Abdominoperineal resection for severe perianal Crohn's disease

Abstract

Despite the high incidence of involvement of the perianal region in Crohn's disease, excisional surgery seldom is required for perianal disease alone. Nine patients are presented who had severe perianal Crohn's disease, which eventually required abdominoperineal excision of the anorectum. In all nine patients, it was secondary manifestations of anal Crohn's disease that precipitated proctectomy, such as high fistulas, strictures, and rectovaginal fistulas. These secondary phenomena, especially fistulas caused by cavitating ulceration, become self-perpetuating by the mechanical effect of feces being forced into the tract. During the same period, 17 patients required rectal excision by abdominoperineal resection, where perianal disease was incidental to severe colorectal disease. There is a tendency for excessive delay before advising surgery for severe perianal disease. An attempt should be made to identify patients with a poor prognosis to avoid unnecessarily prolonged morbidity. Assessment of the exact nature of the anal lesion and assessment of Crohn's disease activity are important in making this decision.

Clinical course of perianal fistulas in Crohn's disease.

“…Proctectomy was necessary in two of our patientsone with severe anal stenosis and the other with intractable high grade proctitis. However, this low number may not reflect the overall proctectomy rate in patients with distal Crohn's colitis or perianal disease, which is probably higher.2 [15][16][17] The indications for a more aggressive surgical approach to treat perianal fistulas is a major point of discussion. With various surgical procedures (fistulotomy, partial fistulotomy, drainage), high healing rates were achieved (up to 85%) in selected groups of patients.10 13 16 18-24 Some of these papers reported only operations on active fistulas,22 others only in patients where an aggressive surgical approach seemed advisable (low lying fistulas and absence of rectal disease as evidenced by rates of rectal involvement in the studied patients as low as 30%,23 as opposed to 61% rectal involvement in our patients).…”

“…Proctectomy was necessary in two of our patients -one with severe anal stenosis and the other with intractable high grade proctitis. However, this low number may not reflect the overall proctectomy rate in patients with distal Crohn's colitis or perianal disease, which is probably higher.2 [15][16][17] The indications for a more aggressive surgical approach to treat perianal fistulas is a major point of discussion. With various surgical procedures ( The results of our prospective follow up indicate that the prognosis of perianal fistulas in Crohn's disease with regard to healing and recurrence may be worse than reported in previous studies.…”

Factors affecting the healing of the perineum following surgery

“…[2][3][4] The wound remains unhealed in up to 33% of patients at 12 months. 5,6 PPS is reported more frequently after surgery for Crohn's disease than after surgery for ulcerative colitis or anorectal cancer. 5,7,8 The incidence of PPS after abdominoperineal resection for low rectal cancer may be as high as 29%, especially in patients who have received preoperative radiotherapy.…”

Persistent Perineal Sinus After Ileoanal Pouch Excision in Inflammatory Bowel Diseases: Incidence, Risk Factors, and Clinical Course

“…Several investigators have suggested that some perineal lesions are associated with delayed perineal healing, including fistulous tracts exiting beyond 5 cm from the anal verge, 10 complex abscesses, and pelvic sepsis. 11 Consideration of the factors identified above that increase the risk of PPS is helpful because they provide additional predictors for determining intraoperative surgical technique and wound management.…”