Perianal Crohn’s disease is a challenging disease phenotype associated with abscess formation, fistulizing disease, pelvic sepsis, risk of progressive tissue destruction and impaired quality of life. Acute presentations require prompt recognition and coordinated medical and surgical management. This chapter reviews the evaluation, classification, and emergency management of perianal Crohn’s disease, with an emphasis on abscess drainage, seton placement, and the distinction between simple and complex fistulas. Adequate drainage under anesthesia remains the cornerstone of management for perianal abscesses, while seton placement may be used selectively to control sepsis and preserve future treatment options. The chapter also discusses the role and timing of biologic and immunosuppressive therapy, highlighting the importance of excluding uncontrolled pelvic sepsis before initiation or continuation of systemic treatment. Optimal care requires a multidisciplinary approach involving colorectal surgery, gastroenterology, radiology, and wound/ostomy specialists. Early intervention, accurate anatomic assessment, and staged treatment strategies are essential to reduce morbidity, preserve sphincter function, maintain quality of life and improve long-term outcomes.
Abstract Cryptoglandular anal fistulas arise from infection of the anal glands and can develop into a chronic, recurrent condition in which treatment must balance fistula healing with preservation of continence. Although relatively uncommon in the general population, they frequently affect adults in their working years, with persistent drainage, pain, and repeated interventions imposing a substantial burden on quality of life. Understanding this burden begins with the relationship between anorectal abscess and fistula formation, traditionally explained by glandular obstruction and infection that progresses through the intersphincteric plane. While this cryptoglandular model remains central to understanding disease development, emerging evidence suggests that inflammatory signaling, immune dysregulation, and tissue remodeling also contribute to persistence. These mechanisms distinguish cryptoglandular disease from other causes of anal fistula, particularly Crohn's disease, and provide context for understanding the anatomical patterns that guide classification and treatment. As knowledge of these patterns has advanced, classification systems have evolved from clinical observations, such as Goodsall's rule, to the anatomical framework established by Parks and subsequent approaches incorporating imaging and functional risk. Within this evolution, magnetic resonance imaging has improved recognition of secondary tracts, associated abscesses, and extensions that may otherwise remain undetected, informing both the St. James's University Hospital classification and contemporary multidimensional systems such as the Garg classification. By combining these anatomical findings with sphincter involvement, baseline continence, and prior treatment, clinicians can better assess fistula complexity and select an appropriate operative approach. This chapter reviews these developments alongside the epidemiology and pathogenesis of cryptoglandular anal fistulas, emphasizing how an integrated understanding of disease biology and classification supports surgical planning, patient counseling, and the pursuit of durable healing while preserving function.
Abstract Achieving an ileal pouch-anal anastomosis (IPAA) without tension can be difficult in cases where the mesentery doesn't easily reach the pelvis. Risk factors for inadequate reach are discussed. Maneuvers to gain additional length for the ileal pouch to reach are reviewed, including how to measure for adequate reach, release of small bowel mesentery from the retroperitoneum, duodenal mobilization, mesenteric relaxing incisions, selective ligation or skeletonization of the mesenteric arcade, vascular ligation, intentionally long rectal cuff, shorter efferent limb length, J pouch orientation, and creating an S pouch. When the ileal pouch still won't reach despite exhaustion of appropriate lengthening maneuvers, “parking” the pouch, conversion to a Kock pouch, and permanent end ileostomy are discussed. Complications related to difficult ileal pouch reach include ischemia and tension on the IPAA.
Abstract Anastomotic leak (AL) remains a major source of morbidity in colorectal surgery, with leak rates showing little change despite advances in technique and perioperative care. This persistent risk has prompted the development of novel technologies and strategies targeting different aspects of anastomotic construction and healing. This article summarizes current evidence on emerging approaches, including compression and magnetic compression anastomosis (MCA), intraoperative fluorescence angiography (FA), robotic-assisted techniques, and modulation of the intestinal microbiome. These innovations vary substantially in maturity and clinical impact. Among device-based approaches, the nickel–titanium compression anastomosis ring is the most established compression device, with outcomes comparable to conventional stapling. In contrast, MCA remains limited in colorectal practice to a salvage role for recanalization of strictures and atresia rather than an alternative for primary anastomosis. FA has been evaluated extensively, with meta-analyses suggesting a potential reduction in AL rates, particularly for left-sided and low rectal anastomoses, although variability in its interpretation persists. Robotic platforms have facilitated intracorporeal anastomosis and expanded technical capabilities, while the intestinal microbiome has emerged as a modifiable factor influencing anastomotic healing; notably, combined mechanical and oral antibiotic bowel preparation remains the only intervention with consistent clinical evidence of leak reduction. Together, these advances address complementary components of anastomotic success—construction, perfusion, access, and healing—yet none independently eliminates risk. Current evidence supports selective integration into practice while highlighting important gaps, including the need for standardized protocols and high-quality prospective trials to define their role in improving outcomes.
Abstract The NICE (Natural orifice IntraCorporeal anastomosis with transrectal Extraction) procedure represents an evolution in minimally invasive colorectal surgery, combining robotic precision with natural orifice specimen extraction to minimize abdominal wall trauma. The technique involves mesenteric-sparing resection of the diseased segment, transrectal natural orifice specimen extraction, and creation of an end-to-end intracorporeal anastomosis, thereby eliminating the need for an abdominal extraction-site incision and avoiding the intersecting staple lines inherent to a conventional double-stapling technique. Multiple publications have demonstrated the feasibility, reproducibility, and favorable outcomes of this approach, with 100% success rates for intracorporeal anastomosis and 95 to 100% success rates for transrectal extraction in large consecutive series. The NICE procedure has become the standard of care at our institution and has been increasingly adopted by other centers. This article outlines the history, indications, and key technical steps necessary for safe and successful performance of the NICE procedure, presented in a standardized, stepwise manner to provide surgeons with a reproducible and practical framework for adopting the technique in the management of diverticular disease. Foundational principles include mesenteric-sparing resection with division above the superior rectal artery, systematic mobilization of the pararectal and anterior rectal reflections to straighten and elongate the rectum, and protection of the rectal cuff during extraction using an Alexis wound retractor (Applied Medical, Rancho Santa Margarita, CA). An end-to-end anastomosis is preferred to avoid intersecting staple lines and is achieved through purse-string suture placement on the proximal colon and secure closure of the rectal cuff. In select cases involving thickened mesentery from chronic diverticular disease, a mesenteric-shaving technique may be used to permit safe extraction of a bulky specimen. Compared with conventional minimally invasive approaches that require a mini-laparotomy extraction site, the NICE procedure is associated with an earlier return of bowel function, a shorter length of stay, reduced postoperative pain and opioid consumption, and fewer wound-related complications, without an increase in operative time or overall complication rates.
