Anal Fissure: Recurrence After Lateral Internal Sphincterotomy
Anal fissure is a common cause of perianal pain. When patients fail medical treatments, surgical management through a lateral internal sphincterotomy (LIS) provides relief with cure rates as high as 96–100 % [1–5]. However, some patients present with recu
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Anal Fissure: Recurrence After Lateral Internal Sphincterotomy Christy Cauley and Liliana Bordeianou
Introduction Anal fissure is a common cause of perianal pain. When patients fail medical treatments, surgical management through a lateral internal sphincterotomy (LIS) provides relief with cure rates as high as 96–100 % [1–5]. However, some patients present with recurrent anal fissures after surgical treatment. This represents a difficult problem for the patient and their colorectal surgeon. While cure of the painful anal fissure is the ultimate goal, repeat interventions come with the potential increased risk of incontinence. In recommending a treatment solution to patients with recurrent anal fissure, the surgeon must evaluate the patient carefully and weigh the decrement to quality of life from continued pain with chronic fissure versus the risk of incontinence. The first step in determining the proper treatment for these patients is to ensure that there is not an alternative underlying cause for the fissure. This can be done by performing a focused history and physical exam. Due to the significant pain associated with anal fissure, exam under anesthesia is often appropriate. Secondary etiologies of anal fissure, such as inflammatory bowel disease, syphilis, tuberculosis, leukemia, and human immunodeficiency virus, and alternative diagnoses, such as cancer, can thus be ruled out in refractory cases. Furthermore, examination under anesthesia
C. Cauley Colorectal Surgery Program, Department of Surgery, Massachusetts General Hospital (MGH), 15 Parkman Street, ACC 460, Boston, MA 02114, USA L. Bordeianou, MD, MPH (*) Colorectal Surgery Program, Department of Surgery, Massachusetts General Hospital (MGH), 15 Parkman Street, ACC 460, Boston, MA 02114, USA MGH Center for Pelvic Floor Disorders, Boston, MA, USA e-mail: [email protected] © Springer International Publishing Switzerland 2017 N. Hyman, K. Umanskiy (eds.), Difficult Decisions in Colorectal Surgery, Difficult Decisions in Surgery: An Evidence-Based Approach, DOI 10.1007/978-3-319-40223-9_35
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can allow for inspection of the extent of the fissure and completeness of previous LIS. This may provide important insight into why previous interventions were unsuccessful. In addition, biopsy of the fissure may be performed if cancer is suspected. In addition to an exam under anesthesia, we also advocate for adjunct testing with anal manometry and anal ultrasound. The anal ultrasound can help quantify the extent of the previous LIS. Inadequate sphincterotomy is thought to be a common cause of recurrent fissure. Anal manometry, which is done in an awake patient who can hopefully tolerate the insertion of the probe into their anus, can help determine if the fissure is associated with low or high resting sphincter tone. Resting anal pressure of the internal anal sphincter can be useful in identifying the cause of anal fissure. Primary anal fissure is due to compression of end arteries associated with elevated resting pre
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