Ostomy Management for Pediatric Perianal Crohn's Disease

William R Johnston; Rosa Hwang; Peter Mattei

doi:10.1016/j.jpedsurg.2023.11.009

Ostomy Management for Pediatric Perianal Crohn's Disease

J Pediatr Surg. 2023 Nov 24:S0022-3468(23)00693-0. doi: 10.1016/j.jpedsurg.2023.11.009. Online ahead of print.

Authors

William R Johnston¹, Rosa Hwang², Peter Mattei³

Affiliations

¹ General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Hospital of the University of Pennsylvania, Philadelphia, PA, USA. Electronic address: JohnstonW@chop.edu.
² General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
³ General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA; FAAP, USA.

PMID: 38104035
DOI: 10.1016/j.jpedsurg.2023.11.009

Abstract

Introduction: Pediatric patients with perianal Crohn's Disease (CD) suffer recalcitrant fistulas, abscesses, and strictures. Fecal diversion is a palliative last resort, but the expected clinical course and long-term management of the ostomy for this population is unclear. We sought to identify factors predictive of ostomy takedown and establish management recommendations for fistulizing and stenosing disease.

Methods: We reviewed our institutional registry for patients aged 1-18 years with CD who received perianal surgery from 2011 to 2021. We analyzed medical therapy, examinations under anesthesia (EUA), fistula and stenosis response, and rates of fecal diversion and reversal.

Results: There were 109 patients with fistulizing CD and 21 with stenosing CD. There were 8 diverted for fistula and 4 due to stricture [8/109 (7 %) vs 4/21 (19 %), p = 0.213]. Three patients with fistulizing disease had their ostomy reversed at an average of 1.46 years. Each demonstrated consistent CD control and with no additional perianal flares. The remainder have been diverted 3.15 ± 4.57 years with 2.1 ± 2.8 EUAs. Only one patient with stricture was durably reversed, but they still require serial anal dilation. Two were reversed but required re-diversion due to stricture progression.

Conclusion: Reversal rates after fecal diversion for pediatric perianal CD remain disappointingly low and diversion does not obviate the possibility of future EUAs. While reversal was successful for medically responsive patients with fistulizing disease, those with stenosing disease remained dependent on anal dilations and were more likely to fail reversal. Fecal diversion does nothing to reverse an established stricture and such patients will likely need to decide between indefinite dilations or permanent ostomy.

Level of evidence: IV.

Type of study: Retrospective review.

Keywords: Fecal diversion; Perianal Crohn's disease.