What is the optimal surgical strategy for complex perianal fistulous disease in pediatric Crohn's disease? A systematic review

Purpose Perianal fistulous disease is present in 10-15% of children with Crohn's disease (CD) and is frequently complex and refractory to treatment, with one-third of patients having recurrent lesions. We conducted a systematic review of the literature to examine the best surgical strategy or strategies for pediatric complex perianal fistulous disease (CPFD) in CD. Methods We searched CENTRAL, MEDLINE, EMBASE, and CINAHL for studies discussing at least one surgical strategy for the treatment of pediatric CPFD in CD. Reference lists of included studies were hand-searched. Two researchers screened all studies for inclusion, quality assessed each relevant study, and extracted data. Resutls One non-randomized prospective and two retrospective studies met our inclusion criteria. Combined use of setons and infliximab therapy shows promise as a first-line treatment. A specific form of fistulectomy, cone-like resection, also shows promise when combined with biologics. Endoscopic ultrasound to guide medical and surgical management is feasible in the pediatric population, though it is unclear if it improves outcomes. Conclusions There is a paucity of evidence regarding the treatment of CPFD in the pediatric population, and further research is required before recommendations can be made as to what, if any, surgical management is optimal.