Surgical Treatment of Perianal Fistulizing Crohn’s Disease: From Lay-Open to Cell-Based Therapy—An Overview

Abstract

Background. Perianal Crohn's disease (CD) can be challenging. Despite the high incidence of fistulizing CD, literature lacks clear guidelines. Several medical, surgical, and combined treatment modalities have been proposed, but evidences are scarce. Methods. We searched the literature to assess the facets of perianal CD, with particular focus on complex fistulae. Disease epidemiology, classification, diagnosis, activity scoring systems, and medical-surgical treatments were assessed. Results. Perianal fistulizing CD is common, frequently associated with upper gastrointestinal and colorectal CD. Complex fistulas often require repeated treatments. Continence is a major concern when dealing with repeated procedures. A prudent pathway is to resolve active sepsis and to limit damages, delaying a definitive treatment to the time when acute phase has been controlled. The improved diagnostic techniques allow better preoperative planning and are useful in monitoring the response to treatment. Besides newer devices, cell-based treatments are promising tools which have recently enriched the treatment portfolio. However, the need for proctectomy is still disturbingly high in CD patients with complex perianal fistulae. Conclusions. Perianal CD can impair quality of life and lead to need for proctectomy. A staged approach is reasonable. Treatment success can be improved by multimodal treatment and collaborative management by experienced gastroenterologists and surgeons.

Cone-like resection, fistulectomy and mucosal rectal sleeve partial endorectal pull-through in paediatric Crohn's disease with perianal complex fistula

“…However, as reported by Pellino et al [24], other surgical treatments like fibrin glue or adipose tissue-derived stem cell injection have shown promising preliminary results and further studies are required to improve surgical outcomes for the treatment of complex fistula.…”

MR Imaging of Perianal Crohn Disease

“…The seton inhibits premature closure of the external opening, thereby discouraging abscess formation, and poses minimal risk for incontinence (20). The optimal timing for seton removal is unclear, but premature removal runs the risk of recurrent sepsis while prolongation may impede healing owing to foreign body reaction or fibrosis (71,72). Draining setons, often in conjunction with medical therapy, provide good short-term inflammation control and symptomatic improvement, but long-term sustained healing is suboptimal (35,(72)(73)(74)(75)(76).…”

Management of complex perianal Crohn’s disease

“…This is clearly beyond the scope of this review, and the reader should look into recent and comprehensive papers [27]. Several techniques, such as advancement flap, laser therapy, and ligation of the intersphincteric fistula tract, among others, can be attempted, but only by an experienced surgical team.…”