Systematic review with meta-analysis: faecal diversion for management of perianal Crohn's disease.
BACKGROUND
Temporary faecal diversion is sometimes used for management of refractory perianal Crohn's disease (CD) with variable success.


OBJECTIVE
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.
Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.|Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA.
S
S
Singh
Department of Gastroenterology, St. Mark's Hospital, North West London Hospitals NHS Trust, Harrow, UK.
N S
NS
Ding
Division of Colorectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
K L
KL
Mathis
Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA.
P S
PS
Dulai
Mayo Clinic Libraries, Mayo Clinic, Rochester, MN, USA.
A M
AM
Farrell
Division of Colorectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
J H
JH
Pemberton
Department of Gastroenterology, St. Mark's Hospital, North West London Hospitals NHS Trust, Harrow, UK.
A L
AL
Hart
Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA.
W J
WJ
Sandborn
Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
E V
EV
Loftus
D001004:Anus Diseases / Q000453:epidemiology / Q000473:pathology / Q000601:surgery*; D003082:Colectomy / Q000009:adverse effects / Q000706:statistics & numerical data; D003424:Crohn Disease / Q000453:epidemiology / Q000473:pathology / Q000601:surgery*; D005243:Feces; D006801:Humans; D007081:Ileostomy / Q000009:adverse effects / Q000379:methods / Q000534:rehabilitation / Q000706:statistics & numerical data; D016737:Proctocolectomy, Restorative / Q000706:statistics & numerical data; D012008:Recurrence