Back to Annual Meeting Program

Purpose: Colonic Crohn’s disease is a therapeutic challenge in up to 80% of pediatric patients. Temporary fecal diversion aims to induce remission and avoid colonic resection by providing bowel rest. This mantra has been historically scrutinized for the potential risk of retaining a permanent stoma without reducing the need for bowel resection. Recent data demonstrate the usefulness of anti-TNFα therapy in inducing and maintaining remission in Crohn’s disease, but its effect on pediatric colonic Crohn’s patients is unclear. We hypothesized anti-TNFα therapy in conjunction with temporary fecal diversion would induce remission and reduce the need for bowel resection in medically refractory pediatric colorectal Crohn’s disease, ultimately, allowing successful restoration of bowel continuity.
Methods: Following IRB approval, records of Crohn's disease patients who underwent fecal diversion, between July 2006 and April 2011, at our institution were reviewed. Analysis focused on the clinical course and medical therapy in the perioperative periods, and long term results. Outcomes were analyzed using Fisher’s exact test.
Results: Eleven patients with colorectal or perianal Crohn’s disease had undergone proximal fecal diversion with either ileostomy (81.8%) or colostomy (18.2%) between July 2006 and April 2011. Average follow-up was 27.4 months (4.0-61.4 months) and average age at diversion was 15.1 years (7-21 years). A diversion procedure reduced the number of patients requiring corticosteroids from 10 (90.9%) to 7 (63.6%), but this was not statistically significant (p=0.3). Seven patients (63.6%) required segmental colon resections and 2 (18.2%) required proctocolectomy. Restoration of continuity was performed in 8 (72.7%) patients after an average of 9.7 months (3.0-15.1 months). Four of the 5 patients (80%) treated with an anti-TNFα (Tumor Necrosis Factor) agent after diversion and 4 of the 6 patients (66.7%) off anti-TNFα therapy underwent restoration of continuity (p=1.0). However, three patients (37.5%) required re-diversion (2 in the anti-TNFα group and 1 in the non-anti-TNFα-treated patients; p=1.0). At the conclusion of the follow-up period only 5 (45.5%) of the patients retained intestinal continuity. Complications secondary to the original ostomy occurred in 9.1% of patients and in 66.7% of the re-diverted patients.
Conclusions: Despite therapeutic advances, particularly the advent of anti-TNFα agents, fecal diversion in pediatric patients with colorectal or perianal Crohn’s disease is ultimately associated with a low rate of restoration and maintenance of intestinal continuity. Proximal diversion does not obviate the need for colonic resection in this patient population. Counseling families regarding temporary fecal diversion in pediatric patients with Crohn’s colitis requires tempered optimism in ultimately regaining intestinal continuity.