title: Lateral internal sphincterotomy for surgically recurrent chronic anal fissure.
abstract: BACKGROUND
  Lateral internal sphincterotomy cures chronic anal fissure by preventing internal sphincter hypertonia. However, cutting sphincter predisposes to sphincter dysfunction, manifests as incontinence of gas, liquid, or stool. Surgeons, therefore, can be too cautious in its use, making ineffective superficial incisions or avoiding the operation altogether. This study is designed to confirm the role of redo lateral internal sphincterotomy in the treatment of surgically recurrent chronic anal fissure.
  
  
  METHODS
  Patients undergoing repeat lateral internal sphincterotomy for surgically recurrent chronic anal fissure were accessed from a prospectively maintained database. Chronicity was defined by symptoms persisting more than 3 weeks. Contralateral sphincterotomy was performed with electrocautery through a stab incision over the intersphincteric plane. The length of sphincter division was the same as the length of the fissure. Phone questionnaire was administered and fecal continence was assessed by modified Cleveland Clinic Incontinence Score. Patients were asked to rank their overall satisfaction with the operation, and pre- and postoperative quality of life.
  
  
  RESULTS
  There were 57 patients, 24 women and 33 men; mean age was 47.9 ± 14.8 years. Mean follow-up was 12.5 ± 4.2 years (range 6.2 to 25.2 years). Presenting symptoms included pain (100%), bleeding (80%), pruritus ani (39%), constipation (26%), and diarrhea. Fifty patients (90%) presented with 1 fissure, and 40 were posterior. Most procedures were performed on an outpatient basis. Fissure healing rate was 98%, and 2 patients (4%) developed minor incontinence postoperatively (one of gas, the other, gas and seepage). Overall satisfaction was 9.7 ± .9 out of 10 with a significant improvement in the quality of life from 5.7 ± 2.4 out of 10 to 9.3 ± 1.4 out of 10 (P < .001).
  
  
  CONCLUSIONS
  Judicious repeat lateral sphincterotomy cures recurrent chronic fissures with minimal risk of incontinence.
authors.affiliation: Department of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44143, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Liang
authors.affiliation: Department of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44143, USA. Electronic address: church@ccf.org.
authors.forename: James M
authors.initials: JM
authors.lastname: Church
mesh_terms: D000328:Adult; D001003:Anal Canal / Q000601:surgery*; D002908:Chronic Disease; D005260:Female; D005401:Fissure in Ano / Q000150:complications / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D011788:Quality of Life; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D016896:Treatment Outcome
keywords: Chronic anal fissure; Incontinence; Quality of life; Redo lateral sphincterotomy