Many patients with anorectal Crohn's disease present other intestinal locations of the disease, requiring an evaluation of the colon and small bowel. The presence of proximal disease poses a therapeutic dilemma: early reports suggest that perianal conditions persist in the presence of proximal disease and improve only if proximal disease is resected [10,11]; however, other reports refute these findings and show no improvement in perianal disease after treatment of proximal disease .
Thus, the proximal intestinal tract should be evaluated but does not necessarily require surgery before treatment of perianal manifestations unless they are symptomatic. Surgical management of the perianal area is a challenge. Historically, surgeons were reluctant to perform surgery because of delayed wound healing and the risk of compromising sphincter competence. Alexander-Williams expressed a prevailing sentiment in 1974: "Faecal incontinence is the result of aggressive surgeons and not progressive disease." Advocates of this non-invasive approach, which included medicinal and hygienic management, considered that aggressive surgical procedures only created more complex problems [13,14].
In the late eighties, investigators found that a more aggressive but still limited surgical approach to perianal disease was possible [15, 16]. Two resolutions were adopted:
1. the management of a septic focus is an indication for surgery.
2. The sphincter should be preserved if a patient is continent .
One multicentre study reviewing treatment of patients with perianal Crohn's disease shows medical treatment to be curative in only a few patients, whereas surgical procedures were curative in more than half of the patients . A role for both approaches exists and success is attributed to careful patient selection, limited surgical intervention, and improved perioperative medical management [18,19].
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