Letter to the editor on article Subcutaneous lateral internal sphincterotomy (SLIS)—a safe technique for treatment of chronic anal fissure

Abstract

Dear Editor: We read with interest the article on the efficacy of subcutaneous lateral internal sphincterotomy (SLIS) for chronic anal fissure. The important outcome was the low incidence of incontinence (6%) as against that quoted in literature. We believe the technique and supervision of an experienced consultant could be the contributing factor, which unfortunately cannot be well addressed in a singlesurgeon case series. We would like to highlight two aspects of the management of chronic anal fissure. The author has been honest about the 42-year-old woman with multiple vaginal deliveries and second degree tear, who continues to be incontinent. Any patient with such an obstetric history or previous perianal surgery including the old school anal stretch (beware! it is still practiced in some countries other than UK) should have undergone an endo-anal ultrasound for assessment of sphincter before proceeding to SLIS. The other point we would like to highlight is the increasing role of botulinum toxin as an option if GTN/ diltiazem is not effective, before subjecting the patient to SLIS, especially in young patients with chronic fissure. In short, we believe that the debate on management of chronic anal fissure has moved from one of the efficacy of different techniques to one of patient selection.