Perineal wound morbidity following proctectomy for inflammatory bowel disease (IBD)

Delayed perineal wound healing following 'conventional' excision of the rectum for IBD is common-up to 58% in patients with ulcerative colitis (UC) and 72% in those with Crohn's disease (CD) 6 months following proctectomy. The risk of perineal wound morbidity is increased if anorectal sepsis is present at the time of proctectomy. The aim of this study was to establish the incidence of perineal wound sepsis in a consecutive series of patients treated by close rectal and intersphincteric anal canal dissection to preserve the pelvic floor and suction drainage to minimize the residual pelvic dead space.

Anorectal sepsis if present was drained preoperatively. Omental transposition was used selectively to occlude residual cavities after fistula tracks had been laid open. Between 1989 and 1996, 46 patients (median age 56 years) underwent rectal excision, 27 for UC and 19 for CD. In seven patients the faecal stream was diverted at least 2 months prior to proctectomy. In all but five patients primary closure of the perineum was carried out (89.1%).

Uncomplicated wound healing occurred in 37/46 (80.4%) patients. All patients in whom the perineum was left open healed within 6 months without subsequent chronic sinus formation. At a median follow up of 3.4 years (2.1-7.4 years), no patient with UC had further perineal wound problems and only 2/19 (10.5%) of CD patients had a persistent chronic perineal sinus. Preoperative faecal diversion had no influence on the incidence of subsequent perineal wound morbidity.

Uncomplicated perineal wound healing after rectal excision for IBD appears more likely to occur after preoperative control of anorectal sepsis, minimizing dead space in the pelvis by perimuscular rectal excision, use of suction drainage, intersphincteric dissection of the anal canal and selective use of omental transposition.