2 Results of a national survey among gastrointestinal surgeons 41 Introduction Chronic anal fissure (CAF) is defined as a longitudinal ulcer in the squamous epithelium with persisting symptoms for longer than four to six weeks or recurrent fissures.1,2 Patients usually experience anal pain, during and immediately after defecation, which may last several hours and therefore has a substantial impact on daily activities and quality of life.3,4 Despite current Dutch and international guidelines optimal management of CAF is quite challenging, mainly because of its recurrent nature, therapy compliance and the variety of non-operative and operative treatments.5,6 Treatment of CAF has undergone an alteration in the last two decades from invasive to non-invasive, reserving surgical interventions for lesions refractory to conservative therapy.7 Initial conservative management are comprised of lifestyle advice, fibre intake and/or use of laxatives and ointments. The use of ointments is aimed at reducing elevated internal sphincter tone and consequently increase the anodermal vascular blood flow, for which nitro-glycerine as well as calcium channel blockers may be prescribed. Botulinum toxin can be considered as an alternative or as a next step when standard conservative therapy fails.5,6 In addition, various surgical procedures are possible such as fissurectomy, advancement flap repair and lateral internal sphincterotomy (LIS). Currently, LIS is considered the golden standard6,8 with healing rates of 90-100% but with a potential risk of incontinence.1,9-12 Although most anal fissures probably heal spontaneously or with conservative measures, a percentage tend to recur or persist. A proportion of these patients have a history of constipation and obstructed defecation due to an unrecognized pelvic floor dysfunction. Consequently, these patients have complaints of excessive straining, incomplete evacuation, and hard stools together with infrequent stooling which might be due to, for instance, dyssynergia.13,14 Dyssynergia can primarily lead to anorectal pain but can also evolve secondary to disorders causing anorectal pain.15 Pelvic floor dysfunctions are associated with urological, bowel, gynecological and sexual complaints, and chronic pelvic pain16,17 and can be treated with pelvic floor physical therapy. It is unknown if surgeons treating these patients are sufficiently aware of this condition in patients with CAF. Although Dutch and international guidelines are largely based on high-quality evidence, recommendations are ambiguous. As a result, there is variation in clinical practice. The aim of this study is to evaluate current practice in the management of CAF among gastrointestinal surgeons in the Netherlands.
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