In patients with CD and an active high trans‑sphincteric perianal fistula who have failed initial seton drainage, is diverting ileostomy before definitive fistulotomy or proceeding directly to fistulotomy preferred

What is known

- Fistulotomy should be avoided in fistulas with significant sphincter involvement to avoid fecal incontinence; high/complex tracts are managed with sphincter-preserving repair. ^1,2 - Temporary diverting ileostomy/colostomy for perianal crohn's is now rarely primary therapy because such patients almost never have continuity restored. ³ - Perianal disease invariably recurs when continuity is restored; one series reported 100% fistula recurrence after diverting colostomy closure. ^1,4 - A diverting stoma is used selectively for recurrent multiple abscesses/refractory sepsis to allow subsequent advancement-flap repair, not as routine pre-fistulotomy step. ^5,6

What is unknown / caveats

- One series reports diversion improves active perianal disease; others show near-universal failure to restore continuity and 100% recurrence after stoma closure - No retrieved study directly compares upfront diversion vs direct fistulotomy for this scenario - Evidence is heterogeneous, largely observational/narrative, and predates or under-represents current biologic-era practice - No head-to-head data on diversion-then-fistulotomy versus direct fistulotomy for high trans-sphincteric crohn's fistula was retrieved.

## References

1. Cima RR, Pemberton JH. Surgical Management of Inflammatory Bowel Disease. Curr Treat Options Gastroenterol. 2001;4(3):215-225. PMID: 11469979.

2. Burri E, Vavricka SR. [Perianal Crohn's disease]. Ther Umsch. 2013;70(7):417-28. PMID: 23798025.

3. Sandborn WJ, Fazio VW, Feagan BG, Hanauer SB, American Gastroenterological Association Clinical Practice C. AGA technical review on perianal Crohn's disease. Gastroenterology. 2003;125(5):1508-30. PMID: 14598268.

4. Danelli P, Bartolucci C, Sampietro GM, Panizzo V, Sartani A, Maconi G, Parente E, Taschieri AM. [Surgical options in the treatment of perianal Crohn's disease]. Ann Ital Chir. 2003;74(6):635-40. PMID: 15206804.

5. PMID: 16108891. (metadata not in corpus)

6. Sordo-Mejia R, Gaertner WB. Multidisciplinary and evidence-based management of fistulizing perianal Crohn's disease. World J Gastrointest Pathophysiol. 2014;5(3):239-51. PMID: 25133026.

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_Draft — generated by the IBDology RAG and not yet clinician-reviewed. Answers are grounded in the retrieved literature listed above; a high faithfulness score means the answer matches its sources, not that the sources are correct._