Management of nonhealing perineal wounds.

The manifestations of perianal Crohn's disease vary from primary lesions such as skin tags and fissures, to diffuse septic destruction of tissue and sphincter muscle. These manifestations are often persistent and refractory to surgical treatment; however, a more disappointing scenario is when the treatment itself results in a chronic wound. The ideal approach for management involves basic surgical principles, careful patient selection, and realistic expectations. Choice of appropriate procedure, effective elimination of sepsis, thorough evaluation to rule out concomitant systemic disease, and appropriate use of fecal diversion are each an important principle. If proctectomy is necessary, several strategies such as intersphincteric dissection, avoidance of fecal contamination, and appropriate wound closure, are effective in diminishing the postoperative morbidity of an unhealed perineal wound. When an unhealed perineal wound develops in a patient with Crohn's disease, the initial management is conservative. When surgical treatment is necessary, success depends on careful patient selection, optimizing the patient's condition, elimination of sepsis, and choice of an effective technique for healing.