Should we monitor Crohnʼs disease patients for postoperative recurrence after permanent ileostomy?

Leal-Valdivieso, Carles; Marín, Íngrid; Mañosa, Míriam; Naves, Juan E.; Zabana, Yamile; Piñol, Marta; Cabré, Eduard; Domènech, Eugeni

doi:10.1002/ibd.21730

Cited by 15 publications

(18 citation statements)

References 5 publications

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“…They found a 9% rate of recurrence in the group that underwent total proctocolectomy with a longer time to recurrence when compared to those with segmental resection or total colectomy. A smaller Spanish series of only 16 patients identified a recurrence rate of 31% at a median follow-up of 77 months 17 . In a smaller series by Onali et al .…”

Section: Discussionmentioning

confidence: 95%

Natural History of Crohnʼs Disease Following Total Colectomy and End Ileostomy

Lopez

Konijeti

Nguyen

et al. 2014

Inflammatory Bowel Diseases

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Background Crohn's disease (CD) requires surgical management in up to two-thirds of patients. Few studies have addressed the issue of ileal recurrence after colectomy and permanent ileostomy. The aims of our study were to assess the rate and predictors of postoperative recurrence of CD in patients with permanent ileostomy. Methods In a retrospective study from a tertiary referral center, we analyzed the natural history of CD patients who underwent total colectomy and permanent ileostomy. Our primary outcomes were (1) overall disease recurrence including luminal recurrence, perianal disease or peristomal lesions requiring therapy, and (2) luminal recurrence alone defined as endoscopic and clinical recurrence within the terminal ileum. We examined if patient characteristics predicted recurrence using multivariate Cox proportional hazard models. Results Our study included 73 CD patients followed for a mean of 28 months (range 0-168 months) after total colectomy and permanent ileostomy. Twenty patients had overall disease recurrence within 10 years after surgery, at rates of 15% and 50% 1 and 5 years. Rate of luminal recurrence was 8% and 35% at 1 and 5 years. Diagnosis at age less than 18 years (HR 2.94, 95% CI 1.14 – 7.62) and anti-TNF therapy prior to surgery (HR 4.75, 95% CI 1.25 – 18.13) were the only independent predictive factors for overall disease recurrence. Conclusions Up to one-third of CD patients have overall recurrence of disease after treatment with total colectomy and permanent ileostomy. There is need to develop algorithms for surveillance and management of this select subgroup of patients.

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Section: Discussionmentioning

confidence: 95%

Natural History of Crohnʼs Disease Following Total Colectomy and End Ileostomy

Lopez

Konijeti

Nguyen

et al. 2014

Inflammatory Bowel Diseases

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“…We identified an additional unpublished study through personal communication with content experts, and hence, included a total of 16 studies in our meta‐analysis. The primary reasons for exclusion after full‐text review were: lack of data on long‐term efficacy of FD, specifically rates of restoration of bowel continuity (six studies), FD performed for colonic CD without severe perianal CD (seven studies), and reporting recurrence of CD after intended permanent ileostomy for colonic and/or perianal CD (five studies) . Figure shows the schematic diagram of study selection.…”

Section: Resultsmentioning

confidence: 99%

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

Singh

Ding

Mathis

et al. 2015

Aliment Pharmacol Ther

157

118

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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.

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“…Of 2017 unique studies identified using our search strategy, 17 studies met our inclusion criteria. 10,11,[16][17][18][19][20][21][22][23][24][25][26][27][28][29][30] In addition, we identified one abstracts from conference proceedings 31 and hence, included a total of 18 studies for quantitative synthesis. Figure 1 shows the schematic diagram of study selection.…”

Section: Resultsmentioning

confidence: 99%

“…There is limited data on the effectiveness of pharmacological therapy in preventing and treating recurrence of CD in the small bowel after TC‐PI as this population is typically excluded from clinical trials. In the included studies, only two studies reported on postoperative prophylactic therapy, and neither of these studies reported on the impact of preventive therapy on the risk of recurrence . Four studies reported on the effectiveness of pharmacological therapies after established clinical recurrence, and of 85 patients treated, 27 responded to medical management .…”

Section: Discussionmentioning

confidence: 99%

“…Overall, the studies were at moderate risk of bias, 17 were performed in referral centres 10,11,[16][17][18][19][20][21][22][23][24][25][26][28][29][30][31] and one in population, 27 17 were retrospective 10, 16-31 and one prospective. 11 Table S1 details the quality of these included studies according to NICE criteria.…”

Section: Characteristics Of Included Studiesmentioning

confidence: 99%

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Systematic review with meta‐analysis: recurrence of Crohn's disease after total colectomy with permanent ileostomy

Fuméry

Dulai

Meirick

et al. 2016

Aliment Pharmacol Ther

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Background Subtotal or total colectomy or proctocolectomy with permanent ileostomy (TC-PI) may be a treatment option for medically refractory colonic Crohn's disease (CD). Aim To perform a systematic review and meta-analysis to evaluate the rate, risk factors and outcomes of CD recurrence after TC-PI. Methods In a systematic review ending March 31, 2016, we identified 18 cohort studies (1438 adults) who underwent TC-PI for colonic CD (median follow-up, 7.4 years; interquartile range, 5.3-9.0). We estimated pooled rates (with 95% confidence interval [CI]) of clinical and surgical recurrence, and risk factors for disease recurrence. Results On meta-analysis, the risk of clinical recurrence after TC-PI was 28.0% (95% CI, 21.7-35.3; 14 studies, 260/1004 patients), with a 5- and 10-year median cumulative rate of 23.5% (range, 7-35) and 40% (range, 11-60), respectively. The risk of surgical recurrence was 16.0% (95% CI, 11.1-22.7; 10 studies; 183/1092 patients), with a 5- and 10-year median cumulative rate of 10% (range, 3-29) and 18.5% (range, 14-34), respectively. The risk of clinical and surgical recurrence in patients without ileal disease at baseline was 11.5% (95% CI, 7.7-16.8) and 10.4% (95% CI, 4.5-22.5), respectively. History of ileal disease was associated with 3.2 times higher risk of disease recurrence (RR, 3.2; 95% CI, 1.8-5.6). Other inconsistent risk factors for disease recurrence were penetrating disease and young age at disease onset. Conclusions Small bowel clinical recurrence occurs in about 28% of patients after TC-PI for colonic CD. Disease recurrence risk is 3.2 times higher in patients with history of ileal disease, and continued medical therapy may be advisable in this population. In patients without ileal inflammation at surgery, continued endoscopic surveillance may identify asymptomatic disease recurrence to guide therapy.

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Should we monitor Crohnʼs disease patients for postoperative recurrence after permanent ileostomy?

Cited by 15 publications

References 5 publications

Natural History of Crohnʼs Disease Following Total Colectomy and End Ileostomy

Natural History of Crohnʼs Disease Following Total Colectomy and End Ileostomy

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

Systematic review with meta‐analysis: recurrence of Crohn's disease after total colectomy with permanent ileostomy

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