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Siouxland GI Surgery
Simply put, a fissure is a cut. The problem is that it is in an area that requires constant use. Because the anal canal is richly innervated with sensory pain fibers, a fissure is often very painful.
CAUSES A FISSURE
A fissure is usually caused by a hard stool. This stretches and tears the opening. It is not surprising that it hurts and bleeds. Anal fissures result in severe pain on defecation, with anal sphincter spasm, and further tearing. This often leads to the avoidance of defecation, establishing a vicious cycle of constipation and repeated anal fissuring.
ACUTE AND CHRONIC FISSURE
Acute anal fissures are usually a benign condition not associated with more serious diseases, such as bowel cancer. Failure to heal can result in the development of a chronic anal fissure. Over time, this can cause extensive scar tissue at the site of the fissure (sentinel pile).
NON SURGICAL OPTIONS
Proper healing depends on 3 therapies:
1. Changing bowel habits:
- Avoid straining during defecation
- Drink 64 oz of water
- Fiber supplements (e.g. Metamucil, Citrucel, Benefiber)
- Stool softeners/laxatives (Colace, Milk of magnesium)
- Avoid spending long time on the toilet
2. Relieve the Pain:
- Apply Lidocaine Gel with a finger inside the anal canal, directly on the fissure before and after the bowel movement.
- Sitz bath (Sitting in plain warm water for 15 minutes) after the bowel movement.
3 Break the Spasm: Apply Nifedipine Cream with a finger. Place a 'pea size' of medication outside the opening, up to 4 times a day.
It takes months to heal properly. During this time you may have days when it seems healed, only to have a 'bad' bowel movement and a recurrence of symptoms. Stay on the Program!
Indications - If medical treatment does not work for you, surgery is offered to loosen the opening. It is done as an outpatient surgery. Post-operative recovery can be painful for the first week or two while you are healing. However, pain can be limited if postoperative instructions are followed properly.
These procedure is done as a same day surgery. This procedure is done in the operating room under local anesthesia and sedation.
1) Botox injection -
Neurotoxin (Botulin toxin A) injections work by temporarily paralysing a portion of the internal sphincter muscle. Botox has the advantage of being effective in 60-80% of cases as well as being reversible and repeatable.
2) Partial lateral internal sphincterotomy
Relaxation of the anal sphincter may be achieved by performing a lateral sphincterotomy. In this procedure less than a third of the inner anal sphincter is divided at the level of the anal fissure, to provide relief from anal sphincter spasm to allow healing of the fissure.
3) Advancement flap- can be considered in patient where there is a concern for continence.
RETURN TO WORK
Time off of work will depend on your pain threshold, how well you can soften the bowel movement, and what type of work you do.
COMPLICATIONS WITH SURGERY
Although the vast majority of patients are very pleased with the results; the following complications can occur but are not limited to:
(1) Loss of some control of gas or diarrhea: The most serious complication is possible loss of some control over flatus (gas), or diarrhea. Can be seen in upto 3% of patients. This is because in order to loosen the opening, one of the muscles that helps control the bowel movement must be partially cut. Most patients do not notice any difference. There is an operation to repair the muscles if necessary.
(2) The fissure can return: Occasionally the fissure recurs.
(3) A tract can form: The wound can heal with a small 'tract'. This can require another operation to repair.
(4) Bleeding: On a rare occasion, a bowel movement can tear the sutures and heavy bleeding can occur. If this happens, apply pressure to the wound and call the office or go to the nearest emergency room.