I have posted here a few times and I am very close to making a decision as to whether to pursue LIS or not. I need some feedback from the group on some advice/recommendations that I received from an out-of-state CRS, who has never examined or treated me in the past. I found this particular CRS online and sent him an email regarding my history of chronic rectal pain, most likely the result of some sort of pelvic floor dysfunction, my chronic bowel evacuation difficulties, and the recent development of some recurring fissures. I did tell him that I have only had three diagnosed fissures in the past 5 years, all of which healed with little to no treatment and I had several months between each episode. The following is his recommendation based on the information that I provided to him:
"You have alot of features that tell me that you would benefit positively from sphincterotomy. Recurrent anal fissure disease being the most important. Problems with external hemorrhoid swelling on an intermittent basis and a high resting anal sphincter pressure with evacuation constipation are more minor reasons. Sphincterotomy will get rid of your anal fissure disease, improve swelling of external hemorrhoids and improve a tight sphincter that might aggravate constipation. I would not expect it to totally eliminate external hemorrhoid swelling or evacuation constipation. Any improvement in constipation and straining will help levator spasm. The internal sphincter muscle is an involuntary muscle and is contracted at rest. When a bowel movement comes down and distends the rectum, nerves tell the internal sphincter muscle to relax such that the bowel movement or gas can come down where you can sense what is there. Then, with your external sphincter muscle (voluntary control muscle)., you decide whether to hold it or let it pass. Everything works fine up to that point with a patient who has an anal fissure or high resting anal sphincter pressure. However, when you decide to go, the base of the fissure is the internal sphincter muscle and it spasms causing pain and funneling the anal canal applying pressure to the front and the back and propagating the anal fissure. Sphincterotomy is done by making a small left lateral incision and identifying the internal sphincter muscle and putting a small 1 cm cut in the muscle. This takes pressure off of the front and back of the canal and the fissure heals. Have never seen one not heal. Nor have I seen anyone who has undergone sphincterotomy have recurrent anal fissures going forward. The hemorrhoids sit on top on the internal sphincter and, although it is not well-documented, it has been alot of our impressions in the profession that the internal sphincter spasm forms a concentric ring and aggravates external hemorrhoid swelling. I think it helps patients that have that problem in addition to anal fissure. Some patient have undergone hemorrhoidectomy under these circumstances and gotten worse. Yes, there is a risk of some change in continence, but I really have not seen that. I think a sphincterotomy for you is definitely indicated given the understanding that it will eliminate your anal fissure disease and possibly help some with recurrent external hemorrhoid swelling and evacuation issues. If levator spasm is present , then by helping with evacuation and decreased straining, it might get some better too. Although continence issues have to be mentioned, I really dont think that is an issue. I probably do about 30 of these a year and have been in practice 25 years. Hope this helps."
He went on to say, in future email correspondence, that he would do LIS whether I presented with an active fissure or not, he was not a big fan of botox, he did not feel it necessary to perform a fissurectomy at the same time as LIS, and that I would only need to spend a week, at most, before I could return back home and that most patients feel immediate relief from the procedure. Please let me know what your thoughts are on his comments. Thanks