Surgical Resection for Extensive Perianal Crohn's Disease Treatment: Case Series Report

Background: Crohn’s disease (CD) can affect any segment of the gastrointestinal tract (GIT), often requiring a combination of medical and surgical treatment. Economical resections are generally recommended, whether intestinal or perianal/perineal. The objective of the study is to present four patients with CD with perineal involvement, who underwent perineal medical and surgical treatment with extensive resections. Methods: Review of the medical records of four patients who underwent extensive perianal resection at a hospital affiliated with the Brazilian Coloproctology Residency program. Results: Case 1: A 25-year-old man using adalimumab underwent 5 surgeries with placement of setons in multiple fistulas in the first surgery, followed by removal of setons, curettage and placement of new setons in subsequent approaches. Recent abscess with new approach. Case 2: Woman, 43 years old, undergoing treatment with infliximab, underwent fistulotomy with seton placement. Six months after surgery, she developed pain during bowel movements and hematochezia. She underwent a new fistulotomy surgery with dilation of the anal canal and drainage of the abscess. Currently with healing of the perianal wound. Case 3: Woman, 27 years old, using infliximab, with terminal ileostomy after total colectomy in emergency due to unblocked Crohn’s perforation of the colon, presenting severe perianal involvement. She underwent 5 extensive surgeries (including vulvar), as well as correction of rectal stenosis. Healing of 90% of the area. Case 4: A 26-year-old man, using adalimumab and azathioprine, underwent surgery with extensive debridement and placement of seton in three fistulas and removal of seton after eight months. Perineal wound healing. Conclusions: All patients underwent pelvic magnetic resonance imaging to identify the fistula path and received combined treatment involving surgery, anti-TNF immunobiologicals and antibiotic therapy. The timing of surgical intervention depends on the presence of active inflammation in the distal rectum and perineum and anal canal. 2 or more perineal surgical procedures are necessary to control the disease. Wound healing (complete or partial) takes on average 2.4 to 2.7 years. Complete healing is achieved in only 54% of treated patients. For most patients with perianal CD, complete cure of the disease, including fistulas, fissures or post-drainage anal abscesses, is the main therapeutic goal. However, in complex cases of perianal disease, the desirable therapeutic goal is symptomatic improvement (e.g., reduction in rectal pain, decreased drainage) and, consequently, an improvement in quality of life.