title: The anal fistula plug in Crohn's disease patients with fistula-in-ano: a systematic review.
abstract: OBJECTIVE
  This study aimed to review, consolidate and analyse the findings of studies investigating the efficacy of anal fistula plugs (AFPs) in treating fistula-in-ano in patients with Crohn's disease.
  
  
  METHODS
  A literature review was conducted via Pubmed, Embase, Medline, Scopus and the Cochrane Library for the period 1995-2015. Articles were selected and reviewed based on specific inclusion and exclusion criteria.
  
  
  RESULTS
  A total of 16 studies were extracted, of which 12 were included in the systematic review. In total, 84 patients (n = 1-20 per study) with a median age of 45 (18-72) years and a median follow-up time of 9 (3-24) months were analysed. The total success rate, defined as closure of the fistula tract, was 49/84 (58.3%, 95% CI 47-69). Success in patients with recurrent anal fistulae was 2/5 (40%, 95% CI 5-85). Overall, the success rates of Surgisis and GORE BIO-A brand plugs were 48/80 (60%, 95% CI 48-71) and 1/4 (25%, 95% CI 1-81). The recurrence rate of fistula-in-ano in the five studies that reported recurrence was 3/22 (13.6%). In two comparative studies, inferior overall success rates were found in patients who received preoperative immunomodulators vs. those who did not [3/11 (27.3%) vs. 17/23 (73.9%)].
  
  
  CONCLUSIONS
  The studies suggest that the use of an AFP in patients with Crohn's disease is a safe procedure with reasonable success, little morbidity and a low risk of incontinence. The current literature is limited by a number of factors, including small study cohorts, grouping of fistulae in Crohn's disease with other types of anal fistula, short and highly variable follow-up times and multiple confounding factors such as number of fistula tracts, use of preoperative steroids or immunosuppressants, previous use of setons and variation in surgical technique.
authors.affiliation: The Surgery Group of Los Angeles, Los Angeles, California, USA.
authors.forename: Y
authors.initials: Y
authors.lastname: Nasseri
authors.affiliation: The Surgery Group of Los Angeles, Los Angeles, California, USA.
authors.forename: L
authors.initials: L
authors.lastname: Cassella
authors.affiliation: The Surgery Group of Los Angeles, Los Angeles, California, USA.
authors.forename: M
authors.initials: M
authors.lastname: Berns
authors.affiliation: Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA.
authors.forename: K
authors.initials: K
authors.lastname: Zaghiyan
authors.affiliation: The Surgery Group of Los Angeles, Los Angeles, California, USA.
authors.forename: J
authors.initials: J
authors.lastname: Cohen
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003424:Crohn Disease / Q000150:complications*; D013505:Digestive System Surgical Procedures / Q000295:instrumentation* / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012003:Rectal Fistula / Q000209:etiology / Q000601:surgery*; D013525:Surgical Instruments; D016896:Treatment Outcome; D055815:Young Adult
keywords: Anal fistula plug; Crohn's disease; fistula-in-ano; systematic review