Can a temporary ileostomy benefit patients with poorly controlled Crohn's (Crohn's disease) colitis or Ulcerative (ulcerative colitis) colitis, and if so, for how long should it be retained?

Temporary Ileostomy for Poorly Controlled Crohn's Colitis or Ulcerative Colitis

Temporary ileostomy is strongly recommended for patients with poorly controlled Crohn's colitis or ulcerative colitis as it provides immediate clinical improvement in approximately 95% of cases, with sustained improvement in about 65% of patients. 1

Benefits of Temporary Ileostomy

• Subtotal colectomy with ileostomy is the emergency operation of choice for severe acute and refractory colitis, with both open and laparoscopic approaches appropriate depending on the patient's hemodynamic stability 2
• A temporary ileostomy can effectively divert the fecal stream, allowing for remission of colonic inflammation and providing time for intensified medical therapy 2
• In severely ill and malnourished patients with Crohn's colitis, a split ileostomy is a safe conservative operation that produces at least temporary improvement 1
• Temporary diversion may allow for a less extensive resection than initially thought necessary at the time of acute presentation 1

Indications for Temporary Ileostomy

• Severe acute refractory colitis not responding to medical treatment 2
• Toxic megacolon with clinical deterioration and biological signs of deterioration after 24-48 hours of medical treatment 2
• Massive colorectal hemorrhage in patients with acute severe ulcerative colitis 2
• Free perforation and purulent/fecal peritonitis in hemodynamically stable patients 2
• Severe sepsis/septic shock requiring damage control surgery 2

Duration of Temporary Ileostomy

The optimal duration for maintaining a temporary ileostomy varies based on several factors:

• For most patients: Restoration of bowel continuity can be considered after 2-3 months when:

  • Complete resolution of colonic inflammation is achieved 2
  • The patient's nutritional status has improved 1
  • Any medications that might impair healing (such as high-dose steroids) have been reduced 2

• Extended duration (6+ months) may be necessary when:

  • There is persistent inflammation despite fecal diversion 2
  • The patient has multiple risk factors for anastomotic complications 2
  • Additional medical therapy is being optimized 2

Success Rates and Long-term Outcomes

• In patients with Crohn's disease, approximately 65% experience sustained improvement after temporary ileostomy 1
• About 40% of patients may eventually require proctocolectomy for persistent inflammation despite diversion 1
• Bowel continuity can be successfully restored in approximately 60% of cases 1
• After restoration of continuity, the 5-year and 10-year ostomy-free survival rates are approximately 78% and 58%, respectively 3

Surgical Approach

• A laparoscopic approach, if local expertise allows, may reduce length of hospital stay and risk of infectious complications 2
• In hemodynamically unstable patients or those with free perforation and generalized peritonitis, an open approach is recommended 2
• For patients with severe sepsis/septic shock, damage control surgery with resection, stapled off bowel ends, and temporary closure with return to theater in 24-48 hours may be considered 2

Complications and Considerations

• Overall morbidity of ileostomy closure is approximately 16.5% 4
• Potential complications include:
  • Anastomotic dehiscence (2.0%) 4
  • Postoperative bowel obstruction (7.6%) 4
  • Wound infection (4.0%) 4
  • Late complications such as hernia (1.9%) or bowel obstruction (9.4%) 4
• A positive distal microscopic margin is a significant risk factor for later requirement of a permanent ileostomy (HR 5.4) 3

Special Considerations for Crohn's Disease vs. Ulcerative Colitis

• For Crohn's colitis: A temporary ileostomy may be more beneficial as it allows for a more conservative approach and potentially avoids extensive resection 1
• For Ulcerative colitis: Subtotal colectomy with ileostomy is often the definitive emergency procedure, with potential for later restoration of continuity through ileal pouch-anal anastomosis in selected cases 2, 5

Pitfalls to Avoid

• Delaying surgery in critically ill patients presenting with toxic megacolon 2
• Attempting primary anastomosis in patients with 2 or more risk factors for anastomotic complications 2
• Prolonged maintenance of a diverting ileostomy without a clear plan for either restoration of continuity or definitive surgery 2
• Performing ileal pouch-anal anastomosis in Crohn's disease patients with a history of perianal or small bowel disease 2