Clinical and surgical factors for successful stoma reversal in patients with Crohn's disease-results of a retrospective cohort study

Temporary Faecal Diversion for Refractory Perianal and/or Distal Colonic Crohn's Disease in the Biologic Era: An Updated Systematic Review with Meta-analysis

BACKGROUND AND AIMS

We evaluated short- and long-term outcomes of temporary faecal diversion [FD] for management of refractory Crohn's disease [CD], focusing on outcomes in the biologic era.

METHODS

Through a systematic literature review until March 15, 2023, we identified 33 studies [19 conducted in the biologic era] that evaluated 1578 patients with perianal and/or distal colonic CD who underwent temporary FD [with intent of restoring bowel continuity] and reported long-term outcomes [primary outcome: successful restoration of bowel continuity, defined as remaining ostomy-free after reconnection at a minimum of 6 months after diversion or at the end of follow-up]. We calculated pooled rates (with 95% confidence interval [CI]) using random effects meta-analysis, and examined factors associated with successful restoration of bowel continuity.

RESULTS

Overall, 61% patients [95% CI, 52-68%; 50% in biologic era] experienced clinical improvement after FD. Stoma takedown was attempted in 34% patients [28-41%; 37% in biologic era], 6-18 months after diversion. Among patients where bowel restoration was attempted, 63% patients [54-71%] had successful restoration of bowel continuity, and 26% [20-34%] required re-diversion. Overall, 21% patients [17-27%; 24% in biologic era] who underwent FD were successfully restored; 34% patients [30-39%; 31% in biologic era] required proctectomy with permanent ostomy. On meta-regression, post-diversion biologic use and absence of proctitis was associated with successful bowel restoration after temporary FD in contemporary studies.

CONCLUSION

In the biologic era, temporary FD for refractory perianal and/or distal colonic CD improves symptoms in half the patients, and bowel continuity can be successfully restored in a quarter of patients.

Biologic use is not associated with postoperative complications in patients with Crohn's disease undergoing stoma reversion

PURPOSE

Stoma creation is a common procedure in patients with Crohn's disease (CD), and early prophylaxis with biologics is recommended for high-risk patients. However, the effect of biologic exposure on morbidity after stoma closure remains unknown. Therefore, this study aimed to investigate the impact of biologic use on the occurrence of complications in CD patients following stoma closure.

METHODS

Consecutive patients diagnosed with CD who underwent ileostomy reversal at a tertiary care centre between 1 January 2013 and 1 December 2021, were included in the study. The primary outcome was the occurrence of 90-day postoperative complications.

RESULTS

The study included 347 eligible patients who underwent ileostomy reversal. There was no significant difference in terms of infectious complications, overall complications or length of postoperative stay between the biologic and non-biologic groups. Multivariate logistic regression analysis identified several predictors of postoperative morbidity, including preoperative haemoglobin levels below 100 g/L, CRP levels above 10 mg/L, anastomotic site, ileostomy-related infectious complications and albumin levels below 35 g/L.

CONCLUSIONS

This study demonstrated that the use of biologics is not associated with adverse outcomes. However, such as high CRP levels, ileostomy-related infectious complications, hypoproteinemia, and hemoglobinemia, should be optimized prior to surgery to reduce postoperative morbidities.

Long-term outcomes after enterostomy for very early-onset inflammatory bowel disease with interleukin-10 signaling deficiency

BACKGROUND

Very early-onset inflammatory bowel disease (VEOIBD) with interleukin-10 (IL10R) signaling deficiency usually requires enterostomy in patients who are refractory to traditional treatment. This study aimed to evaluate long-term outcomes after enterostomy for VEOIBD patients with IL10R signaling deficiency.

METHODS

The medical records of all patients undergoing enterostomy for signaling deficiency were retrospectively assessed during 2012.1-2022.7 in a tertiary teaching hospital, Children's Hospital of Fudan University, Shanghai, China. Data on disease history, diagnosis and details of enterostomy and stoma closure and follow-up were collected. Univariate and multivariate logistic regression analyses were used to evaluate the risk factors associated with the long-term outcome of delayed stoma closure.

RESULTS

A total of 46 patients underwent an enterostomy, 19 who required emergency enterostomy and 27 with selective enterostomy. After ten years of follow-up, 35 patients underwent hematopoietic stem cell transplantation (HSCT), and 25 patients were alive after HSCT. The median timeframe between HSCT and stoma closure was 19.6 [15.9,26.2] months. Nineteen patients underwent stoma closure and had an average age of 3.9 ± 1.5 years; 6 patients were waiting for stoma closure. Based on a univariate logistic model, risk factors significantly associated with late stoma closure were age at enterostomy and age at HSCT. However, multivariate logistic regression showed no statistically significant factor associated with late stoma closure. There was no significant difference between the stoma closure group and delay closure group in the z scores of weight for age at follow up.

CONCLUSIONS

This study determined the long-term outcomes after enterostomy for VEOIBD with interleukin-10 signaling deficiency. The appropriate time point of enterostomy and HSCT may improve quality of life in the long term.