Improved Outcomes in Colon and Rectal Surgery part 23. Written by many of the worlds leading colorectal surgeons, this evidence-based text investigates the risks and benefits of colorectal surgeries. By using clinical pathways, algorithms, and case discussions, the authors identify the best practices for patient safety and positive outcomes to ensure that physicians correctly recognize potential problems and carefully manage complications | improved outcomes in colon and rectal surgery limited versus full internal sphincterotomy. In one study early incontinence in patients undergoing full sphincterotomy was increased compared to patients who underwent limited sphincterotomy p . 91 However this difference did not persist with long-term follow-up with only 2 patients who underwent full sphincterotomy reporting persistent incontinence. In the other study there was no significant difference in posttreatment and baseline incontinence scores between the two types of sphinc-terotomy. 92 Overall internal sphincterotomy up to the dentate line has been shown to produce faster healing and pain relief but is associated with increased rates of early incontinence compared to sphincterotomy to the fissure apex. Given the significant variation in incontinence rates after sphincterotomy several investigators have sought to further characterize incontinence in patients with chronic anal fissure with respect to type frequency and permanence. In a study of preoperative and postoperative incontinence in 126 patients with chronic anal fissure Anmari and colleagues found that 28 of patients had minor preoperative disturbances in continence that persisted postopera-tively. 93 Casillas and colleagues found that patients endorsed a higher rate of incontinence in response to a questionnaire than was recorded in their medical record or was reported in a telephone survey. 94 In other studies risk factors for incontinence were identified. 95-96 These include preexisting sphincter injuries IAS division 50 injury to external anal sphincter during the procedure functional impairment with age shorter sphincter in females and posterior keyhole deformity. While external anal sphincter injury during anal stretch and a posterior keyhole deformity after posterior sphincterotomy clearly result in higher rates and more severe forms of incontinence the presence of other risk factors in patients who are undergoing lateral .
