Systematic review with meta‐analysis: faecal diversion for management of perianal Crohn's disease

Abstract

Summary Background Temporary faecal diversion is sometimes used for management of refractory perianal Crohn's disease (CD) with variable success. Aims To perform a systematic review with meta‐analysis to evaluate the effectiveness, long‐term outcomes and factors associated with success of temporary faecal diversion for perianal CD. Methods Through a systematic literature review through 15 July 2015, we identified 16 cohort studies (556 patients) reporting outcomes after temporary faecal diversion. We estimated pooled rates [with 95% confidence interval (CI)] of early clinical response, attempted and successful restoration of bowel continuity after temporary faecal diversion (without symptomatic relapse), and rates of re‐diversion (in patients with attempted restoration) and proctectomy (with or without colectomy and end‐ileostomy). We identified factors associated with successful restoration of bowel continuity. Results On meta‐analysis, 63.8% (95% CI: 54.1–72.5) of patients had early clinical response after faecal diversion for refractory perianal CD. Restoration of bowel continuity was attempted in 34.5% (95% CI: 27.0–42.8) of patients, and was successful in only 16.6% (95% CI: 11.8–22.9). Of those in whom restoration was attempted, 26.5% (95% CI: 14.1–44.2) required re‐diversion because of severe relapse. Overall, 41.6% (95% CI: 32.6–51.2) of patients required proctectomy after failure of temporary faecal diversion. There was no difference in the successful restoration of bowel continuity after temporary faecal diversion in the pre‐biological or biological era (13.7% vs. 17.6%, P = 0.60), in part due to selection bias. Absence of rectal involvement was the most consistent factor associated with restoration of bowel continuity. Conclusions Temporary faecal diversion may improve symptoms in approximately two‐thirds of patients with refractory perianal Crohn's disease, but bowel restoration is successful in only 17% of patients.

Predicting Outcomes to Optimize Disease Management in Inflammatory Bowel Diseases

“…57,60 Additionally, patients undergoing rectal resection or temporary faecal diversion for perianal disease control have a higher rate of permanent faecal diversion. 55,61 Patients with permanent stoma have typically experienced a greater number of previous abdominal surgeries than those without a permanent stoma. 55,59 It is important to acknowledge that the likelihood of successful stoma reversal after temporary diversion for control of perianal sepsis or disease is low.…”

The role of multimodal treatment in Crohn′s disease patients with perianal fistula: a multicentre retrospective cohort study

“…Perianal CD is an extremely disabling condition that can impact on the physical, psychosocial, and sexual life of patients . CD‐pAF patients may require multiple surgeries with associated morbidity and work impairment, which can lead to permanent disability due to radical surgery, such as proctectomy and permanent stoma . Perianal disease is also a risk factor for more disabling course of the disease on the long term …”

“…The need for repeat surgical interventions may indicate uncontrolled or poorly controlled state in CD‐pAF status and can be a measure for evaluating success of initial multimodality approach. Furthermore, CD‐pAF is associated with a high risk of radical surgery (such as defunctioning ± proctectomy which often leads to a definitive stoma) and, consequently, with a permanent disability for the patients …”

Molecular classification of Crohn's disease reveals two clinically relevant subtypes

“…Although the adult patient sample size was limited, in only the colon-like CD subclass were there patients with rectal disease, or that required a colectomy. Rectal CD is particularly difficult to manage, and though it may represent a unique CD phenotype, its underlying molecular mechanisms are unknown[22, 23, 24]. Pediatric patients with colon-like disease were more likely to have macroscopic inflammation, deep ulcers, and involvement of both the ileum and colon.…”