Review article: medical, surgical and radiological management of perianal Crohn’s fistulas

Aliment Pharmacol Ther 2011; 33: 5–22 Summary 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. Aim 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.