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P147 Systematic review: diverting loop ileostomy as treatment option in severe inflammatory bowel disease

M. STEENHUIS, K. van Son

Leiden University Medical Centre, Gastroenterology, Leiden, The Netherlands

Background

Severe colitis in the setting of inflammatory bowel disease (IBD), refractory to medical treatment, has traditionally been treated with an emergent colectomy, typically consisting of a two-step approach with a loop diversion in a setting of acute colitis, followed by a colectomy when inflammation has decreased as to minimise the risk of post-operative complications. More recently, several studies have questioned the need for secondary colectomy or have considered stoma reversal a viable option after diversion. We conducted a literature search primarily looking at the incidence of successful reversal or acute colectomy during follow-up. Secondary outcomes were post-surgical complications and clinical improvement after diversion.

Methods

We identified articles using a literature search using six medical databases. Articles were selected on the following criteria; severe colitis (either Crohn’s disease (CD) or ulcerative colitis (UC)), refractory to medical treatment, treated using a temporary loop ileostoma instead of an acute setting colectomy and scoring of clinical improvement parameters, such as decreased medication use and improvement of nutritional state.

Results

Seven studies, of which one was an extension and one was paediatric, were included. All were small studies with 13 to 33 participants, resulting in a total of 145 patients. A range of 16–60% underwent stoma reversal of the diversion based on mucosa and clinical remission with a follow-up rate varying from 4 to 33 months. In six studies, 15–29% of patients undergoing stoma reversal were symptom free during follow-up. Two studies showed partial remission in 55.2% and 69% of participants. Total colectomy in the diverted group, described in 5 studies, was seen in 9–53%. Complication rates ranged from 12–29%. Overall clinical improvement was seen in >80% % of diverted patients. Only 2 studies made subgroup analyses of CD and UC, which showed a better result in CD patients regarding clinical improvement (>90% improvement vs. >80% improvement in UC patients) and rates of successful diversion, which was seen in 3/14 (21%) CD patients and 3/19 (16%) UC patients.

Conclusion

Diverting loop ileostomy in severe IBD is an effective treatment to avoid acute setting colectomy, with improvement in clinical status in >80% of patients and a chance of 15–29% of successful stoma reversal without symptoms of IBD.