Surgery Today

, Volume 39, Issue 3, pp 189–193 | Cite as

Persistent perineal sinus: Incidence, pathogenesis, risk factors, and management

  • Varut Lohsiriwat
Review Article

Abstract

This review discusses the incidence, pathogenesis, risk factors, diagnosis, and therapeutic options for persistent perineal sinus (PPS), defined as a perineal wound that remains unhealed more than 6 months after surgery. The incidence of PPS after surgery for inflammatory bowel disease (IBD) ranges from 3% to 70% and after abdominoperineal resection (APR) for low rectal cancer, it can be up to 30%. These unhealed wounds are frequently related to perioperative pelvic or perineal sepsis. Crohn’s disease (CD) and neoadjuvant radiation therapy are also important risk factors. The management of PPS is based on an understanding of pathogenesis and clinical grounds. The advantages and disadvantages of the current therapeutic approaches, including the topical administration of various drugs, vacuum-assisted closure, and perineal reconstruction with a muscle flap or a myocutaneous flap are also discussed.

Key words

Pathogenesis Persistent perineal sinus Risk factors Treatment 

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References

  1. 1.
    Karoui M, Cohen R, Nicholls J. Results of surgical removal of the pouch after failed restorative proctocolectomy. Dis Colon Rectum 2004;47:869–875.PubMedCrossRefGoogle Scholar
  2. 2.
    Watts JM, de Dombal FT, Goligher JC. Long-term complications and prognosis following major surgery for ulcerative colitis. Br J Surg 1966;53:1014–1023.PubMedCrossRefGoogle Scholar
  3. 3.
    Kobayashi M, Mohri Y, Tonouchi H, Miki C, Nakai K, Kusunoki M. Randomized clinical trial comparing intravenous antimicrobial prophylaxis alone with oral and intravenous antimicrobial prophylaxis for the prevention of a surgical site infection in colorectal cancer surgery. Surg Today 2007;37:383–388.PubMedCrossRefGoogle Scholar
  4. 4.
    Miles WE. A method of performing abdominoperineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet 1908;2:1812–1813.Google Scholar
  5. 5.
    Keighley MR, Allan RN. Current status and influence of operation on perianal Crohn’s disease. Int J Colorectal Dis 1986;1:104–107.PubMedCrossRefGoogle Scholar
  6. 6.
    Mylonakis E, Allan RN, Keighley MR. How does pouch construction for a final diagnosis of Crohn’s disease compare with ileoproctostomy for established Crohn’s proctocolitis? Dis Colon Rectum 2001;44:1137–1142.PubMedCrossRefGoogle Scholar
  7. 7.
    Yamamoto T, Allan RN, Keighley MR. Audit of single-stage proctocolectomy for Crohn’s disease: postoperative complications and recurrence. Dis Colon Rectum 2000;43:249–256.PubMedCrossRefGoogle Scholar
  8. 8.
    Manjoney DL, Koplewitz MJ, Abrams JS. Factors influencing perineal wound healing after proctectomy. Am J Surg 1983;145:183–189.PubMedCrossRefGoogle Scholar
  9. 9.
    Williams JG, Hughes LE. Abdominoperineal resection for severe perianal Crohn’s disease. Dis Colon Rectum 1990;33:402–407.PubMedCrossRefGoogle Scholar
  10. 10.
    Bauer JJ, Gelernt IM, Salk BA, Kreel I. Proctectomy for inflammatory bowel disease. Am J Surg 1986;151:157–162.PubMedCrossRefGoogle Scholar
  11. 11.
    Corman ML, Veidenheimer MC, Coller JA, Ross VH. Perineal wound healing after proctectomy for inflammatory bowel disease. Dis Colon Rectum 1978;21:155–159.PubMedCrossRefGoogle Scholar
  12. 12.
    Chadwick MA, Vieten D, Pettitt E, Dixon AR, Roe AM. Short course preoperative radiotherapy is the single most important risk factor for perineal wound complications after abdominoperineal excision of the rectum. Colorectal Dis 2006;8:756–761.PubMedCrossRefGoogle Scholar
  13. 13.
    Fingerhut A, Hay JM, Delalande JP, Paquet JC. Passive vs. closed suction drainage after perineal wound closure following abdominoperineal rectal excision for carcinoma. A multicenter, controlled trial. The French Association for Surgical Research. Dis Colon Rectum 1995;38:926–932.PubMedCrossRefGoogle Scholar
  14. 14.
    Delalande JP, Hay JM, Fingerhut A, Kohlmann G, Paquet JC. Perineal wound management after abdominoperineal rectal excision for carcinoma with unsatisfactory hemostasis or gross septic contamination: primary closure vs. packing. A multicenter, controlled trial. French Association for Surgical Research. Dis Colon Rectum 1994;37:890–896.PubMedCrossRefGoogle Scholar
  15. 15.
    Tompkins RG, Warshaw AL. Improved management of the perineal wound after proctectomy. Ann Surg 1985;202:760–765.PubMedCrossRefGoogle Scholar
  16. 16.
    Ferrari BT, DenBesten L. The prevention and treatment of the persistent perineal sinus. World J Surg 1980;4:167–172.PubMedCrossRefGoogle Scholar
  17. 17.
    Silen W, Glotzer DJ. The prevention and treatment of the persistent perineal sinus. Surgery 1974;75:535–542.PubMedGoogle Scholar
  18. 18.
    Prudhomme M, Dehni N, Dozois RR, Tiret E, Parc R. Causes and outcomes of pouch excision after restorative proctocolectomy. Br J Surg 2006;93:82–86.PubMedCrossRefGoogle Scholar
  19. 19.
    Lohsiriwat V, Clark SK. Persistent perineal sinus after ileoanal pouch excision in inflammatory bowel diseases: incidence, risk factors, and clinical course. Dis Colon Rectum 2008;51(12):1795–1799.PubMedCrossRefGoogle Scholar
  20. 20.
    Sher ME, Bauer JJ, Gorphine S, Gelernt I. Low Hartmann’s procedure for severe anorectal Crohn’s disease. Dis Colon Rectum 1992;35:975–980.PubMedCrossRefGoogle Scholar
  21. 21.
    Bullard KM, Trudel JL, Baxter NN, Rothenberger DA. Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure. Dis Colon Rectum 2005;48:438–443.PubMedCrossRefGoogle Scholar
  22. 22.
    Winslow ER, Kodner IJ, Mutch MG, Birnbaum EB, Fleshman JW, Dietz DW. Outcome of salvage abdominoperineal resection after failed endocavitary radiation in patients with rectal cancer. Dis Colon Rectum 2004;47:2039–2046.PubMedCrossRefGoogle Scholar
  23. 23.
    Yamamoto T, Bain IM, Allan RN, Keighley MR. Persistent perineal sinus after proctocolectomy for Crohn’s disease. Dis Colon Rectum 1999;42:96–101.PubMedCrossRefGoogle Scholar
  24. 24.
    Christian CK, Kwaan MR, Betensky RA, Breen EM, Zinner MJ, Bleday R. Risk factors for perineal wound complications following abdominoperineal resection. Dis Colon Rectum 2005;48:43–48.PubMedCrossRefGoogle Scholar
  25. 25.
    Ehrlichman RJ, Seckel BR, Bryan DJ, Moschella CJ. Common complications of wound healing. Prevention and management. Surg Clin North Am 1991;71:1323–1351.PubMedGoogle Scholar
  26. 26.
    Lubbers EJ. Healing of the perineal wound after proctectomy for nonmalignant conditions. Dis Colon Rectum 1982;25:351–357.PubMedCrossRefGoogle Scholar
  27. 27.
    Zeitels JR, Fiddian-Green RG, Dent TL. Intersphincteric proctectomy. Surgery 1984;96:617–623.PubMedGoogle Scholar
  28. 28.
    Irvin TT, Goligher JC. A controlled clinical trial of three different methods of perineal wound management following excision of the rectum. Br J Surg 1975;62:287–291.PubMedCrossRefGoogle Scholar
  29. 29.
    Hurst RD, Gottlieb LJ, Crucitti P, Melis M, Rubin M, Michelassi F. Primary closure of complicated perineal wounds with myocutaneous and fasciocutaneous flaps after proctectomy for Crohn’s disease. Surgery 2001;130:767–772.PubMedCrossRefGoogle Scholar
  30. 30.
    Bell SW, Dehni N, Chaouat M, Lifante JC, Parc R, Tiret E. Primary rectus abdominis myocutaneous flap for repair of perineal and vaginal defects after extended abdominoperineal resection. Br J Surg 2005;92:482–486.PubMedCrossRefGoogle Scholar
  31. 31.
    Sarani B, Orkin BA. Squamous cell carcinoma arising in an unhealed wound in Crohn’s disease. South Med J 1997;90:940–942.PubMedGoogle Scholar
  32. 32.
    Lewis R, Whiting P, ter Riet G, O’Meara S, Glanville J. A rapid and systematic review of the clinical effectiveness and cost-effectiveness of debriding agents in treating surgical wounds healing by secondary intention. Health Technol Assess 2001;5:1–131.PubMedGoogle Scholar
  33. 33.
    Maeda Y, Lohsiriwat V, Clark SK. Effects of topical administration of 10% metronidazole ointment on longstanding persistent perineal sinus: a pilot study. Colorectal Dis 2007;9(suppl 3):55.Google Scholar
  34. 34.
    Hjortrup A, Moesgaard F, Kjaergard J. Fibrin adhesive in the treatment of perineal fistulas. Dis Colon Rectum 1991;34:752–754.PubMedCrossRefGoogle Scholar
  35. 35.
    Hollister C, Li VW. Using angiogenesis in chronic wound care with becaplermin and oxidized regenerated cellulose/collagen. Nurs Clin North Am 2007;42:457–465.PubMedCrossRefGoogle Scholar
  36. 36.
    Enoch S, Grey JE, Harding KG. Non-surgical and drug treatments. In: Grey JE, Harding KG, editors. ABC of wound healing. 1st ed. Oxford: Blackwell Publishing; 2006. p. 39–42.Google Scholar
  37. 37.
    Yousaf M, Witherow A, Gardiner KR, Gilliland R. Use of vacuum-assisted closure for healing of a persistent perineal sinus following panproctocolectomy: report of a case. Dis Colon Rectum 2004;47:1403–1407.PubMedCrossRefGoogle Scholar
  38. 38.
    Schaffzin DM, Douglas JM, Stahl TJ, Smith LE. Vacuum-assisted closure of complex perineal wounds. Dis Colon Rectum 2004;47:1745–1748.PubMedCrossRefGoogle Scholar
  39. 39.
    Branagan G, Thompson MR, Senapati A. Cleft closure for the treatment of unhealed perineal sinus. Colorectal Dis 2006;8:314–317.PubMedCrossRefGoogle Scholar
  40. 40.
    Anderson R, Turnbull RB, Jr. Grafting the unhealed perineal wound after coloproctectomy for Crohn disease. Arch Surg 1976;111:335–338.PubMedGoogle Scholar
  41. 41.
    McLeod RS, Palmer JA, Cohen Z. Management of chronic perineal sinuses by wide excision and split-thickness skin grafting. Can J Surg 1985;28:315–316.PubMedGoogle Scholar
  42. 42.
    Anthony JP, Mathes SJ. The recalcitrant perineal wound after rectal extirpation. Applications of muscle flap closure. Arch Surg 1990;125:1371–1376.PubMedGoogle Scholar
  43. 43.
    Brough WA, Schofield PF. The value of the rectus abdominis myocutaneous flap in the treatment of complex perineal fistula. Dis Colon Rectum 1991;34:148–150.PubMedCrossRefGoogle Scholar
  44. 44.
    Collie MH, Potter MA, Bartolo DC. Myocutaneous flaps promote perineal healing in inflammatory bowel disease. Br J Surg 2005;92:740–741.PubMedCrossRefGoogle Scholar
  45. 45.
    Menon A, Clark MA, Shatari T, Keh C, Keighley MR. Pedicled flaps in the treatment of nonhealing perineal wounds. Colorectal Dis 2005;7:441–444.PubMedCrossRefGoogle Scholar
  46. 46.
    Rius J, Nessim A, Nogueras JJ, Wexner SD. Gracilis transposition in complicated perianal fistula and unhealed perineal wounds in Crohn’s disease. Eur J Surg 2000;166:218–222.PubMedCrossRefGoogle Scholar
  47. 47.
    Yamamoto T, Mylonakis E, Keighley MR. Omentoplasty for persistent perineal sinus after proctectomy for Crohn’s disease. Am J Surg 2001;181:265–267.PubMedCrossRefGoogle Scholar
  48. 48.
    Regimbeau JM, Panis Y, Pocard M, Bouhnik Y, Lavergne-Slove A, Rufat P, et al. Long-term results of ileal pouch-anal anastomosis for colorectal Crohn’s disease. Dis Colon Rectum 2001;44:769–778.PubMedCrossRefGoogle Scholar

Copyright information

© Springer 2009

Authors and Affiliations

  • Varut Lohsiriwat
    • 1
  1. 1.Department of Surgery, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand

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