Long-Term Outcome of Total Colectomy and Ileostomy for Crohn Disease

Abstract

Total colectomy and end ileostomy is a safe and effective procedure. However, a few patients underwent ileorectal anastomosis, and half of the patients required proctectomy. The small-bowel recurrence rate is low. Regular surveillance of the retained rectum is advised because of a small cancer risk.

Natural History of Crohnʼs Disease Following Total Colectomy and End Ileostomy

“…Data informing natural history of recurrent disease is primarily from patients undergoing curative ileocecal resection with ileocolonic anastomosis 6-8 . Much less is known about the recurrence of disease in the terminal ileum following total colectomy with endileostomy in patients with medically refractory disease 14-18 . In the largest series examining this question to date in the anti-TNF era, we report that nearly a quarter of patients developed recurrent disease or required re-initiation of therapy by 2 years though half the patients were able to remain disease-free 5 years after the definitive surgery.…”

“…However, for a subgroup of patients with refractory CD with more extensive colonic or perianal involvement, limited ileocecal resection is not a therapeutic option and such patients often require total colectomy with an end-ileostomy. There is limited data to help understand the natural history of ileal recurrence in such patients 14-18 . Yet such information will help inform key decisions including whether there is the need for prophylactic medical therapy post-operatively or if there is need for endoscopic surveillance in a high-risk subset.…”

Low Incidence of Dysplasia and Colorectal Cancer Observed among Inflammatory Bowel Disease Patients with Prolonged Colonic Diversion

“…Von Roon et al 26 in a meta-analysis of all CD patients including those not diverted reported a rectal cancer rate of 0.169 per 1000 patient years of disease. In a study similar to ours, Yamamoto et al 4 reviewed the long-term outcome of 69 CD patients who had undergone ileostomy with rectal stump formation between 1962 and 1997, the majority of whom had rectal or perianal involvement. One case of rectal cancer was reported, occurring in a rectovaginal fistula, though neither pyd nor dpy were reported.…”

“…CD patients operated on for refractory disease or severe perianal disease frequently undergo a staged approach with a diverting ostomy. 4 Re-anastomosis may be delayed, sometimes indefinitely, on account of refractory disease, concern for poor wound healing, lack of clinical follow-up, or patient preference. 5…”

“…Case reports of cancer in diverted large bowel and rectal stumps have been published. 4, 9–17 The current risk remains unclear, particularly in light of recent evidence suggesting a decreasing risk of CRC amongst IBD populations over time, 8, 17 a trend that has been attributed to better pharmacological control of inflammation, improved colonoscopic surveillance, increased implementation of colectomy, and an effect of aging IBD cohorts, with sick patients previously censored. 8, 18 Currently, there are no consensus guidelines to inform surveillance endoscopy for diverted segments.…”