Long-term outcomes of ‘temporary’ defunctioning in patients with severe perianal Crohn's disease

Aim: This study aimed to analyse long-term outcomes in patients undergoing temporary faecal diversion for therapy-refractory Crohn's perianal fistulas. Methods: In this retrospective study, Crohn's patients who underwent defunctioning for perianal disease between 2012 and 2022 were included. The primary endpoints were successful ostomy reversal and proctectomy/proctocolectomy rates. Secondary endpoints were clinical fistula closure, development of proximal colonic disease recurrence, and the influence of medication, patient and disease characteristics on ostomy reversal. Results: In total, 53 patients were included, 35 colostomies and 18 ileostomies. Previous L2 disease was more frequently seen in the ileostomy group (colostomy 29%, ileostomy 83%; P = 0.004). Clinical closure of the fistula was seen in 26%. 21% (11/53 patients) underwent an attempt at ostomy reversal during a median overall follow-up of 90.1 months (interquartile range 17.5–82.5) of which nine ostomies (colostomy 23%, ileostomy 6%; P = 0.244) were closed successfully. In 35%, a proctectomy/proctocolectomy was required to control ongoing perianal sepsis. Factors associated with ostomy reversal were fistula closure (P < 0.001) and L1/L3 disease (P = 0.043). In patients with ostomy reversal attempt (n = 11), successful reversal was associated with colostomy (P = 0.055) and use of anti-tumour necrosis factor (anti-TNF) (P = 0.055) despite being previously classified as anti-TNF refractory. Conclusion: Ostomy reversal rates are low, so defunctioning ostomies should be carefully considered because in most patients the ostomy will be permanent. In one-third of the patients, a proctectomy/proctocolectomy is required to treat ongoing perianal sepsis. If a patient is eligible for ostomy reversal, reversal should preferably be done under anti-TNF to optimize chances of success.