or anorectal malignancies. Fifty patients (23 females and 27 males; mean age, 40.5 years; range, 25–60 years) were included in this study. A control group included 12 normal volunteers: 5 women and 7 men (mean age, 40 years; range, 25–54 years). All patients had a limited bowel preparation with one Fleet (Dexxon) enema 250 mL. Manometric evaluation was carried out using a 6-channel water perfusion polyvinyl catheter (Zinetics AMC), with 60° angle radial at 5 cm from tip. The catheter's outside diameter was 4.5 mm and the inside diameter 0.8 mm radial lumens with 1.8 mm center lumen. The catheter was connected to the Mui Scientific perfusion pump, and the pressure was recorded by PC Polygraf system (Medtronic) through a pressure transducer. The lubricated catheter was introduced manually into the rectum, with patients in the left lateral decubitus position with flexed knees and hips. Water was perfused at a flow rate of 0.2 mL/min. The continuous pull-through technique was used with the catheter puller at a constant speed of 0.5 cm/s. Each investigation was repeated 3 times, and the mean value was taken as the result. For patients with anal fissure, the examination was performed 1 month before surgery and 1, 3, 6, and 12 months following surgery. In the control group, 3 examinations were performed, 6 months apart (ie, at 0, 6, and 12 months). The site of the fissure was located and recorded in all anal fissure patients. Statistical Analysis Statistical analysis was performed using Microsoft Excel software. The statistical tests used were: t test paired 2-sample for means and t test 2-sample assuming equal variances. Probability is 2-tailed, with P < 0.05 regarded as significant.



Body by God; alterations by Buchwald.  I love Jesus.  I so so so appreciate my DS.

Michelle H.
on 6/1/10 3:17 am - Canada
I have not read the whole post so forgive me if this has been mentioned, but have you read the information that Diana Cox has on her page in regards to this and what works best before surgery? I would contact her if you have not already done so as she has some excellent information.

I am sorry you are in such pain. I had this problem when I was Pregnant with my daughters and it was the worst thing in the world.
My is Debbie M.......I am to lo24 (Louisa)
RNY 338- 185.  Regain to SW260 CW 236 GW 150ish?

on 6/1/10 3:29 am - Fridley, MN
Aw Kathy, I'm really sorry.  Sounds pretty miserable. 
Lilypie - (SzbI)
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