When nothing else matters: proctectomy for complex perianal Crohn’s disease—indications, timing, techniques, and outcomes

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.