title: Systematic review: the combined surgical and medical treatment of fistulising perianal Crohn's disease.
abstract: BACKGROUND
  The management of perianal Crohn's fistulas represents a significant challenge. A combination of medical and surgical therapy, guided by radiology, is often required.
  
  
  OBJECTIVE
  To 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).
  
  
  METHODS
  The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Two independent reviewers searched the literature.
  
  
  RESULTS
  Twenty-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.
  
  
  CONCLUSIONS
  Combined 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.
authors.affiliation: 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.
authors.forename: N A
authors.initials: NA
authors.lastname: Yassin
authors.forename: A
authors.initials: A
authors.lastname: Askari
authors.forename: J
authors.initials: J
authors.lastname: Warusavitarne
authors.forename: O D
authors.initials: OD
authors.lastname: Faiz
authors.forename: T
authors.initials: T
authors.lastname: Athanasiou
authors.forename: R K S
authors.initials: RK
authors.lastname: Phillips
authors.forename: A L
authors.initials: AL
authors.lastname: Hart
mesh_terms: D003131:Combined Modality Therapy; D003424:Crohn Disease / Q000188:drug therapy* / Q000601:surgery*; D006801:Humans; D007155:Immunologic Factors / Q000627:therapeutic use*; D012003:Rectal Fistula / Q000188:drug therapy* / Q000601:surgery*; D016896:Treatment Outcome; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors
chemical_list: D007155:Immunologic Factors; D014409:Tumor Necrosis Factor-alpha