Respectful Insolence

Relieving a pain in the posterior

I’ve been meaning to mention this post by Sid Schwab of Surgeonsblog for a while now. It’s a wonderful example of how nothing heals like surgical steel in even the most humble-seeming conditions. In this case, he’s talking about anal fissures, a condition that makes defecation very painful. It turns out that, for cases that won’t heal with conservative measures, there’s a very simple and underutilized operation that can be done in the office known as the lateral sphincterotomy, which can relieve the pain and in essence “cure” the condition instantly. Few operations provide such instant relieve. Unfortunately, it’s an operation that’s far too often not done, either because patients with an anal fissure aren’t referred to a surgeon as their docs endlessly try to treat the condition with soaks and stool softeners beyond the point that it’s clear that the fissure won’t heal or because many general surgeons were never really trained in the procedure.

When I was a resident, I once asked a colorectal surgeon why he had gone into the specialty, given the frequent contact with stool and staring up people’s behinds. His response was instructive. He told me that being able to defecate normally is something most people take for granted but that’s highly disruptive to a patient’s quality of life and that if you can fix a patient’s problems pooping that that will be the most grateful patient you’ve ever seen. The results of a lateral sphincterotomy were one of the things that opened my eyes to the truth of his words.

It wasn’t enough to inspire me to become a colorectal surgeon, though.

Comments

  1. #1 Skeptyk
    August 21, 2007

    Good post. What are some of your other favorite “simple” operations?

  2. #2 Scott Belyea
    August 21, 2007

    We praise the colorectal surgeon
    Misunderstood and much maligned
    Slaving away in the heart of darkness
    Working where the sun don’t shine

    http://www.youtube.com/watch?v=EmQ02Zt05ow

  3. #3 Barry Zimmerman
    August 21, 2007

    An experienced surgeon once told me “If you want to operate, never lose a patient, and have all your patients eternally grateful, restrict your practice to pediatric hernias and anal fissures.”

  4. #4 Palolo lolo
    August 21, 2007

    Having had a temporary colostomy due to diverticular disease, I totally concur-pooping naturally is a wonderful thing when
    faced with alternatives. As it were. ;)

  5. #5 daedalus2u
    August 21, 2007

    The anal sphincter is nitrergic, it is relaxed by nitric oxide. I suspect that is so that when there is an infection, and inducible nitric oxide synthase is expressed, it opens up. Also, many facultative anaerobes use nitrate as an electron receptor and generate NO. If they generate too much, it opens up too, purging the system.

    The primary non-surgical treatment is topical nitroglycerine which tends to relax it so it can heal. Constriction tends to reduce blood flow, which causes hypoxia and reduces NO levels making it more difficult to relax.

  6. #6 DuWayne
    August 21, 2007

    What would enaman say!?!

    Thankfully, I have never had to deal with this myself. I have a friend who had really pervasive anal fissures and it was sheer hell for him. Given the amount of time and all the crap the doctor had him do, I’m guessing his health care provider, was unaware of this procedure.

    Being a lifelong bathroom reader, this would be a great tragedy for me. Having a five year old, my morning stints on the can, make up the bulk of my quiet time. With the next boy due in December, I am guessing that this will continue to be my time of peace, for the foreseeable future. To mar it with excruciating pain, would be kind of crappy. . .

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