Considering LIS - part 2

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Considering LIS - part 2

Postby SteveR » 01 Jan 2013, 07:12

Hello All,
Firstly thank you to everyone that has provided advice to my previous posts - these are totally invaluable ( as per my other post with the same title)
So I went back to my consultant 24th Dec to discuss my care post botox surgery that happened on 13th December.
To cut a long story short, I have two fissures front and back and have been suffering with these since April 2012. I have tried all other treatments including creams, and now two blasts at Botox. I am currently now using Anoheal at the same time as botox. (trouble with Anoheal for me is that it dries me up and makes my BM harder to pass - not good).
At my meeting with the consultant on the 24th Dec he said I was 'moving towards' LIS although he had concerns because the fissure at the back runs the full length from inside through to outside. Therefore any cut that they would have to do will also run the full length too - which is the maximum that they can cut. He says that this increases the risk of incontinence.
Has anyone else had LIS with a fissure that large?
Do people know of other options - for example a shorter LIS cut and treating the rest with botox?
What questions should I be asking?
The consultant also said that at the last operation my muscle tone was relaxed, which suggests that I should heal with botox and anoheal. And also that he was giving me caution about the operation. However my experience is that this is not the case - I am not healing. Also I still have spasms and I certainly do not have any problems with wind incontinence with botox - which he says is encouraging.
My next visit to the consultant is on 31st Jan. For me I was put off on the 13th December and at 24th December agreed to give myself a good 6 weeks between operation and next steps before thinking about anything.
if I heal between now and then - fantastic. But if I dont - I need to have all the information together to have a really good conversation with him and agree a sensible timeline for LIS.
Your comments and views would be appreciated. Cheers.
SteveR
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Re: Considering LIS - part 2

Postby Lauren12 » 16 Jan 2013, 18:37

Hi Steve
Sorry not to have replied to you sooner but my mother died last week, having been ill in hospital for a while, so my mind has been all over the place.
I take it that as no one else has replied yet, possibly people who've experienced a similar fissure presentation to yourself haven't seen your post. it does seem that whilst we may all suffer, or have suffered, from fissures, the individual presentations can vary. This is where the skill of the surgeon comes in I suspect. It seems the questions you're asking about your particular presentation are the sort of thing only a surgeon could address, unless someone here has had a near identical experience.
The other day, a member here posted the American Gastroenterological Association (AGA) guidelines which have a section discussing the extent of sphincterotomy:
http://anal-fissure.org/t5830-aga-guidelines-for-anal-fissures#80813
However, I'm not sure that it goes far enough to address your query. Surgeons can disagree with each other however. When I went to the final surgeon who fixed me (the third I tried) he mentioned that there were aspects of the approaches of the previous two that he would not have taken, had he been consulted. When it comes to the degree of incision, or type of incision, or whether LIS can be combined with Botox - this seems to be specialist information which might be beyond the knowledge of most members of this forum, unless they've experienced something identical.
As to what questions it would be useful to ask, one might be why, if your muscle tone is relaxed and the first lot of Botox seemed to be working initially, you later had a recurrence of the pain. Was it because the first lot of botox wore off? Had there been healing and then you refissured and if so, why? It is good though, that your muscle tone was relaxed - even if the Botox had worn off, if your muscle tone was still relaxed, perhaps that's a good sign? You do still get some spasms with Botox - I don't think it immobilises the muscles completely. However this would be another question to put to him.
As you haven't posted for a while, I hope this indicates that you've healed!
All the best.
Lauren12
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Re: Considering LIS - part 2

Postby Lauren12 » 16 Jan 2013, 19:16

Also, there's a recent thread on this forum about anal dilatation, which some people in the US appear to have found as effective as surgery. The link provided in my post above discusses this method also. If I was considering treatment options now, I'd at least ask the CRS about this particular option, out of curiosity if nothing else! It's not one I heard discussed by any of the surgeons I consulted and I wonder if it's offered in the UK and if not, why not. I'd like to hear a surgeon's opinion on it.
http://anal-fissure.org/t5804-seeing-crs-that-does-anal-dilitation
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Re: Considering LIS - part 2

Postby jr2 » 19 Jan 2013, 15:03

Steve,
Gosh, so tough to know. Like Lauren suggested, Imight look into standardized dilatation if you can locate someone who performs it. Just my thought, but I would speculate that if the LIS doesn't run the length of the fissure, and is therefore incomplete, you aren't as likely to have a successful outcome, and if you are going to undergo surgery and all of its risks and postoperative pain I would think you'd want to go in with the highest chances of success.
I've known a few people over the years who tried the approach you mentioned, making a more conservative cut, and for the most part it failed to heal the fissure and they ended up with a second surgery.
But really, these are all questions for the surgeon. One of the problems with incontinence as an after effect of these surgeries is you don't know in the very long term how it could affect sphincter control as you age and lose some of the muscle tone just from the aging process. It doesn't mean it isn't worth going forward with it, but these are really important questions that don't necessarily have absolute answers. I can say that in all the years I've been suffering fissures and talking to many many people in all sorts of forums about their experiences, I've only known of two individuals who ended up with complete incontinence. The most common form of incontinence is to gas, and to a bit of leakage, and to a lessened ability to distinguish between stool and gas.
That being said, two top colorectal surgeons in my area strongly advise me against LIS for my fissures due to urgency and diarrhea problems I live with chronically. They both feel this raises the risk of incontinence, and also likely won't help my fissure problems which they feel are related to my digestive problems. So, I think recommendations on surgery really depend on an individual and their health history.
I think you've already got some good questions to ask at your next visit. You might want to ask some numbers questions. Likely rate of success for that surgeon, how many of these has the surgeon performed, rate of complications like abscess or fistula, rate of incontinence. Just to give yourself a picture of what this surgeon has seen in his experience with the surgery.
Good luck, and keep us posted on what you decide!
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