Rate, Risk Factors and Outcomes of Recurrence of Crohnʼs Disease After Total Colectomy with Permanent Ileostomy: a Systematic Review and Meta-analysis

Abstract

Introduction: Total colectomy with permanent ileostomy (TC-PI) may be a treatment option in patients with medically refractory colonic Crohn's disease (CD). We performed a systematic review and metaanalysis to evaluate the rate, risk factors and outcomes of small bowel CD recurrence after TC-PI. Methods: Through a systematic review of multiple electronic databases, through March 31, 2016, we identified 18 cohort studies including 1438 adults who underwent TC-PI for colonic CD (median follow-up, 7.4 years; IQR, 5.3-9.0 years). We estimated pooled rates (with 95% confidence interval [CI]) of clinical and surgical recurrence, reoperation for stoma complications, as well as risk factors for disease recurrence. Results: On meta-analysis, the risk of clinical recurrence was 28% (95% CI, 21.7-35.3; 14 studies, 260/1004 patients; I2=80%), with a 5- and 10-year median cumulative rate of 23.5% (range, 7-35) and 40% (range, 11-60), respectively (Figure 1). The risk of surgical recurrence was 16.0% (95% CI, 11.1-22.7; 10 studies; 183/1092 patients; I2=84%), with a 5- and 10-year median cumulative rate of 10% (range, 3-29) and 18.5% (range, 14-34), respectively (Figure 2). Rate of reoperation for stoma complication was 15.6% (95% CI, 8.5-27.0; 7 studies; 108/701 patients). Rates of clinical recurrence were similar among studies published before (prior to 1998) and after the advent of biologics (26.9% vs. 30.0%, p=0.64). Presence of ileal disease at time of TC-PI was associated with 3.2 times higher risk of disease recurrence (RR, 3.2; 95% CI, 1.8-5.6); the risk of clinical and surgical recurrence in patients without ileal disease at the time of surgery was 23.5% (95% CI, 15.7-38.3) and 10.1% (95% CI, 5.7-17.5%), respectively. Other risk factors for disease recurrence were penetrating disease and young age at disease onset.Figure 1Figure 2Conclusion: Small bowel clinical recurrence occurs in about 28% patients after TC-PI for colonic CD. Disease recurrence risk is 3.2 times higher in patients with known ileal disease at time of surgery, and continued medical therapy is advisable in this population. In patients without ileal disease at surgery, continued endoscopic surveillance may identify asymptomatic disease recurrence to guide therapy.