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P497. Has the role of a defunctioning stoma for large bowel Crohn's disease changed in the biological era?

M. Marti-Gallostra1, P. Myrelid2, R. Lovegrove3, S. Travis4, B. George3, 1Hospital Vall d'Hebron, Colorrectal Surgery, Barcelona, Spain, 2Linköping University Hospital, Colorectal Surgery, Lipköping, Sweden, 3John radcliffe Hospital, Colorectal Surgery, Oxford, United Kingdom, 4John radcliffe Hospital, Gastroenterology, Oxford, United Kingdom

Background

The importance of anti-TNF therapy (biological) in the management of perianal Crohn's disease (PACD) and Crohn's colitis (CC) is well established. This study aimed to assess the role of a defunctioning stoma in the management of PACD and CC since the widespread introduction of biological therapy. The secondary end point was to identify factors which may help the long-term outcome after a defunctioning stoma.

Methods

All patients who underwent a defunctioning stoma for PACD or CC between 2004–2011 were identified from a prospective database. Indication for surgery, pre-operative medical therapy, response to defunction (defined as reduction/cessation of gastrointestinal symptoms, reduction in inflammatory markers and improvement in general well being) and long-term clinical outcome were recorded.

Results

75 patients underwent a defunctioning stoma of whom 57 were receiving biological therapy. Of those receiving biologicals, 34 underwent surgery for PACD and 23 for CC. Clinical response was 13/34 with PACD and 11/23 with CC (overall response 43%). At long-term follow-up (median 50m), 5/34 patients with PACD and 6/23 with CC have achieved restoration of gastrointestinal continuity and satisfactory function. We found that 50% of those patients classified at MRI as simple fistulas in PCD have achived bowel restoration copared with a 7.4% of thouse classified as a complex fistulas, with statistical significance, and 44% of patients with inflamation reduction at endoscopy and histology in CC have achieved restoration bowel continuity compared with 8.3% of those without inflammation reduction at endoscopy and histology.

Conclusion

The clinical response to defunctioning stoma formation in patients receiving anti-TNF is significantly lower than in the pre-biological era (86% in our previously reported cohort). The long-term outcome remains similar with low rates of restoration of gastrointestinal continuity (19%). We found that simple fistulas at predefunction MRI in perineal Crohn's disease and reduction of inflammation (endoscopy and histology) in Crohn's Colitis are both predictors of restoration of bowel continuity.