Choosing the Right Surgery for Chronic Anal Fissures: Pros and Cons

Choosing Surgical Options for Chronic Anal Fissures: Pros and Cons

I would like to consult a physician regarding a condition I have been experiencing for three years, which involves internal and external hemorrhoids accompanied by anal fissures and bleeding.
Initially, I applied medication and took sitz baths for five months, but the bleeding after bowel movements did not improve.
I then underwent an outpatient procedure for the excision of external hemorrhoids under local anesthesia.
Following that, I continued to return for three months for rubber band ligation of internal hemorrhoids, successfully treating three internal hemorrhoids and one external hemorrhoid.
However, the bleeding from the anal fissures after bowel movements has persisted for over two years.
Each time I have a bowel movement, I experience a tearing sensation as the stool passes through the anus.
Although there has been slight improvement compared to three years ago, I still notice blood on toilet paper after wiping, and I experience sharp pain for several hours post-defecation.
I typically have bowel movements every night, but on days when I do not, I experience unexplained sharp pain at night that disrupts my sleep.
I have been informed during consultations that there is an ulcer at the fissure site, and the topical medications prescribed for the fissures have not been very effective.
Therefore, I would like to ask the doctor several questions regarding surgical and treatment options:
1.
Regarding anal fissure surgery, how should I choose between Fissurectomy and Lateral Internal Sphincterotomy (LIS)? Which procedure has a lower rate of incontinence and recurrence? Since LIS involves cutting a few centimeters of the sphincter muscle, will this loss significantly affect someone who already has a loose anal sphincter? After either type of fissure surgery, do patients typically regain the sensation of normal bowel movements as they experienced before the condition?
2.
During my last examination about five months ago, I was informed that I have a grade one internal hemorrhoid and slight swelling at the anal opening resembling varicose veins of external hemorrhoids.
Is it possible to address both the anal fissure and hemorrhoids in a single surgical procedure for complete excision? Additionally, I would like to inquire about the "minimally invasive surgery with same-day discharge" that is often advertised by aesthetic medical institutions.
What is the actual name of this procedure? Compared to traditional surgery, does it offer better prevention against the recurrence of hemorrhoids (as traditional methods seem to last for about ten years)?
3.
For the ulceration of the anal fissure, can over-the-counter Calcium channel blockers (e.g., 2% diltiazem ointment) fully heal the ulcer? I have also seen a self-paid product called "Pineapple Green Warrior Hydrogel," which contains chlorine dioxide 1ppm, water, and PEG-400.
I would like to know if such ointments can effectively reverse and repair long-standing ulcerative wounds.
4.
Why do I experience unexplained pain at the fissure site on days when I do not have a bowel movement, especially close to midnight? The same sharp pain occurs the following day if I do not have a bowel movement.
5.
Is traditional dry toilet paper truly more likely to cause tearing during wiping compared to wet wipes, or is the occurrence of fissures unrelated to the wiping technique, depth, or material used? Wet wipes have only become mainstream in the last decade.

Xiao Xiao Bing, 30~39 year old female. Ask Date: 2024/01/30

Dr. Ke Fangxu reply Surgery

1.
To my knowledge, there is only one type of surgery for anal fissures, which is the lateral internal sphincterotomy (LIS) you mentioned.
Fissurectomy refers to the excision of the fissure itself; however, this step is optional.
Once the sphincter is cut, the fissure will heal on its own.

2.
Anal fissures and hemorrhoids can indeed be treated simultaneously.
As for minimally invasive surgeries, there are various methods, with laser coagulation and infrared treatment being the primary outpatient options.
The use of a harmonic scalpel typically requires hospitalization.
It is essential to consult with the physician to determine which surgical method is appropriate, as literature indicates that the long-term recurrence rate of minimally invasive surgeries is slightly higher than that of traditional surgeries.
3.
The mechanism of calcium channel blockers is to reduce the contraction force of the sphincter.
However, topical applications may have a milder effect.
I personally do not have experience with their efficacy, and they are not recommended as a treatment option in textbooks.
I also have not used chlorine dioxide; upon researching, I found that it is merely a water disinfectant.
I am unsure if it can reverse or heal long-standing ulcerative wounds.
4.
Sphincter contractions can also cause pain at the site of the anal fissure.
5.
As long as there is no excessive wiping, it does not matter which method is used.
Alternatively, a bidet or warm sitz baths can also be utilized.

Reply Date: 2024/01/30

More Info

Chronic anal fissures can be a painful and persistent condition, often requiring surgical intervention when conservative treatments fail. Based on your detailed history, it seems you've already undergone several treatments, including topical medications and minor surgical procedures, but continue to experience significant discomfort. Let's address your questions regarding the surgical options and other related concerns.

1. Choosing Between Fissurectomy and Lateral Internal Sphincterotomy (LIS):
- Fissurectomy involves the excision of the fissure and any surrounding scar tissue, which can provide relief but may not address the underlying hypertonicity of the anal sphincter.
- Lateral Internal Sphincterotomy is a more common procedure for chronic fissures. It involves cutting a portion of the internal anal sphincter to relieve tension, which can promote healing. While it does involve cutting a few centimeters of the sphincter, studies suggest that the risk of incontinence is low, especially in patients who do not have pre-existing sphincter issues. The recurrence rate for LIS is also generally lower compared to fissurectomy.

- Post-surgery, many patients report a return to normal bowel function and sensation, although individual experiences can vary. It’s essential to discuss your specific concerns about sphincter control with your surgeon.

2. Combining Procedures for Fissures and Hemorrhoids:
- It is often possible to address both fissures and hemorrhoids in a single surgical session. This can be beneficial as it minimizes recovery time and the need for multiple anesthetics. The term "minimally invasive surgery" often refers to techniques that use smaller incisions or specialized instruments, which may lead to quicker recovery times. However, the effectiveness of these techniques in preventing recurrence of hemorrhoids compared to traditional methods can vary, and it’s crucial to consult with your surgeon about the best approach for your situation.

3. Topical Treatments for Fissures:
- Calcium channel blockers, such as diltiazem ointment, are commonly used to promote healing of anal fissures by relaxing the anal sphincter and increasing blood flow to the area. While these can be effective, they may not always lead to complete healing, especially in chronic cases. The product you mentioned, "品寶綠武士水凝膠," contains chlorine dioxide, which is known for its antiseptic properties. However, there is limited evidence regarding its effectiveness in healing chronic fissures. It’s advisable to consult your healthcare provider before trying new treatments.

4. Pain Without Bowel Movements:
- Experiencing pain in the anal area even when not having a bowel movement can be attributed to several factors, including muscle tension, nerve sensitivity, or residual inflammation from the fissure. The anal region is highly sensitive, and any irritation can lead to discomfort. If this pain persists, it may be worth discussing with your doctor to rule out other underlying conditions.

5. Hygiene Practices:
- The choice between dry and wet wipes can indeed affect anal hygiene and comfort. While dry toilet paper can sometimes cause irritation due to friction, wet wipes can provide a gentler cleaning method. However, it’s essential to choose wipes that are free from irritants and fragrances. The technique of wiping (gentle vs. aggressive) and the material used can also play a role in preventing further irritation or injury to the anal area.

In conclusion, given your ongoing symptoms and history, it may be beneficial to consider surgical options like LIS, especially if conservative treatments have not provided relief. Discussing your concerns and preferences with a colorectal surgeon will help you make an informed decision tailored to your specific situation. Additionally, addressing hygiene practices and exploring effective topical treatments can further aid in managing your symptoms.

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