Download PDF
Clin Colon Rectal Surg 2007; 20(4): 322-328
DOI: 10.1055/s-2007-991032
© Thieme Medical Publishers

Management of Nonhealing Perineal Wounds

Jill C. Genua1 , David A. Vivas1
  • 1Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
Further Information

Publication History

Publication Date:
16 October 2007 (online)

    Permissions and Reprints

ABSTRACT

The manifestations of perianal Crohn's disease vary from primary lesions such as skin tags and fissures, to diffuse septic destruction of tissue and sphincter muscle. These manifestations are often persistent and refractory to surgical treatment; however, a more disappointing scenario is when the treatment itself results in a chronic wound. The ideal approach for management involves basic surgical principles, careful patient selection, and realistic expectations. Choice of appropriate procedure, effective elimination of sepsis, thorough evaluation to rule out concomitant systemic disease, and appropriate use of fecal diversion are each an important principle. If proctectomy is necessary, several strategies such as intersphincteric dissection, avoidance of fecal contamination, and appropriate wound closure, are effective in diminishing the postoperative morbidity of an unhealed perineal wound. When an unhealed perineal wound develops in a patient with Crohn's disease, the initial management is conservative. When surgical treatment is necessary, success depends on careful patient selection, optimizing the patient's condition, elimination of sepsis, and choice of an effective technique for healing.

KEYWORDS

Perianal Crohn's disease - nonhealing perineal wounds - perineal sinus - intersphincteric proctectomy

REFERENCES

  • 1 McClane S J, Rombeau J L. Anorectal Crohn's disease.  Surg Clin North Am. 2001;  81 169-183
    CrossrefPubMedGoogle Scholar
  • 2 Singh B, Mortensen N J, Jewell D P, George B. Perianal Crohn's disease.  Br J Surg. 2004;  91 801-814
    CrossrefPubMedGoogle Scholar
  • 3 Jeffery P J, Parks A G, Ritchie J K. Treatment of haemorrhoids in patients with inflammatory bowel disease.  Lancet. 1977;  1 1084-1085
    PubMedGoogle Scholar
  • 4 Wolkomir A F, Luchtefeld M A. Surgery for symptomatic hemorrhoids and anal fissures in Crohn's disease.  Dis Colon Rectum. 1993;  36 545-547
    CrossrefPubMedGoogle Scholar
  • 5 Beck D E. Management of anorectal crohn's fistulas.  Clin Colon Rectal Surg. 2001;  14 117-128
    PubMedGoogle Scholar
  • 6 Michelassi F, Melis M, Rubin M, Hurst R. Surgical treatment of anorectal complications in Crohn's disease.  Surgery. 2000;  128 597-603
    CrossrefPubMedGoogle Scholar
  • 7 Sangwan Y P, Schoetz Jr D J, Murray J J, Roberts P L, Coller J A. Perianal Crohn's disease. Results of local surgical treatment.  Dis Colon Rectum. 1996;  39 529-535
    CrossrefPubMedGoogle Scholar
  • 8 Fry R D, Shemesh E I, Kodner I J, Timmcke A. Techniques and results in the management of anal and perianal Crohn's disease.  Surg Gynecol Obstet. 1989;  168 42-48
    PubMedGoogle Scholar
  • 9 Sarani B, Orkin B A. Squamous cell carcinoma arising in an unhealed wound in Crohn's disease.  South Med J. 1997;  90 940-942
    CrossrefPubMedGoogle Scholar
  • 10 Buchman A L, Arment M E, Doty J. Development of squamous cell carcinoma in chronic perineal perineal sinus and wounds in Crohn's disease.  Am J Gastroenterol. 1991;  86 1829-1832
    PubMedGoogle Scholar
  • 11 Zelas P, Jagelman D G. Loop ileostomy in the management of Crohn's colitis in the debilitated patients.  Ann Surg. 1980;  191 164-168
    PubMedGoogle Scholar
  • 12 Harper P H, Kettlewell M G, Lee E C. The affect of split ileostomy or perianal Crohn's disease.  Br J Surg. 1982;  69 608-610
    PubMedGoogle Scholar
  • 13 Post S, Herfath C, Schumacher H et al.. Experience with ileostomy and colostomy in Crohn's disease.  Br J Surg. 1995;  82 1629-1633
    PubMedGoogle Scholar
  • 14 Galandiuk S, Kimberling J, Al-Mishlab T G, Stromberg A J. Perianal crohn's disease: predictors of need for permanent diversion.  Ann Surg. 2005;  241 796-802
    CrossrefPubMedGoogle Scholar
  • 15 Hyman N H. Unhealed perineal wound. In: Fazio VW, Church JM, Delaney CP Current Therapy in Colon and Rectal Surgery. 2nd ed. Philadelphia, PA; Elsevier Mosby 2005: 241-243
    Google Scholar
  • 16 Fry R D, Shemesh E I, Kodner I J et al.. Techniques and results in the management of anal and perianal Crohn's disease.  Surg Gynecol Obstet. 1989;  168 42-48
    PubMedGoogle Scholar
  • 17 van Dongen L M, Lubbers E J. Perianal fistulas in patients with Crohn's disease.  Arch Surg. 1986;  121 1187-1190
    PubMedGoogle Scholar
  • 18 Buchmann P, Keighley M R, Allan R N et al.. Natural history of perianal Crohn's disease:ten year follow-up:a plea for conservatism.  Am J Surg. 1980;  140 642-644
    CrossrefPubMedGoogle Scholar
  • 19 Williamson P R, Hellinger M D, Larach S W, Ferrara A. Twenty-year review of the surgical management of perianal Crohn's disease.  Dis Colon Rectum. 1995;  38 389-392
    CrossrefPubMedGoogle Scholar
  • 20 Williams J G, Rothenberger D A, Nemer F D, Goldberg S M. Fistula-in-ano in Crohn's disease. Results of aggressive surgical treatment.  Dis Colon Rectum. 1991;  34 378-384
    CrossrefPubMedGoogle Scholar
  • 21 Basu A, Wexner S D. Perianal Crohn's disease.  Curr Treat Options Gastroenterol. 2002;  5 197-206
    CrossrefPubMedGoogle Scholar
  • 22 Corman M L, Veidenheimer M C, Coller J A, Ross V H. Perineal wound healing after proctectomy for inflammatory bowel disease.  Dis Colon Rectum. 1978;  21 155-159
    CrossrefPubMedGoogle Scholar
  • 23 Yamamoto T, Bain I, Allan R N, Keighley M RB. Persistent perineal sinus after proctocolectomy for Crohn's disease.  Dis Colon Rectum. 1999;  42 96-101
    CrossrefPubMedGoogle Scholar
  • 24 Keighley M R, Allan R N. Current status and influence of operation on perianal Crohn's disease.  Int J Colorectal Dis. 1986;  1 104-107
    CrossrefPubMedGoogle Scholar
  • 25 De Dombal F T, Burton I, Goligher J C. The early and late results of surgical treatment for Crohn's disease.  Br J Surg. 1971;  58 805-815
    CrossrefPubMedGoogle Scholar
  • 26 Ritchie J K. Ileostomy and excisional surgery for chronic inflammatory disease of the colon: a survey of one hospital region.  Gut. 1971;  12 528-540
    CrossrefPubMedGoogle Scholar
  • 27 Irvin T T, Goligher J C. A controlled clinical trial of three different methods of perineal wound management following excision of the rectum.  Br J Surg. 1975;  62 287-297
    CrossrefPubMedGoogle Scholar
  • 28 Scammell B E, Keighley M RB. Delayed perineal wound healing after proctectomy for Crohn's colitis.  Br J Surg. 1986;  73 150-152
    CrossrefPubMedGoogle Scholar
  • 29 Sher M E, Bauer J J, Gorphine S, Gelernt I. Low Hartmann's procedure for severe anorectal Crohn's disease.  Dis Colon Rectum. 1992;  35 975-980
    PubMedGoogle Scholar
  • 30 Duffy L C, Zielezny M A, Marshall J R et al.. Cigarette smoking and risk of clinical relapse in patients with Crohn's disease.  Am J Prev Med. 1990;  6 161-166
    PubMedGoogle Scholar
  • 31 Sutherland L R, Ramcharan S, Bryant H et al.. Effect of cigarette smoking on recurrence of Crohn's disease.  Gastroenterology. 1990;  98 1123-1128
    PubMedGoogle Scholar
  • 32 Cottone M, Rosselli M, Orlando A et al.. Smoking habits and recurrence in Crohn's disease.  Gastroenterology. 1994;  106 643-648
    PubMedGoogle Scholar
  • 33 Frizelle F A, Pemberton J H. For debate: removal of the anus during proctectomy.  Br J Surg. 1997;  84 68
    CrossrefPubMedGoogle Scholar
  • 34 Windsor A CJ, Northover J MA. Removal of the anus during proctectomy.  Br J Surg. 1997;  84 1176
    PubMedGoogle Scholar
  • 35 Talbot R W, Ritchie J K, Northover J MA. Conservative proctocolectomy: a dubious option in ulcerative colitis.  Br J Surg. 1989;  76 738-739
    CrossrefPubMedGoogle Scholar
  • 36 Guillem J G, Roberts P L, Murray J J, Coller J A, Viedenheimer M C, Schoetz Jr D J. Factors predictive of persistent or recurrent Crohn's disease in excluded rectal segments.  Dis Colon Rectum. 1992;  35 768-772
    PubMedGoogle Scholar
  • 37 Alabaz O, Weiss E G. Anorectal Crohn's disease. In: Beck DE, Wexner SD Fundamentals of Anorectal Surgery. London, UK; WB Saunders 1998: 498-509
    Google Scholar
  • 38 Bauer J J, Gelernt I M, Salk B, Kreel I. Proctectomy for inflammatory bowel disease.  Am J Surg. 1986;  151 157-162
    CrossrefPubMedGoogle Scholar
  • 39 Lubbers E JC. Healing of the perineal wound after proctectomy for nonmalignant conditions.  Dis Colon Rectum. 1982;  25 351-357
    PubMedGoogle Scholar
  • 40 Zeitels J R, Fiddian-Green R G, Dent T L. Intersphincteric proctectomy.  Surgery. 1984;  96 617-623
    PubMedGoogle Scholar
  • 41 Leicester R J, Ritchie J K, Wadsworth J, Thomson J PS, Hawley P R. Sexual function and perineal wound healing after intersphincteric excision of the rectum for inflammatory bowel disease.  Dis Colon Rectum. 1984;  27 244-248
    CrossrefPubMedGoogle Scholar
  • 42 Warshaw A L, Ottinger L W, Bartlett M K. Primary perineal closure after proctocolectomy for inflammatory bowel disease.  Am J Surg. 1977;  133 414-419
    CrossrefPubMedGoogle Scholar
  • 43 Tompkins R G, Warshaw A. Improved management of the perineal wound after proctectomy.  Ann Surg. 1985;  202 760-765
    CrossrefPubMedGoogle Scholar
  • 44 Lyttle J A, Parks A G. Intersphincteric excision of the rectum.  Br J Surg. 1977;  64 413-416
    CrossrefPubMedGoogle Scholar
  • 45 Lee E CG, Dowling B L. Perimuscular excision of the rectum for Crohn's disease and ulcerative colitis.  Br J Surg. 1972;  59 29-32
    CrossrefPubMedGoogle Scholar
  • 46 Oakley J R, Fazio V W, Jageman D G et al.. Management of the perineal wound after rectal excision for ulcerative colitis.  Dis Colon Rectum. 1985;  28 885-888
    CrossrefPubMedGoogle Scholar
  • 47 Keighley MRB, Williams NS Persistent perineal sinus. Surgery of the Anus, Rectum And Colon. 2nd ed. London, UK; WB Saunders 1993: 309-331
    Google Scholar
  • 48 Moon H K, Caminer D, Boyd B. Unhealed perineal wounds. In: Wexner SD, Vernava III Clinical Decision Making in Colorectal Surgery. New York, NY; Igaku-Shoin 1995: 217-223
    Google Scholar
  • 49 Argenta L C, Morykwas M J. Vacuum-assisted closure. A new method for wound control and treatment: clinical experiences.  Ann Plast Surg. 1997;  38 563-576
    PubMedGoogle Scholar
  • 50 Kirkegaard P, Madsen P V. Perineal sinus after removal of rectum: occlusion with fibrin adhesive.  Am J Surg. 1983;  145 791-794
    CrossrefPubMedGoogle Scholar
  • 51 Ambrose N S, Alexander-Williams J. Appraisal of tissue glue in the treatment of persistent perineal sinus.  Br J Surg. 1988;  75 484-485
    CrossrefPubMedGoogle Scholar
  • 52 Robles C R, Garcia A J, Parrila P P et al.. Management of the perineal wound following abdominoperineal resection: prosepctive study of three methods.  Br J Surg. 1992;  79 29-31
    PubMedGoogle Scholar
  • 53 McLeod R S, Palmer J A, Cohen Z. Management of chronic perineal sinuses by wide excision and split-thickness skin grafting.  Can J Surg. 1985;  28 315-318
    PubMedGoogle Scholar
  • 54 Seckel B R, Schoetz D J, Coller J A. Skin grafts for circumferential coverage of perianal wounds.  Surg Clin North Am. 1985;  65 365-371
    PubMedGoogle Scholar
  • 55 Anderson R. The dilemma of Crohn's disease:management of the posterior wound after coloproctectomy.  Dis Colon Rectum. 1977;  20 393-395
    CrossrefPubMedGoogle Scholar
  • 56 Anderson R, Turnbull Jr R B. Grafting the unhealed perineal wound after coloproctectomy for Crohn's disease.  Arch Surg. 1976;  111 335-338
    PubMedGoogle Scholar
  • 57 Branagan G, Thompson M R, Senapati A. Cleft closure for the treatment of unhealed perineal sinus.  Colorectal Dis. 2006;  8 314-317
    CrossrefPubMedGoogle Scholar
  • 58 Bascom T, Bascom J U. Persistent sinus after proctectomy for Crohn's disease; simplified repair using skin flap.  Am J Surg. 2002;  184 85
    PubMedGoogle Scholar
  • 59 Bascom J U. Repeat pilonidal operations.  Am J Surg. 1987;  154 118-122
    CrossrefPubMedGoogle Scholar
  • 60 Yamamoto T, Mylonakis E, Keighley M RB. Omentoplasty for persistent perineal sinus after proctectomy for Crohn's disease.  Am J Surg. 2001;  181 265-267
    CrossrefPubMedGoogle Scholar
  • 61 Collie M HS, Potter M A, Bartolo D CC. Myocutaneous flaps promote perineal healing in inflammatory bowel disease.  Br J Surg. 2005;  92 740-741
    CrossrefPubMedGoogle Scholar
  • 62 Bell S W, Dehni N, Chaouat M, Lifante J C, Parc R, Tiret E. Primary rectus abdominis myocutaneous flap for repair of perineal and vaginal defects after extended abdominoperineal resection.  Br J Surg. 2005;  92 482-486
    CrossrefPubMedGoogle Scholar
  • 63 Brough W A, Schofield P F. The value of the rectus abdominis myocutaneous flap in the treatment of complex perineal fistula.  Dis Colon Rectum. 1991;  34 148-150
    CrossrefPubMedGoogle Scholar
  • 64 Kroll S S, Pollock R, Jessup J M, Ota D. Transpelvic rectus abdominis flap reconstruction of defects following abdomino-perineal resection.  Am Surg. 1989;  55 632-637
    PubMedGoogle Scholar
  • 65 Shaw A, Futrell J W. Closure of the chronic perineal sinus with gluteus maximus flap.  Surg Gynecol Obstet. 1978;  147 417-420
    PubMedGoogle Scholar
  • 66 Ryan J A. Gracilis muscle flap for the persistent perineal sinus of inflammatory bowel disease.  Am J Surg. 1984;  148 64-70
    CrossrefPubMedGoogle Scholar
  • 67 Rius J, Nessim A, Nogueras J J, Wexner S D. Gracilis transposition in complicated perianal fistula and unhealed perineal wounds in Crohn's disease.  Eur J Surg. 2000;  166 218-222
    CrossrefPubMedGoogle Scholar
  • 68 Gorenstein L, Boyd J B, Ross T M. Gracilis muscle repair of rectovaginal fistula after restorative proctocolectomy.  Dis Colon Rectum. 1988;  31 730-734
    CrossrefPubMedGoogle Scholar
  • 69 Pezim M E, Wolff B G, Woods J E et al.. Closure of post-proctectomy perineal sinus with gracilis muscle flaps.  Can J Surg. 1987;  30 212-214
    PubMedGoogle Scholar
  • 70 Zmora O, Tulchinsky H, Gur E, Goldman G, Klausneer J M, Rabau M. Gracilis muscle transposition for fistulas between the rectum and urethra or vagina.  Dis Colon Rectum. 2006;  49 1316-1321
    CrossrefPubMedGoogle Scholar
  • 71 Vermaas M, Ferenschild F T, Hofer S O, Verhoef C, Eggermont A M, deWitt J H. Primary and secondary reconstruction after surgery of the irradiated pelvis using a gracilis muscle flap transposition.  Eur J Surg Oncol. 2005;  31 1000-1005
    CrossrefPubMedGoogle Scholar
  • 72 Church J M. What is the role of medical treatment in perianal sepsis and fistulas in Crohn's disease?. In: Boulos PB, Wexner SD Challenges in Colorectal Surgery. London, UK; WB Saunders 2000: 120-128
    Google Scholar
  • 73 Lavy A, Weisz G, Adir Y, Ramon Y, Melamed Y, Eidelman S. Hyperbaric oxygen for perianal Crohn's disease.  J Clin Gastroenterol. 1994;  19 202-205
    PubMedGoogle Scholar

Jill C GenuaM.D. 

Department of Colorectal Surgery, Cleveland Clinic Florida

2950 Cleveland Clinic Blvd., Weston, FL 33331

Email: genuaj@hotmail.com

      >