PERIANAL CROHNS-DISEASE

Perianal disease in Crohn's disease is a difficult matter to deal with . The indication for therapy is not always clear in this disease with a relatively mild natural course. More confusion is caused by the fact that not all disease in the perianal region in a patient with Crohn's has to be Crohn-related. The usual ailments such as haemorrhoids may occur in a patient with Crohn's disease. The treatment has to be as fo r every patient. Primary mucosal and submucosal Crohn's disease in the anal canal has to be treated like uncomplicated Crohn's disease in th e rest of the gastrointestinal tract with appropriate medication. The option for therapy in complicated abdominal Crohn's disease, most ofte n resection, is not available in perianal disease without giving up fa ecal continence. One has to make a compromise, wishing to treat the di sease as radically as possible, while preserving faecal continence as much as possible. The basis for treatment for complicated Crohn's dise ase is medical treatment for the primary disease. The choice in surgic al options depends on the type of complication. A different strategy i s needed for each type of complication. The therapy is different for p erianal abscesses, rectovaginal fistulas, stenosis, high perianal fist ulas and low perianal fistulas. It is proposed to treat abscesses by e arly incision and drainage, rectovaginal fistulas by a mucosal advance ment anoplasty, high perianal fistulas by a seton procedure, low peria nal fistulas by fistulotomy, and stenosis by mild dilatation. Rectal e xcision is reserved for perianal disease combined with colorectal invo lvement refractory to therapy. The high incidence of poor healing foll owing radical proctectomy led to a staged procedure in which the rectu m is resected to the pelvic floor, followed, if necessary, at a later stage by perineal resection of the retained anal canal.