Systematic review: The management of unhealed wounds and persistent perineal sinuses following proctectomy in inflammatory bowel disease

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INTRODUCTION: Unhealed wounds and persistent perineal sinuses (PPS) may occur in as many as one third of patients after proctectomy for Crohn's disease. The management of these conditions remains a significant challenge, particularly in the context of inflammatory bowel disease (IBD), with existing therapies plagued by high failure rates. This systematic review of the literature assessed the efficacy of medical and surgical therapy for PPS closure in IBD. Secondary aims included review of classification systems used for PPS. METHODS: A literature search was conducted using Medline, Embase and Cochrane databases on 17 December 2024. The review was registered on PROSPERO (CRD42024622582). Inclusion criteria were adult patients with IBD and PPS or unhealed wounds following proctectomy. We excluded abstract-only publications, case reports, cancer and paediatric cohorts. Two reviewers independently screened abstracts and full texts and extracted data. The primary outcome was clinical healing rate. Secondary outcomes included classification systems used to describe PPS. Risk of bias was assessed. RESULTS: Of 496 records identified, following removal of duplicates, 489 abstracts were screened, and 60 full text articles assessed for eligibility. Of 25 articles included in the final analysis, 23 were case series or retrospective cohort studies, and all were at high risk of bias. No randomised controlled trials were identified. Five articles (including two of the case series) described classification systems for PPS. Interventions included hyperbaric oxygen therapy, Karydakis flap, cleft closure, omentoplasty, skin grafting, gracilis and rectus abdominis flap, platelet-derived growth factor, curettage, lay open and excision of sinuses. Reported healing rates ranged from 30% to 100%. Heterogeneity in the reporting of outcomes, as well as the interventions performed precluded meta-analysis. CONCLUSION: The published evidence for treatment of PPS in IBD consists of low-quality evidence case series with high risk of bias. There is a need for standardised outcome reporting and high-quality, prospective studies to establish effective treatment algorithms.

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