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

Abstract

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.