Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Nov 14, 2020; 26(42): 6572-6581
Published online Nov 14, 2020. doi: 10.3748/wjg.v26.i42.6572
Modern surgical strategies for perianal Crohn's disease
Gilmara Pandolfo Zabot, Ornella Cassol, Rogerio Saad-Hossne, Willem Bemelman
Gilmara Pandolfo Zabot, Department of Coloproctology, Hospital Moinhos de Vento, Porto Alegre 90035-902, RS, Brazil
Ornella Cassol, Department of Surgery, Hospital de Clínicas de Passo Fundo, Passo Fundo 99010-260, RS, Brazil
Rogerio Saad-Hossne, Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu 18618687, São Paulo, Brazil
Willem Bemelman, Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam 19268, Netherlands
Author contributions: Zabot GP and Cassol OS designed and performed the research, analyzed the data and wrote the paper; Bemelman W analyzed the data and wrote the paper; Saad Hossne R designed the research; all authors read and approved the final manuscript.
Conflict-of-interest statement: Authors declare no conflict of interests for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Gilmara Pandolfo Zabot, MSc, Surgeon, Department of Coloproctology, Hospital Moinhos de Vento, R. Ramiro Barcelos, 910 - Moinhos de Vento, Porto Alegre 90035-902, RS, Brazil.
Received: August 13, 2020
Peer-review started: August 13, 2020
First decision: August 22, 2020
Revised: September 5, 2020
Accepted: September 29, 2020
Article in press: September 29, 2020
Published online: November 14, 2020

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.