Figure 2.

A proposed algorithm to manage patients presenting with perianal Crohn's disease. In patient needing immediate drainage of abscess, emergency treatment is performed, aimed at controlling sepsis (1). Should associated fistulous tracks be identified, it is prudent to place loose-seton(s) as bridge-to-definitive treatments, aiming to maintain the drainage, avoiding abscess formation. Patients with very active disease may require temporary faecal diversion (2). Once sepsis is controlled and the patient is in good general health status, definitive treatment can be attempted, consisting of either tissue separating techniques (fistulotomy, fistulectomy) or more conservative and combined approach (3). An interval of 2-3 months seems acceptable. In patients with failure, procedures can be repeated, favoring approaches which do not increase significantly the risk of incontinence. Stoma or proctectomy may be required in refractory, frail patients. LIFT: ligation of the intersphincteric fistula track, VAAFT: video-assisted anal fistula treatment.