title: Review article: medical, surgical and radiological management of perianal Crohn's fistulas.
abstract: BACKGROUND
  Crohn's anal fistulas are common and cause considerable morbidity. Their management is often difficult; medical and surgical treatments rarely lead to true healing with frequent recurrence and complications.
  
  
  OBJECTIVE
  To examine medical treatments previously and currently used, surgical techniques and the important role of optimal imaging.
  
  
  METHODS
  We conducted a literature search in the Pub Med database using Crohn's, Anal Fistula, Surgery, Imaging and Medical Treatment as search terms.
  
  
  RESULTS
  Antibiotics and immunosuppressants have a role, but slow initial response, side effects and relatively low remission rates of up to around a third with frequent recurrence limit their value. Long-term infliximab produces clinical remission in 36-58% of patients with combined medical and surgical management achieving optimal outcomes. Traditional and newer surgical procedures often have a high rate of recurrence with a significant risk of temporary or, in up to 10% of cases, permanent stomas, incontinence and unhealed or slowly healing wounds in 30%.
  
  
  CONCLUSIONS
  Management of Crohn's anal fistulas remains challenging. Established principles are to drain infection, use setons as required, aggressively manage active proctitis, give antibiotics, immunosuppressants and employ anti-TNFα therapy, and they demand significant co-operation between gastroenterologists and surgeons.
authors.affiliation: St Mark's Hospital, Imperial College London, UK.
authors.forename: P J
authors.initials: PJ
authors.lastname: Tozer
authors.forename: D
authors.initials: D
authors.lastname: Burling
authors.forename: A
authors.initials: A
authors.lastname: Gupta
authors.forename: R K S
authors.initials: RK
authors.lastname: Phillips
authors.forename: A L
authors.initials: AL
authors.lastname: Hart
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D000911:Antibodies, Monoclonal / Q000627:therapeutic use*; D003131:Combined Modality Therapy; D003424:Crohn Disease / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy / Q000601:surgery; D005765:Gastrointestinal Agents / Q000627:therapeutic use*; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D000069285:Infliximab; D008279:Magnetic Resonance Imaging / Q000379:methods; D012003:Rectal Fistula / Q000209:etiology / Q000601:surgery; D012008:Recurrence; D012307:Risk Factors; D016896:Treatment Outcome; D014945:Wound Healing
chemical_list: D000900:Anti-Bacterial Agents; D000911:Antibodies, Monoclonal; D005765:Gastrointestinal Agents; D007166:Immunosuppressive Agents; D000069285:Infliximab