Systematic Review of Surgical Interventions for Crohn's Anal Fistula

Overview

Journal BJS Open

Publisher Oxford University Press

Specialty General Surgery

Date 2018 Jun 29

PMID 29951607

Citations 13

Authors

M J Lee

N Heywood

S Adegbola

P Tozer

K Sahnan

N S Fearnhead

S R Brown

Affiliations

Soon will be listed here.

Abstract

Background: Anal fistula occurs in approximately one in three patients with Crohn's disease and is typically managed through a multimodal approach. The optimal surgical therapy is not yet clear. The aim of this systematic review was to identify and assess the literature on surgical treatments of Crohn's anal fistula.

Methods: A systematic review was conducted that analysed studies relating to surgical treatment of Crohn's anal fistula published on MEDLINE, Embase and Cochrane databases between January 1995 and March 2016. Studies reporting specific outcomes of patients treated for Crohn's anal fistula were included. The primary outcome was fistula healing rate. Bias was assessed using the Cochrane ROBINS-I and ROB tool as appropriate.

Results: A total of 1628 citations were reviewed. Sixty-three studies comprising 1584 patients were ultimately selected in the analyses. There was extensive reporting on the use of setons, advancement flaps and fistula plugs. Randomized trials were available only for stem cells and fistula plugs. There was inconsistency in outcome measures across studies, and a high degree of bias was noted.

Conclusion: Data describing surgical intervention for Crohn's anal fistula are heterogeneous with a high degree of bias. There is a clear need for standardization of outcomes and description of study cohorts for better understanding of treatment options.

Citing Articles

Surgical Management of Perianal Crohn's Disease: Current Evidence and Future Directions.

Busbait S Acta Inform Med. 2025; 32(3-4):215-220.

PMID: 40061009 PMC: 11889424. DOI: 10.5455/aim.2024.32.215-220.

Perianal Fistulizing Crohn's Disease: Outcomes of Surgical Repairs and Current State of Stem Cell-Based Therapies.

Dawes A, Lightner A Clin Colon Rectal Surg. 2025; 38(2):126-140.

PMID: 39944301 PMC: 11813615. DOI: 10.1055/s-0044-1786543.

Efficacy and safety of stem cell therapy for fistula management: an overview of existing systematic reviews.

Tripathi T, Mohan S, Alfaifi H, Alfaifi H, Farasani A, R R Int J Surg. 2024; 110(12):7573-7584.

PMID: 39468970 PMC: 11634089. DOI: 10.1097/JS9.0000000000002125.

Extracellular Vesicles Delivered by a Nanofiber-Hydrogel Composite Enhance Healing In Vivo in a Model of Crohn's Disease Perianal Fistula.

Li L, Yao Z, Salimian K, Kong J, Zaheer A, Parian A Adv Healthc Mater. 2024; :e2402292.

PMID: 39240055 PMC: 11882933. DOI: 10.1002/adhm.202402292.

Perianal Fistula; from Etiology to Treatment - A Review.

Sohrabi M, Bahrami S, Mosalli M, Khaleghian M, Obaidinia M Middle East J Dig Dis. 2024; 16(2):76-85.

PMID: 39131109 PMC: 11316198. DOI: 10.34172/mejdd.2024.373.

References

Tanaka S, Matsuo K, Sasaki T, Nakano M, Sakai K, Beppu R . Clinical advantages of combined seton placement and infliximab maintenance therapy for perianal fistulizing Crohn's disease: when and how were the seton drains removed?. Hepatogastroenterology. 2010; 57(97):3-7. View

Gingold D, Murrell Z, Fleshner P . A prospective evaluation of the ligation of the intersphincteric tract procedure for complex anal fistula in patients with Crohn's disease. Ann Surg. 2013; 260(6):1057-61. DOI: 10.1097/SLA.0000000000000479. View

Parks A, Gordon P, Hardcastle J . A classification of fistula-in-ano. Br J Surg. 1976; 63(1):1-12. DOI: 10.1002/bjs.1800630102. View

Cintron J, Abcarian H, Chaudhry V, Singer M, Hunt S, Birnbaum E . Treatment of fistula-in-ano using a porcine small intestinal submucosa anal fistula plug. Tech Coloproctol. 2012; 17(2):187-91. DOI: 10.1007/s10151-012-0897-3. View

Sterne J, Hernan M, Reeves B, Savovic J, Berkman N, Viswanathan M . ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016; 355:i4919. PMC: 5062054. DOI: 10.1136/bmj.i4919. View

Owen G, Keshava A, Stewart P, Patterson J, Chapuis P, Bokey E . Plugs unplugged. Anal fistula plug: the Concord experience. ANZ J Surg. 2010; 80(5):341-3. DOI: 10.1111/j.1445-2197.2010.05278.x. View

Dursun A, Hodin R, Bordeianou L . Impact of perineal Crohn's disease on utilization of care in the absence of modifiable predictors of treatment failure. Int J Colorectal Dis. 2014; 29(12):1535-9. DOI: 10.1007/s00384-014-2013-9. View

Nelson R, CINTRON J, Abcarian H . Dermal island-flap anoplasty for transsphincteric fistula-in-ano: assessment of treatment failures. Dis Colon Rectum. 2000; 43(5):681-4. DOI: 10.1007/BF02235588. View

Gottgens K, Smeets R, Stassen L, Beets G, Pierik M, Breukink S . Treatment of Crohn's disease-related high perianal fistulas combining the mucosa advancement flap with platelet-rich plasma: a pilot study. Tech Coloproctol. 2015; 19(8):455-9. PMC: 4513214. DOI: 10.1007/s10151-015-1311-8. View

10.

Scott H, Northover J . Evaluation of surgery for perianal Crohn's fistulas. Dis Colon Rectum. 1996; 39(9):1039-43. DOI: 10.1007/BF02054696. View

11.

Halme L, Sainio A . Factors related to frequency, type, and outcome of anal fistulas in Crohn's disease. Dis Colon Rectum. 1995; 38(1):55-9. DOI: 10.1007/BF02053858. View

12.

Ciccocioppo R, Bernardo M, Sgarella A, Maccario R, Avanzini M, Ubezio C . Autologous bone marrow-derived mesenchymal stromal cells in the treatment of fistulising Crohn's disease. Gut. 2011; 60(6):788-98. DOI: 10.1136/gut.2010.214841. View

13.

de la Portilla F, Alba F, Garcia-Olmo D, Herrerias J, Gonzalez F, Galindo A . Expanded allogeneic adipose-derived stem cells (eASCs) for the treatment of complex perianal fistula in Crohn's disease: results from a multicenter phase I/IIa clinical trial. Int J Colorectal Dis. 2012; 28(3):313-23. DOI: 10.1007/s00384-012-1581-9. View

14.

Lee M, Heywood N, Sagar P, Brown S, Fearnhead N . Surgical management of fistulating perianal Crohn's disease: a UK survey. Colorectal Dis. 2016; 19(3):266-273. DOI: 10.1111/codi.13462. View

15.

Cho Y, Lee W, Park K, Kim M, Yoo H, Yu C . Autologous adipose tissue-derived stem cells for the treatment of Crohn's fistula: a phase I clinical study. Cell Transplant. 2012; 22(2):279-85. DOI: 10.3727/096368912X656045. View

16.

Mennigen R, Laukotter M, Senninger N, Rijcken E . The OTSC(®) proctology clip system for the closure of refractory anal fistulas. Tech Coloproctol. 2015; 19(4):241-6. DOI: 10.1007/s10151-015-1284-7. View

17.

Schwandner O . Video-assisted anal fistula treatment (VAAFT) combined with advancement flap repair in Crohn's disease. Tech Coloproctol. 2012; 17(2):221-5. DOI: 10.1007/s10151-012-0921-7. View

18.

Ozuner G, Hull T, Cartmill J, Fazio V . Long-term analysis of the use of transanal rectal advancement flaps for complicated anorectal/vaginal fistulas. Dis Colon Rectum. 1996; 39(1):10-4. DOI: 10.1007/BF02048261. View

19.

Kotze P, de Albuquerque I, da Luz Moreira A, Tonini W, Olandoski M, Coy C . Perianal complete remission with combined therapy (seton placement and anti-TNF agents) in Crohn's disease: a Brazilian multicenter observational study. Arq Gastroenterol. 2015; 51(4):284-9. DOI: 10.1590/S0004-28032014000400004. View

20.

Colombel J, Sandborn W, Rutgeerts P, Enns R, Hanauer S, Panaccione R . Adalimumab for maintenance of clinical response and remission in patients with Crohn's disease: the CHARM trial. Gastroenterology. 2007; 132(1):52-65. DOI: 10.1053/j.gastro.2006.11.041. View