• N A Yassin, A Askari, J Warusavitarne, O D Faiz, T Athanasiou, R K S Phillips, and A L Hart.
• Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, London, UK; IBD unit, St Mark's Hospital and Academic Institute, London, UK; Department of Cardiovascular Medicine, St Mary's Hospital, London, UK.
• Aliment. Pharmacol. Ther. 2014 Oct 1; 40 (7): 741-9.

BackgroundThe management of perianal Crohn's fistulas represents a significant challenge. A combination of medical and surgical therapy, guided by radiology, is often required.AimTo review systematically the literature to assess fistula healing rates with medical treatment (anti-TNF-α therapies ± immunomodulators) or surgical treatment alone, compared with combined medical and surgical treatment in fistulising perianal Crohn's disease (CD).MethodsThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Two independent reviewers searched the literature.ResultsTwenty-four articles were included. The total population was 1139 patients; 460 (40%) received single treatment with either medical or surgical therapy, and 679 (60%) received combined medical and surgical therapy. Eight studies compared single and combination therapy, with a total population of 797 patients (single therapy: n = 448, combination therapy: n = 349). In the single therapy group, 191/448 were in complete remission (43%). This was lower than the healing rate of the combination therapy group 180/349 (52%). No response to therapy was noted in 34% (153/448) of the single therapy group compared with 23% (80/349) of the combination group.ConclusionsCombined surgical and medical (anti-TNF-α ± immunomodulators) therapy may have additional beneficial effects on perianal fistula healing in patients with Crohn's disease, compared with surgery or medical therapy alone. A well-designed Crohn's perianal fistula clinical trial is required in a multidisciplinary medical and surgical setting, with clearly defined end points of clinical (and likely patient reported outcomes) and radiological healing.© 2014 John Wiley & Sons Ltd.

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