VY Advancement flap?

Peter

Thanks for update & info. A little odd & coincidental that you have developed pile also. Is it at botox site? Consultant seen yesterday said yes was linked with botox jab. On further reading can be caused by not being injected into correct location which i guess could explain why it is maybe not working for us.

You are right the contradictions are huge we are hearing so maybe understandable why we find it difficult to make informed decision. Yesterday he mentioned that the botox may still need time to work as 4 to 5 weeks is the norm. A little different from Mr B`s 48 hrs.

He was pro fissurectomy but dont think it is for me. He told me 75% success rate with small risk of incon (although as he would not be cutting sphicter muscle dont know how unless was completely incompetent) so for me failure rate is too high to go through surgery.

He did mention something interesting that he was currently treating a GP which high sphinc pressure that will not respond to treatment and that he has seen it prev something called `an executive fissure`where people in high stress jobs get this which needs a complete lifestyle change. I have two careers running parallel meaning long hrs and busy homelife so maybe something in it. Guess this is something that accupuncture may help. Think difficulty we have is that we are moving towards a surgical end to our pains but consultants are generally carrying out less operations due to success of creams/botox meaning its difficult to find a consultant doing fissure ops regular which i think is what we both want.

Steve

Meant to add - apart from Mr D the advanced flap guy who apparantly does lots as he doesnt bother with the diltiazem or creams and recommends goes straight in for sgy as first line treatment.

Also What are fibrotic edges, how do u know u have?

Steve, it would be pretty poor if we both got the haemorrhoid from a misplaced injection. Not that I would complain but I cannot recall being told that it was a risk. Is it conceivable that a mistake was made twice?

The so called executive fissure is very interesting but again I am not in position to change my work.

I am not clear what your route your consultant is recommending you go down. If you are rejecting fissurectomy presumably you are staring LIS in the face unless you go for the flap and for that to work you will have to go with someone who does it all the time imo. There may be only one choice.

My consultant said that I would have growth around the edges and that

the wound would definitely need cleaning. As this is NHS I assume that there is no incentive to have me go through a procedure for the sake of it.

I will go for a 75-80% chance to avoid the certainty of cutting and permanently weakening a muscle. I can only imagine that the incontinence risk relates to the botox.

Anti inflammatories and ice for the haemorrhoid? Not sure that the OTC ointments have much benefit.

Peter

I feel pretty bad that i was the one that encouraged you to see Mr B and you are no further forward especially after hearing your pile issue. The fissurectomy sounds a rational decision for you although will remind you that adv flap was always your first choice and maybe like me you have been put off by subsequent consultants/advice. Mr D is confident that adv flap works for all fissures regardless of pressure. He also performs regular with no risk of incon and reduced risk of it coming back as he widens hole (think am talking myself into it again)

My prob is that all the consultants are telling me my fissure looks healed but am still in pain although visually it doesnt look great with scar tissue, tag etc there is part of me questioning whether i need.

Back to you - Admittedly my advice right now may not be worth much but i can only reflect on what you have consistently sounded like what you want. I remember mentioning to you prev but for you i would check the success rates for adv flap on all sphincter pressures. Springer has lots of studies published and they appear impressive and Mr Ds latest study was this year so before deciding on fissurectomy would perhaps follow your heart especially with all this conflicting advice.

Steve

Steve, I absolutely do not blame you for anything. We do not know for sure what caused the haemorrhoids and even if caused by the injections this could have been the case whoever did them.

As I said, I did not know of the risk but if I had been told I still would have gone ahead so it is a non issue for me and quite frankly I owe you thanks for suggesting him. I did not have a better or any alternative.

I do not know if you found the review I mentiond yestarday but they go pretty much for low pressure=flap, high pressure=LIS. The Oxford consultant took the same view and I think that that is adopted in the position statements of various colorectal associations. Mr B also seems to concur with that view. His argument against was that it is the final solution and if it doesn't work you have two lesions to deal with. My NHS consultant thought that there was a high failure rate but as I mentioned this may simply reflect the lack of practice.

Set againt the above is Mr D and some other studies which have had successful results for all presures either with adv or rotation flap.

For me the cost of a flap privately is too high and I think that we both would probably agree that only Mr D has the competence to do it successfully so far as we know although it is possible that some NHS doctors are doing it. I just don't know who they are.

I don't think that the fissurectomy will rule out the flap if necessary later and I see it as preferable to LIS. I thought that you were going to bite the LIS bullet especially based on initial impression of MrD but it looks like that is changing. It is peculiar that your fissure seems to have healed. Can it just be nerve damage/pressure which is causing the pain rather than the actual fissure?

Peter, Thanks for your kind words. I did read the 2010 review which you mentioned. Really interesting i thought about this new Gonautoxin injection with a 100% cure rate although you may have to go to Chile to receive it which is slight drawback.

Was good report to read for me mainly because it is up to date and still supported LIS which is quite an old technique hesedays but still appears gold standard.

Re healed fissure - i dont know whats going on although despite it looking healed last consultant said intially when he viewed it looked excessively deep so maybe unhealed under the surface. If it is nerve damage i am feeling think this would prob be worse. I read someones story which sounded like same thing and still felt after an LIS and in end was requesting a colostomy. Anyway dont want that thought in head right now so hope things stable if not improved your end and you staying positive? How long you going to leave it before considering Fissurectomy/more botox?

Steve

Steve, to be honest my pain management has probably improved but my condition has not in the slightest.

I guess I could just about continue as I am with the artificial support of stool softeners, suppositories, prunes, flax seed oil, varying degrees of pain and better and not so good days in the context of it not being life threatening and others having to put up with worse pain than me but

I still hope for a better quality of life.

I am due for fissurectomy plus renewed botox within the next 4 weeks.

Are you still undecided over flap v LIS?

If you look up the M62 Coloproctology course you will see in 2005 there is an article on fissures whose author concludes:

In summary destructive procedures on the anal sphincters should be avoided, there are good low risk, highly effective surgical alternatives. Currently the surgical approach of choice is probably a rotation flap. An alternative to consider is a fissurectomy combined with a chemical sphincterotomy with Botox.

What did happen to the rotation flap?

Peter, Guess this 2005 report adds extra uncertainty as am already maxed out on procrastination right now. I think we are following same journey both in our thinking about this and possibly in progress also. Am aware our communication started because of my search and question for support for adv flap and makes sense its just when you listen to enough so called experts who are against it is difficult to keep single minded.

Like you right now my pain is just about manageable but condition same. I took the advice with prunes before bed and that is working a treat alongside lepicol. Four weeks for you is not far away. Have you booked with mr B or someone else or are you waiting to see how things pan out? For me it feels easier to plan surgery when pain is really bad. Also bare in mind that 6 weeks is apparantly the time of most progress after botox according to a few reports (again vastly diff than Mr Bs prediction). Needless to say although have no magic pill to offer if you do decide on the sgy soon then am here to talk through before and after anytime as am anticipating will be nerve racking.

Steve,

Don't forget the flax seed oil with the prunes!

6 weeks may be the time for maximum benefit but I have had zero progress and really cannot see it suddenly starting.

The position regarding the flap appears to be:

For- Mr D, various studies, author of article in coloproctology course etc

Against- (or not advisable in case of high sphincter pressure) Mr B, my NHS consultant, Oxford consultant with whom I corresponded, World Journal 2010 review.

I still think that part of the problem with the flap failure rate is that few have sufficient experience doing it. Do we know anyone apart from Mr D who has extensive experience? Do we know anyone who is performing the rotation flap?

I am committed to the fissurectomy and botox as the next step. It will be done on NHS within 3/4 weeks. Are you still hoping for sufficient improvement to avoid all surgery?

I agree, adv flap problem is there are so few doing it. Other than Mr D i only know of Mr CB in scotland who i prev mentioned. Sounds like you are positive & sure re fissurectomy so maybe good idea not to think too much about other approaches. I know few email ago you mentioned possibility of having more botox with Mr B before considering sgy, have you abandoned that idea now?

Steve, as I mentioned previously what happened to the rotation flap which was being touted as superior to the adv flap?

I think there is better evidence for fissurectomy plus botox rather than just botox so will not be going for a repeat of the latter.

The other reason is that I have just received a bill from the hospital charging a whopping £350 because a so called \"surgical procedure\" was carried out at the time of the consultation. This is in addition to the consultants fee and the cost of the botox. Alarming and unaffordable for me.

Am I right in thinking that you are still hoping for sufficient improvement

to avoid all of it?

That does seem a bit of a rip off charging £350.00 for what exactly as am assuming Mr B pays them to use their facilities. If botox and consultancy time are extra i would contact hospital to ask for a breakdown what the £350 is for.

Yes am managing things at moment, thrombosed hemmy pain has gone leaving the fissure pain to deal with. At present it feels bareable although daily that can change. If/When it does change LIS is my choice probably after trying another burst of botox.

Let me know when you date is for sgy Peter. Sounds like you have evaluated all options and come up with best choice for you so hope all goes well.

Steve

Steve, according to the hospital it is a standard charge which kicks in when a so called surgical procedue takes place.

As I separately paid for the consultant and botox, this effectively means that the actual administration of the injection costs £350.

Whether or not this counts as a \"surgical procedure\" it was not as if other facilities of the hospital were used. Anyway I am disputing it so we will see what happens. I dare say that a form that I signed in a rush on arrival will be produced at some stage but that is not good enough IMO

I have had a reduction in symptoms over the past week particularly soreness and while I should be pleased you are never sure if this is a temporary respite and while the symptoms may have changed I still don't feel that the fissure itself is healing. Of course this may be psychological

and convincing myself I feel better to avoid the impending surgery!

Peter

Really pleased things eased down for you. I feel same and have had good 2 weeks although today pain is back again today and am back to working on my knees in office. if you have been feeling little better around same time as me ( am aware you are week behind) maybe botox kicking in. Most consultants as we have discussed say that 4 or 5 weeks is common to begin recovery after botox. Guess prob is Mr B is saying only lasts 6 weeks so dont get much improvement time before things worsen. Who knows, main thing i guess is that you are feeling somewhat better and long may it continue. Other consultant i seen is sending me for pressure test at hospital in few weeks so will await outcome.

Issue of the £350 i feel is criminal, there is no rational justifiable reason why this should be classed as surgery. No staff required, no surgical instruments that need cleaning, im feeling pretty angry about it also. I am type 1 diabetic injecting many times a day, so in there description i am performing surgery on myself every day of my life - ludicrous.

Chris

Steve, thanks for the support. That is really tough having to deal with two conditions day. What a life for you.

We will see what happens when I get a reply from Mr B but he is likely to pass it on to the hospital I would have thought.

I have to admit that this is the best 10 days I have had and while it is supported by an artificial regime of stool softeners, GTN, diet etc I could live with it although obvioulsy I would prefer a more \"natural\" life.

Having said that the respite may, as you say, be short lived.

The pressure test is an interesting development. I suppose that it will confirm the assumption of high pressure- assuming we know what that means!

Purely out of interest I see that there some studies of a few years ago on using the hyperbaric oxygen chamber for treating chronic anal fissures. Although quite successful which follows if the condition fails to heal due to local ischaemia, you can imagine that the cost and impracticality quickly put a stop to it.