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P575 Efficacy of faecal diversion in managing refractory perianal or colonic Crohn’s disease

I. Parisi*1, R. Vega1, S. McCartney1, C. Hart2, S. Bloom1

1University College London Hospital, Department of Gastroenterology, London, United Kingdom, 2University College London Hospital, GI Surgery Department, London, United Kingdom

Background

Perianal Crohn’s disease (pCD) is frequently refractory to treatment and intriguing to management. Faecal diversion with a formation of stoma has been suggested as a way to induce clinical remission in refractory patients. Indeed clinical improvement post diversion has been described in majority of published studies. However, rates of restoration of intestinal continuity have been variable and relapse or need for reoperation is not uncommon. The aim of this study was to assess response and successful reversal in patients with refractory perianal and colonic CD that had a defunctioning stoma, as well as to identify factors associated with favourable outcomes.

Table 1 Recent studies on faecal diversion for pCD

AuthorMennigen et alGu et alSauk et alHong et alRehg et alRegimbeau et alYamamoto et alEdwards et al
JournalGastroenterol Res PractColorectal DisInflamm Bowel DisColorectal DisAm SurgColorectal DisWorld J SurgBr J Surg
Year20152015201420112009200120002000
DesignRetrospectiveRetrospectiveRetrospectiveRetrospectiveRetrospectiveRetrospectiveRetrospectiveRetrospective
N29138492113173173
Reversal, %7622311946651028
Relapse / New stoma, %7988875027
Proctectomy, %534552

Methods

Between January 2005 and February 2015, 93 patients with Crohn’s disease had a defunctioning stoma. Patients that had a temporary diversion post colectomy or because a surgical complication and those with predominantly small bowel disease were excluded from the study. In total, 37 patients were defunctioned for refractory pCD, and 8 for colonic disease. Clinical response, medical management, successful stoma reversal, and proctectomy rates, as well as clinical remission at last follow-up, were recorded. Potential risk factors for indefinite stoma, ie, rectal inflammation, anal stricture, presence of abscess, and seton in situ were also identified.

Results

In total, 8/37 (21%) pCD patients had their intestinal continuity restored, out of whom 4 relapsed and needed a new stoma. Only 2 of the patients that were reversed stayed in clinical remission at last follow-up. Cumulative stoma closure rates were not associated with use of biologics, presence of ongoing rectal inflammation or seton placement during a 5-year follow-up period. Multivariate analysis did not identify any predictive factors of successful stoma closure. Twelve (32%) pCD patients needed a proctectomy due to refractory symptoms. 19/45 (42%; 16 pCD, 3 colonic) patients were still symptomatic at last follow-up.

Table 2 Multivariate analysis (logistic regression) for predictive factors of stoma reversal

Factors associated with stoma reversalOR, 95% CI, p-value
Gender, M/FOR = 2.08, 95% CI 0.271–5.85; p = 0.48
Previous abscess, Y/NOR = 1.15, 95% CI 0.081–6; p = 0.91
Perianal vs colonic diseaseOR = 0.4, 95% CI 0.036–.3; p = 0.51
Age at faecal diversionOR = 0.99, 95% CI 0.921–.07; p = 0.89

Conclusion

Faecal diversion does not seem to be an effective therapeutic option for refractory perianal or colonic Crohn’s disease. Clinical improvement rates in our cohort were even poorer compared with previous studies. Rates of successful reversal or proctectomy are not differentiated in the biologics era.