Despite a combination of medical and surgical treatments, many patients with perianal Crohn's disease (CD) continue to experience refractory disease, requiring proctectomy or proctocolectomy, with the creation of a permanent stoma. Although proctectomy is seen as an ultimate treatment aimed at effectively relieving debilitating symptoms and enhancing quality of life, many patients may still face long-term and chronic complications. This narrative review aims to provide an overview of the main complications that patients undergoing proctectomy for CD may experience throughout their lives. Relevant publications addressing complications of proctectomy for refractory perianal CD were searched in the Medline/PubMed, Embase, Cochrane, and LILACS databases. The main long-term complications that patients encounter are related to impaired perineal wound healing, stoma-related issues, sexual and urinary dysfunction, small bowel obstructions, and CD recurrence. These complications negatively affect the quality of life and frequently necessitate further treatment. Patients should receive preoperative counselling regarding the implications of these particular issues, and regular follow-up must be guaranteed to identify any problems early, allowing for prompt treatment.

Nonhealing perineal wounds have been reported to be common after proctectomy for Crohn's disease (CD). We performed a systematic review and meta-analysis of perineal wound healing after proctectomy for CD and assessed the risk factors for nonhealing.

A comprehensive literature search was conducted in PubMed, Embase, and Scopus databases from 2010 to 2023, and articles reporting perineal wound healing rates after proctectomy for CD were included. Data on study characteristics and proportion of healed wounds, and risk factors, were extracted. Random-effects meta-analysis was performed to estimate the pooled proportion and 95% CIs using the "meta" package in R. Heterogeneity was assessed using the I2 statistic.

We identified 501 articles, of which 252 remained after de-duplication. After screening, 4 retrospective cohort studies involving 333 patients were included. Across the 4 studies, the pooled proportion of completely healed perineal wounds at 6 months was 65% (95% CI 52%-80%), and 70% (95% CI 60%-83%) at 12 months. Significant heterogeneity was found between studies (I2 = 86% at 6 months). Three studies examined risk factors for impaired healing after proctectomy. One study identified preoperative perineal sepsis as the only independent factor associated with impaired healing (P = .001) on multivariable analysis. In 1 study, male sex, shorter time from diversion to proctectomy, and higher preoperative C-reactive protein levels were all associated with delayed healing in univariate analysis. Another study found that close rectal dissection was associated with significantly lower healing rates than total mesorectal excision (P = .01). Prior use of tumor necrosis factor inhibitors was not associated with wound healing outcomes.

This meta-analysis revealed complete perineal healing in only 70% of patients 12 months after proctectomy for CD. This highlights knowledge gaps, including the identification of modifiable risk factors and methods for preventing or as rescue therapy, such as vacuum-assisted closure and flap reconstruction, for nonhealing perineal wounds after proctectomy for CD. Poor perineal wound healing outcomes are likely related to imperfectly understood underlying inflammatory dysregulation and systemically impaired wound healing in patients with CD.

The role of omental pedicle flaps (OPFs) in reducing the risk of perineal wound complications and postoperative pelvic abscesses in patients with Crohn's disease remains unclear. This study aimed to determine whether OPFs had any effect on the incidence of perineal wound complications requiring a return to the operating room (OR) or the requirement for radiologic-guided drainage of pelvic abscesses in patients with Crohn's disease who underwent proctectomy.

This was a retrospective, single-center study. The study included patients who underwent proctectomy for Crohn's disease with primary perineal closure, with or without an OPF. The primary outcome measures were return to the OR for perineal wound complications or the requirement for radiologically guided drainage of pelvic abscesses.

A total of 219 patients (71 with flap and 148 without flap) underwent proctectomy during the study period. No differences were observed in the rate of unplanned return to the OR (11.27% in the OPF group vs 9.46% in the non-OPF group; P =.81) or the number of patients requiring radiologically guided drainage of pelvic abscesses (11.27% in the OPF group vs 6.76% in the non-OPF group, respectively; P =.30) between the cohorts. Patients in the flap cohort were more likely to have a history of tobacco use (P =.02), fistulizing perianal disease (P =.01), undergo extrasphincteric dissection (P =.03), and use incisional wound vacuum assisted closure (VAC) at the time of surgery (P =.02).

Careful patient selection for the OPF might play a role in reducing wound complications to a level similar to that observed in patients with lower-risk perineal wounds.

Perianal fistulizing Crohn's disease (PFCD) is a challenging and debilitating phenotype of Crohn's disease that can negatively affect quality of life. Studies have begun to uncover the physiologic mechanisms involved in wound repair as it relates to PFCD and how aberrations in these mechanisms may contribute to fistula persistence.

To review the physiologic and pathophysiologic mechanisms of wound repair in PFCD and how specific therapeutic strategies may impact their outcomes.

We reviewed the latest published literature on wound repair as it relates to PFCD.

Wound repair can be categorised into three overlapping biological phases: localised inflammation, cell recruitment/proliferation and tissue remodelling. Each is tightly regulated since insufficient or excessive activation can result in, respectively, chronic wounds and fibrotic tissue, both of which can impair organ function. In PFCD, the outcomes of wound repair include restitution (complete healing), epithelialisation and chronic wounds. Treatment of PFCD should take into consideration the distinct phases of wound repair. Therefore, the ability to differentiate between each phase of wound repair and their outcomes may help physicians deliver the most effective treatment strategy at the most appropriate time.

This review provides a comprehensive overview of the phases of wound repair and specific treatment strategies for each to provide clinicians with a rational framework for managing PFCD.