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Is Surgery The Right Treatment For Anal Fissures?

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Posted on Sat, 15 Oct 2016
Question: I am 42 years female suffering from anal fissure for past 13 years since the birth of our youngest daughter. It healed after the first couple of years but came back since last 5 years. Now since last 4 months, one large and one small sentinel pile have developed. The doctor has suggested to perform surgery to cut-off the sentinel piles after an internal scope examination for fistula. There will be no LIS due to the risk of incontinence. The piles ooze blood, puss and sometimes get too tight to make even walking difficult. Is it worth the risk to go for this surgery and do I expect any relief from the chronic fissure after the surgery?
doctor
Answered by Dr. Dr. Ivan Romich (17 hours later)
Brief Answer:
Hi

Detailed Answer:
Hi and welcome.
Anal fissures that don't heal on conservative therapy,should be treated with surgery,there is no doubt about it. In this case however,I think that hemorrhoids should be treated first and than after 2 months you should do lateral internal sphincterotomy if fissures don't pull back.It would be not good to do both procedures simultaneously. Risk for anal incontinence after such procedure is minor,if done properly so this should not be problematic if you ask me,also closed technique can be used. There is higher risk of anal stenosis or fistula formation if your condition isn't treated.Wish you good health. Regards
Above answer was peer-reviewed by : Dr. Priyanka G Raj
doctor
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Follow up: Dr. Dr. Ivan Romich (11 hours later)
Dear Dr. Rommstein,
Thanks for your response.

Please clarify if sentinel piles are the same as hemorrhoids as referred to in your response. Referring to the surgery in question i.e. excision of sentinel piles, could it result in a slight cut to the sphincter muscles or otherwise how would it help pull back the anal fissure? Also, if before this surgery, if he discovers fistula below the sentinel piles during the anoscopic examination, what course of action is recommended and what are the risks?
doctor
Answered by Dr. Dr. Ivan Romich (1 hour later)
Brief Answer:
Hi

Detailed Answer:
Sentinel pile is usually cause by fissures and these are located at the distal end of fissure. This is actually skin swelling due to skin defect above it. If there are external anal veins under this skin then it is called external hemorrhoids and then it may have more purplish look and be more painful. In every case ,it is treated with simple excision with electrocoagulation and only skin and underlying vessels are removed ,while fissure and external sphincter are left intact. There may be some beneficial effect on fissures but it won't heal completely if sphincterotomy isn't done.If there is fistula which is possible in your case since pus and blood are present,then additional procedure should be done which is also simple and usually include Seton drainage or fistulotomy depending on depth of fissure. Complications are rare since these are routine procedures and incontinence is most serious but very rare and usually temporary.
Above answer was peer-reviewed by : Dr. Prasad
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Follow up: Dr. Dr. Ivan Romich (41 hours later)
Thanks again for a very satisfying answer.

Since we won't know until the anoscopic examination is done, one question that comes to mind is if fistula is diagnosed, the recommendation would be to first perform the excision of sentinel piles and then couple of months later do either Seton drainage or fistulotomy or perform excision and Seton drainage or fistulotomy at the same time? Please also comment on the risk factors and the associated pain if both issues are treated at the same time.
doctor
Answered by Dr. Dr. Ivan Romich (3 hours later)
Brief Answer:
Hi

Detailed Answer:
Hi, it would be good to perform Seton and pile excision at same time since this is safe and it is not necessary to do 2 surgeries for such things. Also, it may lead to spontaneous heal of Fissure as well. Otherwise, Fissure can be treated after 6 weeks of Seton placement.
Above answer was peer-reviewed by : Dr. Raju A.T
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Follow up: Dr. Dr. Ivan Romich (2 days later)
Thanks again. What steps should I take to heal or reduce the adverse impact of the chronic fissure without undergoing sphincteromy? Your detailed response will be very helpful because my doctor is not recommending sphincteromy.
doctor
Answered by Dr. Dr. Ivan Romich (18 hours later)
Brief Answer:
hi

Detailed Answer:
Well, there is medical treatemnt such as topical glyceril nitrate,calcium channel blockers, steroid ointments, botulinum injections,laser therapy or sclerosation.
However, since this lasts for so many years,and there was no improvement, and you have sentinel pile and possible fistula,it would be better to have surgery performed which is permanent solution. These methods that I ve mentioned are not available everywhere and may not be efficient.

Above answer was peer-reviewed by : Dr. Raju A.T
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Dr. Dr. Ivan Romich

General Surgeon

Practicing since :2008

Answered : 13877 Questions

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Is Surgery The Right Treatment For Anal Fissures?

Brief Answer: Hi Detailed Answer: Hi and welcome. Anal fissures that don't heal on conservative therapy,should be treated with surgery,there is no doubt about it. In this case however,I think that hemorrhoids should be treated first and than after 2 months you should do lateral internal sphincterotomy if fissures don't pull back.It would be not good to do both procedures simultaneously. Risk for anal incontinence after such procedure is minor,if done properly so this should not be problematic if you ask me,also closed technique can be used. There is higher risk of anal stenosis or fistula formation if your condition isn't treated.Wish you good health. Regards