Chapter 2 46 with the results of our study showing no consensus on how often one should repeat botulinum toxin. Nevertheless, botulinum toxin remains an effective treatment in recurrent anal fissures as well as in patients with therapeutic failure of prior botulinum toxin injection.7,37 In case botulinum toxin was performed under anesthesia, only 27% always or almost always simultaneously performed fissurectomy and another 27% does this in more than half of the cases. This is comparable to the results of a survey among members of the ASCRS.35 When performing fissurectomy, 51% always or almost always simultaneously injected botulinum toxin and 23% did this in more than half of the patients. The clinical effect of this combined procedure was recently confirmed by Roelandt et al.38 They found that botulinum toxin injections significantly increased the efficiency of fissurectomy, with a healing rate of 90%, compared to 81% in fissurectomy alone.38 Fissurectomy was the surgical procedure of choice in our study (71%), followed by LIS (27%). LIS is the preferred treatment for refractory anal fissures and is still considered the golden standard since LIS has superior healing rates,5,6 although fecal incontinence is a potential risk.8-11 Guideline recommendations differ on this subject. The ASCRS guideline favours LIS,6 the Dutch guideline, however, recommends LIS only for refractory fissures when previous treatment fails.5 The follow-up was diverse in our survey. Twenty-one percent of the respondents stated that they scheduled a telephone call follow-up check after starting the treatment. This is quite interesting given the fact that it concerns a chronic disorder which has a large impact on quality of life and increased health care utilization.39 Besides that, chronic pelvic pain is often accompanied by pelvic floor dysfunctions.40 A physical diagnostic follow-up should be performed since physical rectal examination is important to monitor clinical healing of the fissure and investigation of anal sphincter tone. A physical follow-up will probably better monitor patients’ wellbeing and subsequently ensure that the patient does not end up in a vicious circle of pain again. Forty-three percent referred a patient to another specialist at least once last year. No recommendations are made in clinical guidelines concerning follow-up period or when to refer a patient to another specialist. This study has some limitations that should be mentioned. First, the response rate of 33% may have caused non-response bias. However, this response rate was less compared to earlier published response rates of online surveys.41,42 Second, the questionnaire was sent to all members of the Dutch Coloproctology Working group
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