I. P. Lim1, A. Chernoguz2, R. A. Falcone1, D. Von Allmen1, B. A. Rymeski1, J. S. Frischer1 1Cincinnati Children’s Hospital Medical Center,Colorectal Center, Division Of Pediatric General & Thoracic Surgery,Cincinnati, OH, USA 2Tufts Medical Center,Floating Hospital For Children,Boston, MA, USA
Introduction: Colorectal and perianal Crohn’s disease in the pediatric population poses a formidable therapeutic challenge. In an effort to preserve bowel length while controlling symptoms, fecal diversion is an attractive option. However, fecal diversion has been associated with an increased risk of a permanent stoma in the adult population. We hypothesize that fecal diversion is more likely to be temporary in children when used in combination with anti-tumor necrosis factor (anti-TNFα) agents.
Methods: Records of patients with perianal and colonic Crohn’s disease who underwent fecal diversion (July 2006 – July 2018) at our institution were reviewed. Perioperative outcomes were analyzed using Fisher’s exact test and indepent t-test.
Results: Fecal diversion was performed in 36 patients with colorectal and perianal Crohn’s disease at a mean age of 14 years (range 2.1 to 20.7). Segmental resections were performed in 25 patients (69.4%) and proctocolectomies in 5 (16.7%). Intestinal continuity was restored in 22 (61%) patients within an average of 10.2 months (range 2 to 29), but 6 (27.2%) required re-diversion for recurrent, severe colitis or perianal disease. Re-diversion occurred at a median of 228 days after initial restoration of intestinal continuity (range 20 to 893 days). At the conclusion of the follow-up period, 16 (44.4%) of the patients retained intestinal continuity.
When comparing patients who were diverted for colonic versus perianal Crohn’s, there was no difference in age at time of stoma creation nor was there a difference in the duration of fecal diversion (Table). Both groups had similar rates of initial intestinal continuity and anti-TNFα therapy after diversion. Moreover, both groups had similar rates of re-diversion.
There was no difference in age at the time of fecal diversion between patients whose stomas were reversed (174.9 months, standard deviation 40.2) and those who remained diverted (157.3, standard deviation 73.0; p = 0.36). Twenty-two received anti-TNFα therapy prior to diversion. Of the 31 patients who received anti-TNFα therapy after diversion, 20 (55.6%) had their stomas reversed and 11 (30.6%) did not (p = 1.0). All 6 patients who required re-diversion received anti-TNFα therapy after their initial stoma creation.
Conclusions: Despite widespread use of anti-TNFα agents, fecal diversion in pediatric colorectal or perianal Crohn’s patients is associated with low rates of sustainable restoration of intestinal continuity.
