The role of multimodal treatment in Crohn′s disease patients with perianal fistula: a multicentre retrospective cohort study Shaji Sebastian 1 | Christopher Black 1 | Daniela Pugliese 2 | Alessandro Armuzzi 2 | Kapil Sahnan 3 | Soad M. Elkady 4 | Kostas H. Katsanos 5 | Demitrios K. Christodoulou 5 | Christian Selinger 6 | Giovanni Maconi 7 | Nicola S. Fearnhead 8 | Uri Kopylov 9 | Yana Davidov 9 | Marta M. Bosca-Watts 10 | Pierre Ellul 11 | Martina Muscat 11 | Konstantinos Karmiris 12 | Ailsa L. Hart 3 | Silvio Danese 7 | Shomron Ben-Horin 7 | Gionata Fiorino 7 1 Hull, UK 2 Rome, Italy 3 London, UK 4 Alexandria, Egypt 5 Ioannina, Greece 6 Leeds, UK 7 Milan, Italy 8 Cambridge, UK 9 Tel-Aviv, Israel 10 Valencia, Spain 11 Msida, Malta 12 Crete, Greece Correspondence Prof. S Sebastian, IBD Unit, Hull & East Yorkshire Hospitals NHS Trust, Hull & York Medical School, Hull HU3 2JZ, UK. Email: shaji.sebastian@hey.nhs.uk Summary Background: Treatment paradigms for Crohn′s disease with perianal fistulae (CD‐ pAF) are evolving. Aims: To study the impact of multimodality treatment in CD‐pAF on recurrence rates and the need for re‐interventions and to identify predictive factors for these outcomes. Methods: This was a multinational multicentre retrospective cohort study. Multimodal- ity approach was defined as using a combination of medical treatments (anti‐TNFs ± immunomodulators ± antibiotics) along with surgical approach (examination under anaesthesia (EUA) ± seton drainage) at diagnosis of CD‐pAF. Univariable and multivari- able analyses were performed for variables indicative of the need for reintervention. Results: A total of 253 patients were included. 65% of patients received multi- modality approach. Multimodality treatment resulted in complete fistula healing in 52% of patients. Re‐intervention was needed in 27% of patients with simple and in 40.3% of those with complex fistula. On multivariable analysis multimodality treat- ment (OR: 0.35, 95% CI: 0.17‐0.57, P = 0.001), seton removal (OR: 0.090, 95% CI: 0.027‐0.30, P = 0.0001, therapy with infliximab (OR: 0.19, 95% CI: 0.06‐0.64, P = 0.007), and therapy with adalimumab (OR: 0.12, "95% CI: 0.026‐0.56, P = 0.007) were predictive of avoiding repeat surgery. Proctitis (OR: 3.76, 95% CI: 1.09‐12.96, P = 0.03) was predictive of the need for radical surgery (proctectomy, diverting stoma) while multimodality treatment reduced the need for radical surgery (OR: 0.21, 95% CI: 0.05‐0.81, P = 0.02). Conclusions: Multimodality treatment, anti‐TNFs use, and removal of setons after multimodality treatment can result in improved outcomes in CD patients with peri- anal fistulae and reduce the need for repeat surgery and radical surgery. Authors complete affiliations are listed in Appendix section. The Handling Editor for this article was Dr Nicholas Kennedy, and it was accepted for publication after full peer-review. Received: 12 May 2018 | First decision: 18 June 2018 | Accepted: 8 August 2018 DOI: 10.1111/apt.14969 Aliment Pharmacol Ther. 2018;1–10. wileyonlinelibrary.com/journal/apt © 2018 John Wiley & Sons Ltd | 1