S0798 Long-Term Outcomes of the Excluded Rectum in Crohn’s Disease – Results From the CAPER (Consortium to Assess Prognosis of the Excluded Rectum) Study

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INTRODUCTION: Despite significant progress made in the treatment of Crohn’s disease (CD) there is still a need for fecal diversion in many refractory patients. The long-term outcome of the retained rectum following this surgery is still not fully understood. We reviewed our experience at two large New York City (NYC) Health Systems. METHODS: A database of all CD patients followed at our health systems was searched for all CD between 1990-2014 who underwent diversionary surgery and who had retained excluded rectums for at least 6 months post-operatively. Medical records were reviewed for baseline characteristics, indications for diversion, and outcomes of excluded rectums. Cases from The Mount Sinai Hospital previously reported1 were not included in this study. RESULTS: Among 78 new CD patients identified in our databases, 27 patients met our inclusion criteria. Baseline characteristics are listed in Table 1. Indications for rectal exclusion and fecal diversion were severe perianal disease in 11/27(41%), acute/refractory disease in 9/27(33.3%), internal fistulas in 6/27(22%) and bowel stricture 1/27(3.6%). Primary outcomes are detailed in Figure 1. 12/27(44%) patients underwent completion proctocolectomy. All were symptomatic except for one who underwent elective completion proctocolectomy. Hence, 15/27(56%) still had retained rectums at the time of last follow-up; 6/15(40%) had been reconnected while 9/15(60%) remained excluded. Out of 6/15 patients who had been reconnected, 3(50%) were symptom-free and 3(50%) continued to have problems. Among the 9/15 with continued rectal exclusion, 3(33%) were asymptomatic and 9(67%) experienced ongoing troubles. On intent-to-treat basis, among the 27 new cases added since our prior report, 6 retained their rectums without further problems(22%), while 21(78%) either ultimately lost their rectums or remained symptomatic with retained rectums (reconnected/excluded). These results are strikingly similar to those observed in our prior report of 81 patients.1 CONCLUSION: While many factors enter the decision whether to remove or retain an excluded rectum beyond 6 months in cases of CD, it could be helpful for patients and clinicians alike to know that in our 2 reported series from NYC, only about one-quarter of patients in long-term follow-up maintained their rectums in situ without ongoing symptoms.Table 1.: Baseline characteristics of all included patientsFigure 1.: Primary outcomes for all patients who underwent diversionary surgery and who had retained excluded rectums for at least 6 months post-operatively.