Crohn’s permanent stoma rates plummet in post-biologic era

Permanent stoma creation in patients with extensive Crohn's disease has fallen to a third of its previous rate following the advent of biologic therapy, research shows.

"Comparison of different clinical groups of patients treated in the Biological Era shows that biological drugs can heal anorectal disease to allow restoration of intestinal continuity, thus resulting in a significant reduction of permanent stoma formation," say Maurizio Coscia (University of Bologna, Italy) and colleagues.

The study, reported in Colorectal Disease, included 51 patients who underwent colectomy between 1995 and 2002 (pre-biologic group) and 182 who underwent abdominal surgery after 2002 (post-biologic group).

In the pre-biologic group, 23 (45.1%) patients without anorectal involvement had an ileorectal anastomosis, 11 (21.6%) with anorectal involvement had terminal ileostomy with preservation of the rectal stump, and 17 (33.3%) with severe anorectal involvement had proctocolectomy and permanent ileostomy as the primary procedure.

In the post-biologic group, 73 (40.1%) patients without anorectal involvement underwent colectomy and ileorectal anastomosis, nine (5.0%) patients with total proctocolitis and severe anorectal disease had a proctocolectomy and permanent ileostomy, and 100 (54.9%) patients with severe anorectal involvement underwent colectomy, terminal ileostomy and preservation of the anorectal stump as the primary procedure.

After a mean follow up of 11 years, 31 (60.8%) patients in the pre-biologic group had a permanent ileostomy and 20 (39.2%) had preserved anal function. This compared with corresponding figures of 35 (19.2%) and 147 (80.8%) in the post-biologic group over a mean follow up of 4 years.

Also, among patients in the post-biologic group who underwent colectomy with terminal ileostomy and received biologic treatment with infliximab or adalimumab (n=75), most were able to undergo conversion to ileorectal anastomosis leading to a rate of 81.3% after follow up.

Multivariate analyses showed that biologic treatment was the only factor associated with a higher rate of preserved anal function, leading to a 3.1-fold increase in the odds.

"It can be concluded that treatment with biological agents has modified the management of large bowel Crohn's disease with anorectal involvement, leading to fewer permanent ileostomies and more patients with anal function," the authors say.

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