A 19-year-old woman diagnosed with severe Crohn’s proctosigmoiditis 18 months ago suffers from debilitating perianal pain, swelling, discharge, and incontinence. She has undergone numerous anorectal operations including several incision and drainage procedures and seton placements for three separate fistulas, including one with a supralevator extension. She currently has three setons and a mushroom catheter in place with significant ulceration in the anal canal. In addition to prolonged courses of antibiotics, she had been on infliximab for 12 months prior to being on ustekinumab for the past 6 months without improvement. What is the best next course of action?
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