Summary contentPerianal manifestation in Crohn’s disease patients is likely to complicate the disease course with extra intestinal manifestations, abscesses, deep anal canal ulcers, luminal fistulas and strictures, steroid resistance, and need for multiple surgeries. Diagnosis and management of perianal Crohn’s disease implies a multidisciplinary team approach. Diagnosis and definition of perianal disease requires optimal imaging modality, ideally a pelvic magnetic resonance imaging, with an exam under anesthesia (EUA). However, the lack of a definition consensus on perianal fistula in Crohn’s disease may affect standardization of therapeutic approaches and patients inclusion within clinical trial.
The synergic approach by a surgeon and a gastroenterologist is crucial with perianal Crohn’s disease. Drainage of an abscess and possible seton placement to prevent future septic complications is the basic first step of the treatemnt. Ani-TNF drug have shown the best evidence for decreasing perianal drainage and promote fistula healing. Attempting surgical repair is possibile for selected patients. Surgical strategies include subcutaneous fistulotomy, Ligation of the Intersphincteric Tract (LIFT) procedure, or endorectal advancement flap (ERAF). These surgical strategies work best when associated with anti-TNF or immunomodulation and when mild to moderate proctitis is present. More aggressive interventions include diversion of the fecal stream with loop ileostomy and proctectomy; Mesenchymal stem cells have emerged as possible effective treatment and long term results have been demonstrated by randomized clinical trial.