Temporary Faecal Diversion for Refractory Perianal and/or Distal Colonic Crohn's Disease in the Biologic Era: An Updated Systematic Review with Meta-Analysis.

BACKGROUND AND AIMS: We evaluated short- and long-term outcomes of temporary faecal diversion (FD) for management of refractory Crohn's disease (CD), focusing on outcomes in the biologic era. METHODS: Through a systematic literature review until March 15, 2023, we identified 33 studies (19 conducted in biologic era) that evaluated 1578 patients with perianal and/or distal colonic CD who underwent temporary FD (with intent of restoring bowel continuity) and reported long-term outcomes (primary outcome: successful restoration of bowel continuity, defined as remaining ostomy-free after reconnection at a minimum of 6 months after diversion or at the end of follow-up). We calculated pooled rates (with 95% CI) using random effects meta-analysis and examined factors associated with successful restoration of bowel continuity. RESULTS: Overall, 61% patients (95% CI, 52-68%; 50% in biologic era) experienced clinical improvement after FD. Stoma takedown was attempted in 34% patients (28-41%; 37% in biologic era), 6-18 months after diversion. Among patients where bowel restoration was attempted, 63% patients (54-71%) had successful restoration of bowel continuity, and 26% (20-34%) required re-diversion. Overall, 21% patients (17-27%; 24% in biologic era) who underwent FD were successfully restored; 34% patients (30-39%; 31% in biologic era) required proctectomy with permanent ostomy. On meta-regression, post-diversion biologic use and absence of proctitis was associated with successful bowel restoration after temporary FD in contemporary studies. CONCLUSION: In the biologic era, temporary FD for refractory perianal and/or distal colonic CD improves symptoms half the patients, and bowel continuity can be successfully restored in a quarter of patients.