Modern surgical strategies for perianal Crohn's disease

Abstract

One of the most challenging phenotypes of Crohn’s disease is perianal fistulizing disease (PFCD). It occurs in up to 50% of the patients who also have symptoms in other parts of the gastrointestinal tract, and in 5% of the cases it occurs as the first manifestation. It is associated with severe symptoms, such as pain, fecal incontinence, and a significant reduction in quality of life. The presence of perianal disease in conjunction with Crohn’s disease portends a significantly worse disease course. These patients require close monitoring to identify those at risk of worsening disease, suboptimal biological drug levels, and signs of developing neoplasm. The last 2 decades have seen significant advancements in the management of PFCD. More recently, newer biologics, cell-based therapies, and novel surgical techniques have been introduced in the hope of improved outcomes. However, in refractory cases, many patients face the decision of having a stoma made and/or a proctectomy performed. In this review, we describe modern surgical management and the most recent advances in the management of complex PFCD, which will likely impact clinical practice.

Keywords: Crohn’s disease; Inflammatory bowel disease; Surgical treatment; Perianal fistulas; Anorectal fistula

Core Tip: Perianal Crohn’s disease (CD) occurs in up to 50% of patients who also have symptoms in other parts of the gastrointestinal tract. One of the most challenging phenotypes of CD is perianal fistulizing disease. Treatment is difficult, often requiring more aggressive medical and surgical interventions than luminal disease. Seton placement is the most common technique. However, with the advent of biological therapy, especially anti-TNF agents (infliximab and adalimumab), the approach to these fistulas has changed. Thus, this article aims to review the methods currently available for the management of perianal fistulizing disease.