Fecal Diversion for Perianal Crohn Disease in the Era of Biologic Therapies: A Multicenter Study

Abstract

Background The natural history of perianal Crohn disease (PCD) after fecal diversion in the era of biologics is poorly understood. We assessed clinical and surgical outcomes after fecal diversion for medically refractory PCD and determined the impact of biologics. Methods We performed a retrospective, multicenter study from 1999 to 2020. Patients who underwent fecal diversion for refractory PCD were stratified by diversion type (ostomy with or without proctectomy). Times to clinical and surgical outcomes were estimated using Kaplan-Meier methods, and the association with biologics was assessed using multivariable Cox proportional hazards models. Results Eighty-two patients, from 3 academic institutions, underwent a total of 97 fecal diversions: 68 diversions without proctectomy and 29 diversions with proctectomy. Perianal healing occurred more commonly after diversion with proctectomy than after diversion without proctectomy (83% vs 53%; P = 0.021). Among the patients who had 68 diversions without proctectomy, with a median follow-up of 4.9 years post-diversion (interquartile range, 1.66-10.19), 37% had sustained healing, 31% underwent surgery to restore bowel continuity, and 22% underwent proctectomy. Ostomy-free survival occurred in 21% of patients. Biologics were independently associated with avoidance of proctectomy (hazard ratio, 0.32; 95% confidence interval, 0.11-0.98) and surgery to restore bowel continuity (hazard ratio, 3.10; 95% confidence interval, 1.02-9.37), but not fistula healing. Conclusions In this multicenter study, biologics were associated with bowel restoration and avoidance of proctectomy after fecal diversion without proctectomy for PCD; however, a minority of patients achieved sustained fistula healing after initial fecal diversion or after bowel restoration. These results highlight the refractory nature of PCD.

Fistula Healing Is Low After Fecal Diversion Surgery in Perianal Crohn’s Disease

“…Similar to McCurdy et al, 1 we concluded that objective fistula closure is much lower with FD than anticipated and desired by clinicians. Additionally, we showed that FD was associated with significant stoma-related morbidity.…”

“…To the Editors, We read the article by McCurdy et al with great interest. 1 Perianal fistulas are seen in up to 24% of patients with Crohn's disease (CD), are often refractory to medical therapy, and result in significant impairment of quality of life. 2 Fecal diversion (FD) surgery is used to manage refractory perianal CD fistulas (pCDs), with a meta-analysis showing 63% clinical improvement 3 ; however, objective data on fistula healing rates, such as no fistula drainage despite gentle finger compression, exam under anesthesia (EUA), magnetic resonance imaging (MRI), or endoscopic ultrasound, are often not reported.…”

“…In their retrospective, multicenter study, McCurdy et al demonstrated that in the biologic era, fecal diversion without protectomy resulted in only 36.8% of pCD patients achieving sustained fistula healing after FD, thus reinforcing the overall refractory nature of pCD. 1 We performed a retrospective study to evaluate fistula healing (closure of all individual draining fistulas) and complication rates in pCD after FD. The study was authorized by the institutional review board at University of California, Davis (protocol number 1573192-1).…”

Mesenchymal Stem/Stromal Cell Therapy Is More Cost-Effective Than Fecal Diversion for Treatment of Perianal Crohn’s Disease Fistulas

“…Many prior studies on FD have described symptomatic improvement but do not report actual objective fistula healing rate as determined by no fistula drainage despite gentle finger compression, exam under anesthesia, MRI pelvis, or endoscopic ultrasound. Our recent study evaluating fistula healing after FD as a primary endpoint showed fistula healing of 40% and is similar to two recent multicenter studies which reported between 36.8-42.2% fistula healing after FD, which is much lower than the summary estimate of 63.8% used in our study (8)(9)(10). At the same time, the MSC fistula healing rates are obtained from a robust phase III clinical trial (ADMIRE-CD) (5), and is similar to those reported in multiple studies including In conclusion, our study demonstrates that MSCs are more cost effective than FD for refractory pCD in an academic medical center.…”

Managing complex perianal disease after anti-TNF failure: Where to go next?

“…Twenty percent of the patients ultimately required colectomy. A recent study evaluated the long-term outcomes of 82 patients with fecal diversion with or without proctectomy ( McCurdy et al., 2021 ). Fistula healing occurred more frequently after diversion with proctectomy (in 83% of cases) than after diversion without proctectomy (53%).…”