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Poster presentations: Clinical: Therapy and Observation 2020

P514 Does faecal diversion induce clinical response for Crohn’s disease of the colorectum?

A. Lightner1, H. Buhulaigah2, K. Zaghiyan2, P. Vaidya1, M. Regueiro1, P. Fleshner2

1Department of Colorectal Surgery, Cleveland Clinic, Cleveland, USA, 2Cedars-Sinai, Colon and Rectal Surgery, Cleveland- OH, USA

Background

Fecal diversion is now selectively used in cases of medically refractory Crohn’s proctocolitis or advanced perianal disease. The aim of this study was to evaluate the rate of, and clinical factors, associated with the clinical response following faecal diversion in CD.

Methods

A retrospective chart review of adult CD patients undergoing an ileostomy for medically refractory distal disease (proctocolitis, perianal disease, segmental colitis, proctitis) between 2000 and 2019 at two inflammatory bowel disease centres was conducted. The primary outcome was the rate of clinical response; the secondary outcome was to assess factors associated with clinical response to faecal diversion.

Results

The study cohort of 98 patients had a median age of 40 (range, 19–84) years and included 50 females (51%). Median duration of disease was 15 (1–43) years. Indication for surgery was medically refractory proctocolitis and perianal disease (n = 48;49%), perianal disease alone (n = 34;35%), proctocolitis (n = 8;8%), segmental colitis (n = 5;5%), and proctitis alone (n = 3; 3%). Medications used before surgery included corticosteroids (n = 43;44%), immunomodulators (n = 33;34%) and biologics (n = 52;53%). Biologics used included adalimumab (n = 21), infliximab (n = 10, certolizumab (n = 8), vedolizumab (n = 8) and ustekinumab (n = 5). Only 16 (17%) patients were active smokers. Following ileostomy formation, 32 (33%) patients had a clinical response. The association between patient features and clinical response is shown in Table 1. Clinical response to fecal diversion was significantly decreased in the setting of proctocolitis with perianal disease (p = 0.005) and pre-diversion exposure to biologics (p = 0.04).

VariableStudy cohortRespondersNon-respondersp-value
N9832 (33%)66 (67%)-
Age at surgery (yr)40 (19–84)44 (19–70)37 (19–84)0.24
Female gender50 (51)17 (53)33 (50)0.83
Disease duration (yr)15 (1–43)17 (2–40)14 (1–43)0.63
Indication for surgery
PC+PA48 (49)9 (28)39 (59)0.005
PA34 (35)12 (38)22 (30)0.82
PC8 (8)5 (16)3 (5)0.11
Segmental colitis5 (5)4 (13)1 (2)0.04
Proctitis3 (3)2 (6)1 (2)0.25
Preop medications
Corticosteroids33 (34)14 (44)19 (29)0.18
IMM16 (16)5 (15)11 (17)1
Biologics52 (53)13 (41)39 (59)0.04
Active tobacco use16 (16)4 (12)12 (18)0.57

Values expressed as median (range) or n (%).

PC proctocolitis, PA perianal; IMM immunomodulators.

Conclusion

This largest report in the biologic era of faecal diversion for medically refractory CD proctocolitis or perianal disease showed that only 33% of patients achieved a clinical response. Both biologic uses before faecal diversion and diversion for proctocolitis with perianal disease were associated with a significantly lower clinical response.