ABSTRACT Background and Aims Perianal fistulising Crohn's disease (pfCD) is a heterogeneous phenotype of Crohn's disease with marked variability in anatomical complexity, symptomatology, and disease trajectory. This often creates uncertainty in the optimal approach to management, particularly the surgical aspects of when to perform examination under anaesthesia (EUA) and when to insert or remove setons. Methods We conducted a systematic review following PRISMA guidelines. Multiple databases were searched from inception through December 2025. Eligible publications included clinical guidelines on pfCD and/or rectovaginal fistulas that reported indications for EUA, seton insertion, and/or seton removal. We stratified recommendations by fistula complexity, the presence of abscesses, and clinical symptoms. Risk of bias was assessed using the AGREE II Instrument. Results Twenty‐four guidelines met inclusion criteria. EUA (and often seton placement) was universally recommended for perianal abscesses and frequently for symptomatic complex pfCD. For asymptomatic complex or symptomatic simple fistulas, recommendations were variable and often conditional on the presence of proctitis or plans for biologic therapy. In contrast, EUA and setons were not broadly endorsed for asymptomatic simple fistulas. Recommendations for seton removal varied widely, ranging from predefined intervals after anti‐TNF therapy initiation to individualised criteria based on clinical or radiologic response. Most guidelines did not consider symptom type/severity, prior surgery, suitability for surgical closure, and asymptomatic abscesses detected by imaging. Conclusion Substantial heterogeneity and limitations exist across guidelines on the surgical management of pfCD. This underscores the need for international consensus informed by multidisciplinary expertise to standardise care in this complex population.
Medawar et al. (Mon,) studied this question.