Clin Colon Rectal Surg 2019; 32(04): 273-279
DOI: 10.1055/s-0039-1683916
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Role of Fecal Diversion in Complex Crohn's Disease

John P. Burke
1   Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
2   Department of Surgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
› Author Affiliations
Further Information

Publication History

Publication Date:
02 July 2019 (online)

Abstract

Crohn's disease (CD) is a chronic inflammatory condition of the gastrointestinal tract resulting in progressive tissue damage, which can result in strictures, fistulae, and abscesses formation. The triggering mechanism is thought to be in the fecal stream, and diversion of this fecal stream is sometimes required to control disease when all other avenues of medical and surgical management have been exhausted. Fecal diversion can be temporary or permanent with the indications being defunctioning a high-risk anastomosis, as a result of a surgical complication, for disease control, or due to severe colonic, rectal, or perianal disease. The incidence of ostomy formation in CD has increased epidemiologically over time. The primary indication for ostomy formation is severe perianal fistulizing disease. However, while 64% of patients have an early clinical response after diversion for refractory perianal CD, restoration of bowel continuity is attempted in only 35% of patients, and is successful in only 17%. The current review discusses the indications for ostomy creation in complex CD, strategies for procedure selection, and patient outcomes.

 
  • References

  • 1 Torres J, Mehandru S, Colombel JF, Peyrin-Biroulet L. Crohn's disease. Lancet 2017; 389 (10080): 1741-1755
  • 2 Burman JH, Thompson H, Cooke WT, Williams JA. The effects of diversion of intestinal contents on the progress of Crohn's disease of the large bowel. Gut 1971; 12 (01) 11-15
  • 3 Rutgeerts P, Goboes K, Peeters M. , et al. Effect of faecal stream diversion on recurrence of Crohn's disease in the neoterminal ileum. Lancet 1991; 338 (8770): 771-774
  • 4 D'Haens GR, Geboes K, Peeters M, Baert F, Penninckx F, Rutgeerts P. Early lesions of recurrent Crohn's disease caused by infusion of intestinal contents in excluded ileum. Gastroenterology 1998; 114 (02) 262-267
  • 5 Maxwell EC, Dawany N, Baldassano RN. , et al. Diverting ileostomy for the treatment of severe, refractory, pediatric inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2017; 65 (03) 299-305
  • 6 Geltzeiler CB, Hart KD, Lu KC, Deveney KE, Herzig DO, Tsikitis VL. Trends in the surgical management of Crohn's disease. J Gastrointest Surg 2015; 19 (10) 1862-1868
  • 7 Rayen J, Currie T, Gearry RB, Frizelle F, Eglinton T. The long-term outcome of anti-TNF alpha therapy in perianal Crohn's disease. Tech Coloproctol 2017; 21 (02) 119-124
  • 8 Liu J, Bruch HP, Farke S, Nolde J, Schwandner O. Stoma formation for fecal diversion: a plea for the laparoscopic approach. Tech Coloproctol 2005; 9 (01) 9-14
  • 9 Oliveira L, Reissman P, Nogueras J, Wexner SD. Laparoscopic creation of stomas. Surg Endosc 1997; 11 (01) 19-23
  • 10 Lapidus A, Bernell O, Hellers G, Löfberg R. Clinical course of colorectal Crohn's disease: a 35-year follow-up study of 507 patients. Gastroenterology 1998; 114 (06) 1151-1160
  • 11 Post S, Herfarth C, Schumacher H, Golling M, Schürmann G, Timmermanns G. Experience with ileostomy and colostomy in Crohn's disease. Br J Surg 1995; 82 (12) 1629-1633
  • 12 Hurst RD, Molinari M, Chung TP, Rubin M, Michelassi F. Prospective study of the features, indications, and surgical treatment in 513 consecutive patients affected by Crohn's disease. Surgery 1997; 122 (04) 661-667 , discussion 667–668
  • 13 Cosnes J, Nion-Larmurier I, Beaugerie L, Afchain P, Tiret E, Gendre JP. Impact of the increasing use of immunosuppressants in Crohn's disease on the need for intestinal surgery. Gut 2005; 54 (02) 237-241
  • 14 Burke JP, Velupillai Y, O'Connell PR, Coffey JC. National trends in intestinal resection for Crohn's disease in the post-biologic era. Int J Colorectal Dis 2013; 28 (10) 1401-1406
  • 15 Alves A, Panis Y, Bouhnik Y, Pocard M, Vicaut E, Valleur P. Risk factors for intra-abdominal septic complications after a first ileocecal resection for Crohn's disease: a multivariate analysis in 161 consecutive patients. Dis Colon Rectum 2007; 50 (03) 331-336
  • 16 Tzivanakis A, Singh JC, Guy RJ, Travis SP, Mortensen NJ, George BD. Influence of risk factors on the safety of ileocolic anastomosis in Crohn's disease surgery. Dis Colon Rectum 2012; 55 (05) 558-562
  • 17 de Buck van Overstraeten A, Eshuis EJ, Vermeire S. , et al. Short- and medium-term outcomes following primary ileocaecal resection for Crohn's disease in two specialist centres. Br J Surg 2017; 104 (12) 1713-1722
  • 18 Schwartz DA, Loftus Jr EV, Tremaine WJ. , et al. The natural history of fistulizing Crohn's disease in Olmsted County, Minnesota. Gastroenterology 2002; 122 (04) 875-880
  • 19 Beaugerie L, Seksik P, Nion-Larmurier I, Gendre JP, Cosnes J. Predictors of Crohn's disease. Gastroenterology 2006; 130 (03) 650-656
  • 20 Molendijk I, Nuij VJ, van der Meulen-de Jong AE, van der Woude CJ. Disappointing durable remission rates in complex Crohn's disease fistula. Inflamm Bowel Dis 2014; 20 (11) 2022-2028
  • 21 Bemelman WA, Warusavitarne J, Sampietro GM. , et al. ECCO-ESCP consensus on surgery for Crohn's disease. J Crohns Colitis 2018; 12 (01) 1-16
  • 22 Choi CS, Berg AS, Sangster W. , et al. Combined medical and surgical approach improves healing of septic perianal Crohn's disease. J Am Coll Surg 2016; 223 (03) 506-514.e1
  • 23 Lee MJ, Heywood N, Sagar PM, Brown SR, Fearnhead NS. ; pCD Collaborators. Surgical management of fistulating perianal Crohn's disease: a UK survey. Colorectal Dis 2017; 19 (03) 266-273
  • 24 Lee MJ, Heywood N, Sagar PM, Brown SR, Fearnhead NS. ; ACPGBI Perianal Crohn's Disease Group. Association of Coloproctology of Great Britain and Ireland consensus exercise on surgical management of fistulating perianal Crohn's disease. Colorectal Dis 2017; 19 (05) 418-429
  • 25 Makowiec F, Jehle EC, Becker HD, Starlinger M. Perianal abscess in Crohn's disease. Dis Colon Rectum 1997; 40 (04) 443-450
  • 26 Bell SJ, Williams AB, Wiesel P, Wilkinson K, Cohen RC, Kamm MA. The clinical course of fistulating Crohn's disease. Aliment Pharmacol Ther 2003; 17 (09) 1145-1151
  • 27 Galandiuk S, Kimberling J, Al-Mishlab TG, Stromberg AJ. Perianal Crohn disease: predictors of need for permanent diversion. Ann Surg 2005; 241 (05) 796-801 , discussion 801–802
  • 28 Singh S, Ding NS, Mathis KL. , et al. Systematic review with meta-analysis: faecal diversion for management of perianal Crohn's disease. Aliment Pharmacol Ther 2015; 42 (07) 783-792
  • 29 Ford AC, Sandborn WJ, Khan KJ, Hanauer SB, Talley NJ, Moayyedi P. Efficacy of biological therapies in inflammatory bowel disease: systematic review and meta-analysis. Am J Gastroenterol 2011; 106 (04) 644-659 , quiz 660
  • 30 Sauk J, Nguyen D, Yajnik V. , et al. Natural history of perianal Crohn's disease after fecal diversion. Inflamm Bowel Dis 2014; 20 (12) 2260-2265
  • 31 Spivak J, Landers CJ, Vasiliauskas EA. , et al. Antibodies to I2 predict clinical response to fecal diversion in Crohn's disease. Inflamm Bowel Dis 2006; 12 (12) 1122-1130
  • 32 Narang R, Hull T, Perrins S, Garcia JS, Wexner SD. Should immunomodulation therapy alter the surgical management in patients with rectovaginal fistula and Crohn's disease?. Dis Colon Rectum 2016; 59 (07) 670-676
  • 33 Gaertner WB, Madoff RD, Spencer MP, Mellgren A, Goldberg SM, Lowry AC. Results of combined medical and surgical treatment of recto-vaginal fistula in Crohn's disease. Colorectal Dis 2011; 13 (06) 678-683
  • 34 Linares L, Moreira LF, Andrews H, Allan RN, Alexander-Williams J, Keighley MR. Natural history and treatment of anorectal strictures complicating Crohn's disease. Br J Surg 1988; 75 (07) 653-655
  • 35 Oberhelman Jr HA, Kohatsu S, Taylor KB, Kivel RM. Diverting ileostomy in the surgical management of Crohn's disease of the colon. Am J Surg 1968; 115 (02) 231-240
  • 36 Harper PH, Kettlewell MG, Lee EC. The effect of split ileostomy on perianal Crohn's disease. Br J Surg 1982; 69 (10) 608-610
  • 37 Winslet MC, Andrews H, Allan RN, Keighley MR. Fecal diversion in the management of Crohn's disease of the colon. Dis Colon Rectum 1993; 36 (08) 757-762
  • 38 Régimbeau JM, Panis Y, Cazaban L. , et al. Long-term results of faecal diversion for refractory perianal Crohn's disease. Colorectal Dis 2001; 3 (04) 232-237
  • 39 Edwards CM, George BD, Jewell DP, Warren BF, Mortensen NJ, Kettlewell MG. Role of a defunctioning stoma in the management of large bowel Crohn's disease. Br J Surg 2000; 87 (08) 1063-1066
  • 40 Harper PH, Truelove SC, Lee EC, Kettlewell MG, Jewell DP. Split ileostomy and ileocolostomy for Crohn's disease of the colon and ulcerative colitis: a 20 year survey. Gut 1983; 24 (02) 106-113
  • 41 Zelas P, Jagelman DG. Loop illeostomy in the management of Crohn's colitis in the debilitated patient. Ann Surg 1980; 191 (02) 164-168
  • 42 Coscia M, Gentilini L, Laureti S. , et al. Risk of permanent stoma in extensive Crohn's colitis: the impact of biological drugs. Colorectal Dis 2013; 15 (09) 1115-1122
  • 43 Uzzan M, Stefanescu C, Maggiori L, Panis Y, Bouhnik Y, Treton X. Case series: does a combination of anti-TNF antibodies and transient ileal fecal stream diversion in severe Crohn's colitis with perianal fistula prevent definitive stoma?. Am J Gastroenterol 2013; 108 (10) 1666-1668
  • 44 Rutgeerts P. Review article: treatment of perianal fistulizing Crohn's disease. Aliment Pharmacol Ther 2004; 20 (Suppl. 04) 106-110
  • 45 Régimbeau JM, Panis Y, Marteau P, Benoist S, Valleur P. Surgical treatment of anoperineal Crohn's disease: can abdominoperineal resection be predicted?. J Am Coll Surg 1999; 189 (02) 171-176
  • 46 de Buck van Overstraeten A, Wolthuis AM, Vermeire S. , et al. Intersphincteric proctectomy with end-colostomy for anorectal Crohn's disease results in early and severe proximal colonic recurrence. J Crohn's Colitis 2013; 7 (06) e227-e231
  • 47 Scammell BE, Keighley MR. Delayed perineal wound healing after proctectomy for Crohn's colitis. Br J Surg 1986; 73 (02) 150-152
  • 48 Chau A, Prodeau M, Sarter H. , et al. Persistent perineal sinus after abdominoperineal resection. Langenbecks Arch Surg 2017; 402 (07) 1063-1069
  • 49 Schaden D, Schauer G, Haas F, Berger A. Myocutaneous flaps and proctocolectomy in severe perianal Crohn's disease--a single stage procedure. Int J Colorectal Dis 2007; 22 (12) 1453-1457
  • 50 Brough WA, Schofield PF. The value of the rectus abdominis myocutaneous flap in the treatment of complex perineal fistula. Dis Colon Rectum 1991; 34 (02) 148-150
  • 51 Harling H, Hegnhøj J, Rasmussen TN, Jarnum S. Fate of the rectum after colectomy and ileostomy for Crohn's colitis. Dis Colon Rectum 1991; 34 (10) 931-935
  • 52 Guillem JG, Roberts PL, Murray JJ, Coller JA, Veidenheimer MC, Schoetz Jr DJ. Factors predictive of persistent or recurrent Crohn's disease in excluded rectal segments. Dis Colon Rectum 1992; 35 (08) 768-772
  • 53 Sher ME, Bauer JJ, Gorphine S, Gelernt I. Low Hartmann's procedure for severe anorectal Crohn's disease. Dis Colon Rectum 1992; 35 (10) 975-980
  • 54 Reynolds IS, O'Toole A, Deasy J, McNamara DA, Burke JP. A meta-analysis of the clinicopathological characteristics and survival outcomes of inflammatory bowel disease associated colorectal cancer. Int J Colorectal Dis 2017; 32 (04) 443-451
  • 55 Rieger N, Collopy B, Fink R, Mackay J, Woods R, Keck J. Total colectomy for Crohn's disease. Aust N Z J Surg 1999; 69 (01) 28-30
  • 56 Yamamoto T, Keighley MR. Long-term outcome of total colectomy and ileostomy for Crohn disease. Scand J Gastroenterol 1999; 34 (03) 280-286
  • 57 Lavery IC, Jagelman DG. Cancer in the excluded rectum following surgery for inflammatory bowel disease. Dis Colon Rectum 1982; 25 (06) 522-524
  • 58 Cirincione E, Gorfine SR, Bauer JJ. Is Hartmann's procedure safe in Crohn's disease? Report of three cases. Dis Colon Rectum 2000; 43 (04) 544-547
  • 59 Wright EK, Kamm MA. Impact of drug therapy and surgery on quality of life in Crohn's disease: a systematic review. Inflamm Bowel Dis 2015; 21 (05) 1187-1194
  • 60 Nordin K, Påhlman L, Larsson K, Sundberg-Hjelm M, Lööf L. Health-related quality of life and psychological distress in a population-based sample of Swedish patients with inflammatory bowel disease. Scand J Gastroenterol 2002; 37 (04) 450-457
  • 61 Panara AJ, Yarur AJ, Rieders B. , et al. The incidence and risk factors for developing depression after being diagnosed with inflammatory bowel disease: a cohort study. Aliment Pharmacol Ther 2014; 39 (08) 802-810
  • 62 Carlsson E, Bosaeus I, Nordgren S. What concerns subjects with inflammatory bowel disease and an ileostomy?. Scand J Gastroenterol 2003; 38 (09) 978-984
  • 63 Morris A, Leach B. A qualitative exploration of the lived experiences of patients before and after ileostomy creation as a result of surgical management for Crohn's disease. Ostomy Wound Manage 2017; 63 (01) 34-39
  • 64 Knowles SR, Wilson J, Wilkinson A. , et al. Psychological well-being and quality of life in Crohn's disease patients with an ostomy: a preliminary investigation. J Wound Ostomy Continence Nurs 2013; 40 (06) 623-629
  • 65 Mahadev S, Young JM, Selby W, Solomon MJ. Self-reported depressive symptoms and suicidal feelings in perianal Crohn's disease. Colorectal Dis 2012; 14 (03) 331-335
  • 66 Takahashi K, Funayama Y, Fukushima K. , et al. Stoma-related complications in inflammatory bowel disease. Dig Surg 2008; 25 (01) 16-20
  • 67 Carlstedt A, Fasth S, Hultén L, Nordgren S, Palselius I. Long-term ileostomy complications in patients with ulcerative colitis and Crohn's disease. Int J Colorectal Dis 1987; 2 (01) 22-25
  • 68 Fumery M, Dulai PS, Meirick P. , et al. Systematic review with meta-analysis: recurrence of Crohn's disease after total colectomy with permanent ileostomy. Aliment Pharmacol Ther 2017; 45 (03) 381-390
  • 69 Lopez J, Konijeti GG, Nguyen DD, Sauk J, Yajnik V, Ananthakrishnan AN. Natural history of Crohn's disease following total colectomy and end ileostomy. Inflamm Bowel Dis 2014; 20 (07) 1236-1241
  • 70 Sherlock DJ, Suarez V, Gray JG. Stomal adenocarcinoma in Crohn's disease. Gut 1990; 31 (11) 1329-1332
  • 71 Orkin BA, Telander RL. The effect of intra-abdominal resection or fecal diversion on perianal disease in pediatric Crohn's disease. J Pediatr Surg 1985; 20 (04) 343-347
  • 72 Grant DR, Cohen Z, McLeod RS. Loop ileostomy for anorectal Crohn's disease. Can J Surg 1986; 29 (01) 32-35
  • 73 Yamamoto T, Allan RN, Keighley MR. Effect of fecal diversion alone on perianal Crohn's disease. World J Surg 2000; 24 (10) 1258-1262 , discussion 1262–1263
  • 74 Rehg KL, Sanchez JE, Krieger BR, Marcet JE. Fecal diversion in perirectal fistulizing Crohn's disease is an underutilized and potentially temporary means of successful treatment. Am Surg 2009; 75 (08) 715-718
  • 75 Hong MK, Craig Lynch A, Bell S. , et al. Faecal diversion in the management of perianal Crohn's disease. Colorectal Dis 2011; 13 (02) 171-176
  • 76 Gu J, Valente MA, Remzi FH, Stocchi L. Factors affecting the fate of faecal diversion in patients with perianal Crohn's disease. Colorectal Dis 2015; 17 (01) 66-72
  • 77 Mennigen R, Heptner B, Senninger N, Rijcken E. Temporary fecal diversion in the management of colorectal and perianal Crohn's disease. Gastroenterol Res Pract 2015; 2015: 286315
  • 78 Bafford AC, Latushko A, Hansraj N, Jambaulikar G, Ghazi LJ. The use of temporary fecal diversion in colonic and perianal Crohn's disease does not improve outcomes. Dig Dis Sci 2017; 62 (08) 2079-2086
  • 79 Martí-Gallostra M, Myrelid P, Mortensen N, Keshav S, Travis SP, George B. The role of a defunctioning stoma for colonic and perianal Crohn's disease in the biological era. Scand J Gastroenterol 2017; 52 (03) 251-256
  • 80 Ultee JM, Lagaay EL, Lens J. Results of split-ileostomy in Crohn's disease of the colon. Neth J Surg 1981; 33 (04) 181-185