Hi Everyone,
I hope you’re all feeling well today and your fissures are not causing you too much grief. I am just having a clear out of my laptop and I stumbled across a number of my old posts I drafted during my fissure days – I hope you find them useful
Davo
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Resting Pressure Post-LIS
I found quite an interesting article about anal resting pressure following LIS, now as you may know a tight sphincter (which causes the spasms) is the main cause of non-healing in anal fissures. Both GTN and Botox perform chemical sphincterotomy’s to relax things however if healing still does not occur then a surgeon will make a small nick in the sphincter (LIS) to permanently relax the sphincter.
So the report I was reading compared anal resting pressures in 50 patients (23 female, 27 male).
The resting pressure was read before LIS surgery, straight after and then at 3, 6 and 12 months.
Resting Pressure 1 month before surgery = 138
Resting Pressure 1 month after surgery = 86
Resting Pressure at 3 months = 95.4
Resting Pressure at 6 months = 102
Resting Pressure at 12 months = 110
What this demonstrates to me is why patients may suffer some mild temporary incontinence immediately following surgery and why CRS’s suggest that full healing occurs in 12 months. It shows that the sphincter is at its weakest immediately following surgery and a constant healing improvement continues over the course of 12 months post surgery.
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Incontinence Risk
I know that this is the main worry when having LIS surgery therefore i thought i would post the NHS (UK) information showing their incontinence statistics following LIS. Basically they said that 1 in 10 people will suffer some mild incontinence in the first two months following surgery however this is only permanent in 1 in 200 (0.5%)
This is the quote:
"Around 1 in 10 people will experience bowel incontinence after having surgery due to damage to the anal muscles. This means that they will lose some control of their bowel movements. However, it is usually a mild type of incontinence where the person is unable to prevent themselves from passing wind, and they may also experience some mild soiling.
The symptoms of incontinence usually improve in the first few months after surgery and resolve with two months. However, in around 1 in 200 cases the incontinence is permanent"
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UK vs US Equivalent
Miralax (US) = Movicol (UK)
Advil (US) = Nurofen (UK)
Nitroglycerin or Nitro (US) = rectogesic or GTN (UK)
Metamucil/Citrucel (US) = Fybogel (UK)
Miralax (US) = Movicol (UK) = Restoralax (Canada)
Glossary
AF = Anal Fissure
BM = Bowel Movement
CRS = Colorectal Surgeon
GTN = Glyceryl trinitrate
LIS = Lateral Internal Sphincterotomy
Anoheal = diltiazem
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LIS surgery guide from Wikisurgery
What is a Fissure?
A fissure (fisher) is simply a crack or split in a sensitive part of the skin of the back passage. It is made worse by tightening or spasm of the ring muscle that holds the back passage shut. The fissure causes pain and often some bleeding.
What does the operation consist of?
The ring muscle is cut. This allows the fissure to heal - a process which takes a week or so.
Are there any alternatives?
Simple ointments and creams have not been helpful for you. Your fissure will not go away if you just wait and see. Stretching the muscle is an alternative to cutting it, but there is less control of the wind and motions after stretching. Cutting out the fissure is rarely helpful.
What happens before the operation?
Welcome to the ward
You will be welcomed to the ward by the nurses or the receptionist. You will have your details checked. You will be shown to your bed and will be asked to change into your nightwear. You will have some basic tests done, such as pulse, temperature, blood pressure and urine examination.
You will be asked to hand in any medicines or drugs you may be taking, so that your drug treatment in hospital will be correct. Please tell the nurses of any allergies to drugs or dressings.
Visits by the surgical team
You will be seen first by the House Surgeon, who will interview and examine you. He, or she, will arrange some special tests such as x-rays and blood samples. The operation will be explained to you. You will be asked to sign your consent for the operation. If you are not clear about any part of the operation, ask for more details from the doctors or from the nurses. They are never too busy to do this.
You will be seen by the surgeon who will be doing the operation. He will check that all the necessary preparations have been made.
Visits by the anaesthetic team
One or more anaesthetists who will be giving your anaesthetic will interview and examine you. They will be especially interested in chest troubles, dental treatment and any previous anaesthetics you have had, plus any anaesthetic problems in the family.
Diet
It is important that you have had nothing by mouth for at least 4 hours before the operation. This will let your stomach empty to prevent vomiting during the operation.
Periods
Periods do not affect the operation.
Bowels
The state of the bowels does not affect the operation. You do not need special bowel treatment, which would be painful in any case.
Shaving
You do not need to be shaved for the operation.
Timing of the operation
The operation is usually done towards the end of the morning or afternoon. Do not be surprised if you have to wait a little.
Premedication
You may be given a sedative injection or tablets about 1 hour before the operation.
Transfer to theatre
You will be taken on a trolley to the operating suite by a ward nurse and a theatre porter. You will be wearing a cotton gown. Wedding rings will be fastened with tape. Removable dentures will be left on the ward. There will be several checks on your details on the way to the anaesthetic room where your anaesthetic will begin. You will then go to sleep.
The operation is then performed.
What happens after the operation?
Coming round after the anaesthetic
You will return to consciousness within a minute or two of the operation. You may remember being in the recovery room and being taken back to your bed. Your head should clear within an hour or so.
Warning after a General Anaesthetic
The drugs we give for a general anaesthetic will make you clumsy, slow and forgetful for about 24 hours. This happens even if you feel quite alright.
For 24 hours after your general anaesthetic:
Do not make any important decisions.
Do not drive.
Do not use machinery at work or at home. (e.g. do not boil a kettle).
Will it hurt?
There is some discomfort on moving rather than severe pain. You will be given injections or tablets to control this as required. Ask for more if the pain is still unpleasant.
Drinking and eating
You will be able to drink within an hour or two of the operation provided you are not feeling sick. The next day you should be able to manage small helpings of normal food.
Opening bowels
You may have some of your old discomfort on opening the bowels at first, but this should improve in a day or so. There may be some difficulty controlling the wind from the back passage for a day or two, but this improves rapidly.
Passing urine
It is important that you pass urine and empty your bladder within 6-12 hours of the operation. If you find using a bed pan or a bottle difficult, the nurses will assist you to a commode or the toilet. If you still cannot pass urine let the nurses know and steps will be taken to correct the problem.
Washing
You can bathe or shower as often as you want, using soap and tap water. Salted water is not necessary.
How long in hospital?
You should be able to leave hospital after 3 or 4 hours. The nurse will talk to you about your home arrangements so that a proper time for you to leave hospital can be arranged.
You will be given an appointment to visit the Out-Patient Department for a check up about one month after you leave hospital.
After you leave hospital
You may feel sore in the back passage for a week or more. This gradually improves so that by the end of a month you are well. There may be some difficulty controlling the wind or even the motion for a week or so but this gets better rapidly.
Driving
You can drive as soon as you can make an emergency stop without discomfort in the wound i.e. after about 3 days.
What about sex?
You can restart sexual relations within a week or two, when the wound is comfortable enough.
Work
You should be able to return to work within a day or so. (I disagree!!! Its at least a week and a half)
Complications
Complications are rare and seldom serious. If you think that all is not well, please ask the nurses or doctors. There may be some bruising which settles down in a week or so. Infection is a rare problem and settles down with antibiotics in a week or two.
General advice
The treatment usually leads to complete healing in a week or two. If you have any problems or queries, please ask the nurses or doctors
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Tips from my doc and CRS (Davo)
I have a really good CRS who is one of the top in the UK, he is private consultant from Harley Street and is a trainer of surgeons. He has given me some great advice and has answered many of my questions via email after consultations. I also have a very good doctor who diagnosed my fissure from day one – she has seen many people with fissures and knows a considerable amount about them. Therefore I thought I would share some of the tips they have given me as well as answers to a few of my questions.
I hope this is of some use to people who are also suffering from a fissure at the moment.
SOMETIMES THE FISSURE PAIN SEEMS TO IMPROVE THEN OCCASSIONALLY I WILL HAVE A BAD DAY EVEN THOUGH MY FOOD DIET DOES NOT REALLY CHANGE – WHY WOULD THIS BE?
CRS: The variability of a fissure is extremely common, the explanation for that is really uncertain. Some people beat themselves up trying to blame a piece of food they ate the day before but on most occasions that’s not the case providing you have maintained a high fibre/water intake. The healing progress of a fissure should be measured over a week (and never daily) therefore if you have two bad days with a bit more blood and soreness than usual you should not be concerned as two bad days out of seven would indicate that you are overall improving.
IF THE GTN DOES CLEAR THE FISSURE, IS THERE A GOOD CHANCE THAT THE FISSURE WILL RE-OCCUR AS I HAD READ THAT I WOULD BE AT A GREATER RISK?
CRS: Yes it is true that following repair of a fissure there is a period of time where you are susceptible to further fissures; the feeling is that ultimately that will not be the case when the fissure is healed sufficiently. What is very important is that you stick to the full 8 week course of GTN regardless of whether you achieve complete pain relief and it looks like it has healed. Too many people return to their old ways before full healing has taken place.
Doctor: What people must remember is that something in their diet caused this fissure in the first place therefore if you go straight back to your original diet upon healing then naturally you are going to be at risk (otherwise you would not have got the fissure in the first place). If you were to incorporate additional fruit, fibre and water intake into your original diet then the risk of re-occurrence would be greatly reduced.
I HAVE READ THAT APPLYING WHEATGRASS CREAM CAN HELP WITH THE HEALING, IS THIS CORRECT OR JUST A SALES PITCH BY A SUPPLIER?
CRS: I have not heard of the use of wheatgrass on healing fissures, I imagine it will probably do no harm, it may do some good but there is always a risk of sensitivity to the skin and at the moment if you are winning with the GTN I would probably stick with that.
WHAT ARE THE CHANCES OF SUCCESS WITH GTN AS I HAVE READ MIXED REVIEWS?
CRS: The success rate we see with GTN is around 70% success – As a rule of thumb you should notice a considerable improvement in pain relief within two weeks, if this is not the case then the chances are it probably won’t work for you.
OTHER TIPS FROM MY CRS
Keep taking the GTN (0.4%) twice per day for eight weeks and DO NOT stop even if the pain clears up altogether.
Take Ducoease stool softeners three times per day
Take Magnesium tablets once per day
Take one sachet of movical (Miralax) before bed each night
Drink at least 6-8 glasses of water per day
EXERCISE! Treadmill and X-trainers are fine - Exercise bikes are not.
Keep eating fibre and do everything possible to avoid constipation
Do not strain during bowel movements
OTHER TIPS FROM MY DOCTOR
Do not feel anxious about the fissure. Although it is horribly painful, it is not a dangerous condition
Never avoid going to the bathroom – The more you put it off the larger the eventual BM meaning more pain and a longer healing time
Use cotton wool with warm water rather than toilet paper after each BM
Drink at least 8-10 glasses of water each day