Complex perianal fistulizing Crohn's disease may progress to a functionally end-stage anorectum characterized by refractory proctitis, fixed anorectal stenosis/stricture, cavitating or recurrent pelvic sepsis, and complex branching fistulas, where repeated local salvage offers diminishing returns. This narrative review synthesizes predominantly observational evidence and consensus guidance on indications, timing, operative strategy, and outcomes of definitive proctectomy/abdominoperineal resection (APR). Decision-making should be structured and time-bound: Define anatomy and occult sepsis with pelvic magnetic resonance imaging (MRI) and examination under anesthesia (EUA), and perform EUA-guided biopsy when malignancy is suspected or surveillance is impractical. When reversibility is uncertain, planned temporary diversion can be used as a 3-6-month trial with explicit targets and stop rules; failure to meet milestones should prompt timely discussion of definitive resection. Operative choice (proctectomy/APR versus proctocolectomy) and dissection plane (close intersphincteric versus wider excision beyond the sphincter complex) should prioritize complete excision of chronically infected tissue and oncologic safety. Because perineal wound morbidity and persistent perineal sinus are common, outcomes depend on preoperative optimization, explicit dead-space/closure planning (primary closure, delayed management, omentoplasty, or flap reconstruction), and a postoperative pathway for early imaging and stepwise salvage. Appropriately timed surgery can provide durable control of sepsis and pain and reduce recurrent urgent interventions.

Background: Crohn's disease-associated intestinal strictures represent a major source of morbidity and frequently require endoscopic or surgical intervention. However, patients with stricturing Crohn's disease demonstrate substantial clinical heterogeneity regarding disease localization, penetrating complications, systemic manifestations, metabolic alterations, and treatment exposure. This study aimed to explore phenotypic heterogeneity within patients with Crohn's disease-associated intestinal strictures. Methods: In this retrospective exploratory cohort study, 96 patients with Crohn's disease-associated intestinal strictures treated at a tertiary referral center between 2014 and 2024 were included. Clinical, structural, metabolic, and treatment-related variables were analyzed. Univariate analyses were performed using chi-square, Fisher's exact test, Student's t-test, or Mann-Whitney U test as appropriate. Exploratory multivariable logistic regression models were constructed to explore relationships between different clinical phenotypes and disease-related characteristics, including extraintestinal manifestations (EIMs), smoking status, penetrating disease manifestations, hepatic steatosis, stenosis localization, and abscess formation. Given the limited sample size and event numbers in several subgroup analyses, all multivariable analyses were considered exploratory and hypothesis-generating. Results: The cohort demonstrated a heterogeneous clinical presentation with a high prevalence of perianal disease, penetrating complications, prior intestinal surgery, and biologic therapy exposure. Female sex (OR 4.63, p = 0.044), autoimmune disease (OR 23.5, p = 0.049), rectal stenosis (inverse association; OR 0.08, p = 0.041), and exposure to multiple biologic therapies (OR 20.11, p = 0.036) remained associated with EIMs after multivariable adjustment. Smoking status was associated with anastomotic stenosis (OR 3.16, p = 0.023) and inversely associated with female sex (OR 0.35, p = 0.036). Phenotype-oriented analyses further suggested clustering of penetrating disease manifestations, including associations between intestinal fistulas, perianal fistulas, and abscess formation. Hepatic steatosis demonstrated exploratory associations with intestinal fistulas, intestinal resection, and appendectomy. Several analyses demonstrated wide confidence intervals and should therefore be interpreted cautiously. Conclusions: This exploratory retrospective cohort study highlights the substantial clinical heterogeneity observed among patients with Crohn's disease-associated intestinal strictures. Different structural, systemic, penetrating, behavioral, and metabolic disease manifestations may indicate potentially overlapping phenotypic patterns within stricturing Crohn's disease. Given the retrospective design, limited sample size, and exploratory statistical approach, these findings should be interpreted cautiously and require validation in larger prospective studies.

Acute anorectal and perineal emergencies encompass a wide spectrum of infectious, inflammatory, traumatic, iatrogenic, and neoplastic conditions that often present with nonspecific symptoms but may rapidly progress to significant morbidity if unrecognized. Imaging plays a central role in diagnosis, assessment of disease extent, detection of complications, and treatment planning because clinical examination frequently underestimates involvement of the complex anorectal and perineal spaces. Computed tomography (CT) is the primary imaging modality in the emergency setting owing to its rapid acquisition and ability to detect abscesses, perforation, hemorrhage, extraluminal gas, and deep pelvic extension, whereas magnetic resonance imaging (MRI) provides superior soft-tissue characterization for evaluation of fistulas, sphincteric involvement, and complex inflammatory disease. This review provides an overview of the pertinent anorectal and perineal anatomy, imaging evaluation strategies, and characteristic multimodality imaging features of common anorectal and perineal emergencies. Particular emphasis is placed on key imaging findings, including rim-enhancing abscesses and fistulous tracts, soft-tissue gas with fascial extension in necrotizing infections, bowel wall thickening and perirectal inflammatory changes in proctocolitis, and the presence of extraluminal air or fluid collections associated with rectal perforation and retained foreign bodies. The review also highlights the value of a compartment-based approach in accurately delineating disease extent and guiding clinical management.

The presence of a complex fistula is associated with a high recurrence rate. Lay-open technique with fistulotomy is imperatively contraindicated in cases of complex fistulas due to the 40% risk of early or delayed onset of anal incontinence. Combining different sphincter-preserving approaches aims to significantly reduce the chance of recurrence and preserve the quality of life. We present a case of a 34-year-old woman with a complex perianal fistula. We applied a combination of sphincter-sparing approaches by FiLAC, LIFT and TAFR. The follow-up period is 11 months without incontinence and recurrence. Despite the conflicting data published in the literature the combination of minimally invasive approaches for the treatment of secondary branches, interruption of the fistula tract, and thorough eradication of the internal opening of a highly complex fistula provides the greatest opportunity for achieving maximum success, i.e. minimizing the risk of recurrence while maintaining sphincter continence.

Patients with deep perianal abscess (DPA) and transsphincteric fistula typically require incision and drainage as emergency treatment. However, recurrent abscesses and fistulas are common. This study aimed to evaluate the impact of simultaneous ligation of the intersphincteric fistula tract (LIFT) on abscess recurrence, incontinence, and fistula healing. This study is a retrospective analysis of an institutional protocol and includes 111 patients divided into two groups: Group I (incision and drainage alone, n = 57) and Group II (incision and drainage combined with the LIFT procedure, n = 54). The primary endpoint was persistent fistula at 6 months, confirmed by clinical examination and magnetic resonance imaging (MRI). Secondary endpoints included abscess recurrence, Wexner incontinence score changes, and complications. Firth's penalized logistic regression, inverse probability of treatment weighting (IPTW), and log-rank analyses were performed to assess outcomes. At the 3rd month, the number of patients with persistent fistula was 16 (28.1%) in Group I, while it was 3 patients (5.6%) in Group II (P = 0.002). At the 6th month, persistent fistula was observed in 21 of 55 patients (38.2%) in Group I and 3 of 53 patients (5.7%) in Group II (P < 0.001). Firth's penalized logistic regression showed that the LIFT procedure was significantly associated with reduced fistula persistence (OR = 0.079, 95% CI 0.019-0.327, P < 0.001). A sensitivity analysis restricted to patients with MRI-confirmed transsphincteric fistula (Group I: n = 34; Group II: n = 54) confirmed these findings (59.4% vs. 5.7%, P < 0.001). IPTW-adjusted analysis yielded consistent results (weighted OR = 0.063). This study demonstrates that the LIFT procedure, when applied together with drainage, reduces the incidence of persistent fistula and shows a non-significant reduction in abscess recurrence in patients with DPA and complex anal fistula. These findings should be interpreted with caution due to the non-randomized design and require confirmation through prospective randomized controlled trials.

We report a 48-year-old man with poorly controlled ulcerative colitis (UC) who presented with severe rectal pain, hematochezia, and a chronically draining lesion on the left buttock. Initial cross-sectional imaging revealed active colitis, and targeted ultrasound of the left buttock suggested a benign epidermal inclusion cyst. Colonoscopy demonstrated continuous Mayo 3 proctosigmoiditis with a normal proximal colon and terminal ileum. While he clinically improved with intravenous corticosteroids, the gluteal lesion persisted. Before discharge, pelvic magnetic resonance imaging unexpectedly revealed a rectocutaneous fistula extending from the distal rectum into the left gluteal soft tissues. This case illustrates that, although rare, rectocutaneous fistulas can complicate UC. Clinicians should include fistulizing disease in the differential diagnosis of any chronically draining perianal or gluteal lesion in UC, and consider early pelvic magnetic resonance imaging when symptoms are discordant with endoscopic findings or fail to resolve with standard therapy.