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Long-term Outcomes After Continent Ileostomy Creation in Patients With Crohn’s Disease

Aytac, Erman M.D.; Dietz, David W. M.D.; Ashburn, Jean M.D.; Remzi, Feza H. M.D.

Diseases of the Colon & Rectum: May 2017 - Volume 60 - Issue 5 - p 508–513
doi: 10.1097/DCR.0000000000000815
Original Contributions: Inflammatory Bowel Disease
Denotes Associated Video Abstract
Denotes Podcast
Denotes Visual Abstract

BACKGROUND: Patients with Crohn’s disease have a higher failure rate after ileal pouch surgery compared with their counterparts with ulcerative colitis.

OBJECTIVE: We hypothesized that risk of continent ileostomy failure can be stratified based on the timing of Crohn’s disease diagnosis and aimed to assess long-term outcomes.

DESIGN: This was a retrospective cohort study.

SETTINGS: The investigation took place in a high-volume, specialized colorectal surgery department.

PATIENTS: Patients with Crohn’s disease who underwent continent ileostomy surgery between 1978 and 2013 were evaluated.

MAIN OUTCOME MEASURES: Functional outcomes, postoperative complications, requirement of revision surgery, and continent ileostomy failure were analyzed.

RESULTS: There were 48 patients (14 male patients) with a median age of 33 years at the time of continent ileostomy creation. Crohn’s disease diagnosis was before continent ileostomy (intentional) in 15 or made in a delayed fashion at a median 4 years after continent ileostomy in 33 patients. Median follow-up was 19 years (range, 1–33 y) after index continent ileostomy creation. Major and minor revisions were performed in 40 (83%) and 13 patients (27%). Complications were fistula (n = 20), pouchitis (n = 16), valve slippage (n = 15), hernia (n = 9), afferent limb stricture (n = 9), difficult intubation (n = 8), incontinence (n = 7), bowel obstruction (n = 7), valve stricture (n = 5), leakage (n = 4), bleeding (n = 3), and valve prolapse (n = 3). Median Cleveland global quality-of-life score was 0.8. Continent ileostomy failure occurred in 22 patients (46%). Based on Kaplan–Meier estimates, continent ileostomy survival was 48 % (95% CI, 33%–63%) at 20 years. Continent ileostomy failure was similar regardless of timing of diagnosis of Crohn’s disease (p = 0.533).

LIMITATIONS: This study was limited by its retrospective and nonrandomized nature.

CONCLUSIONS: Outcomes of continent ileostomy in patients with Crohn’s disease are poor, regardless of the timing of diagnosis. Very careful consideration should be given by both the surgeon and the patient before undertaking this procedure in patients with Crohn’s disease. See Video Abstract at http://links.lww.com/DCR/A327.

Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio

Financial Disclosure: None reported.

Podium presentation at the meeting of The American Society of Colon and Rectal Surgeons, Los Angeles, CA, April 30 to May 4, 2016.

Correspondence: David W. Dietz, M.D., University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106. E-mail: David.Dietz@UHhospitals.org

© 2017 The American Society of Colon and Rectal Surgeons