Crohn’s disease (CD) is a long-term inflammatory condition that affects the digestive tract, often causing damage that progresses over time. The inflammation can occur anywhere from the mouth to the anus, but it most commonly affects the end of the small and the beginning of the large intestine. While medical treatments have advanced, surgery remains a frequent and often unavoidable part of disease management for many patients, sometimes including the creation of a stoma.
The Necessity of Surgical Intervention in Crohn’s Disease
Surgery becomes necessary when inflammation causes irreversible damage to the bowel wall that cannot be resolved by medication alone. The most frequent reason for intervention is the development of strictures, which are areas of severe narrowing in the intestine. These blockages prevent the normal passage of food and waste, leading to painful obstruction and requiring surgical resection or widening.
Another major indication for surgery is the penetrating form of the disease, which involves the formation of fistulas and abscesses. Fistulas are abnormal, tunnel-like connections that burrow from the inflamed intestine to other organs or to other sections of the bowel. Abscesses are painful collections of pus that require drainage, often necessitating a stoma to divert the fecal stream.
The goal of surgical intervention is to remove the diseased section of the bowel and restore continuity, preserving as much healthy intestine as possible. Chronic inflammation can make rejoining the bowel segments risky due to poor healing or a high risk of an anastomotic leak. In these cases, or when disease is extensive, a stoma is created to safely reroute the digestive flow away from the damaged or recently repaired area.
Prevalence of Ostomy Procedures in Crohn’s Patients
While a large percentage of Crohn’s patients will require intestinal surgery during their lifetime, the rate of ostomy creation is much lower. Estimates suggest that between 70% and 80% of individuals with CD will need surgery, often a bowel resection, at some point. The cumulative risk of requiring any stoma, whether temporary or permanent, is reported to be around 41% after 20 years of disease duration.
When focusing specifically on the need for a permanent stoma, the percentage is smaller. Modern studies suggest that approximately 10% to 14% of all Crohn’s disease patients will ultimately require a permanent ostomy. Within five years of diagnosis, the cumulative incidence of a permanent stoma can be as low as 0.8% in cohorts treated with modern therapies, reflecting a shift toward earlier and more effective medical management.
The difference between the high surgery rate and the lower permanent ostomy rate is due to the frequent use of temporary stomas and successful bowel re-anastomosis. Many patients who receive a stoma will have it reversed once the downstream bowel has fully healed. The stable rate of permanent ostomy over the last two decades, despite increasing use of advanced medical treatments, highlights that a small subgroup of patients still develops refractory, complicated disease.
Types of Stomas Used for Crohn’s Disease
A stoma, or ostomy, is a surgically created opening that brings a portion of the intestine through the abdominal wall, allowing waste to be collected in an external pouch. The type of stoma created depends on which part of the bowel is affected by Crohn’s disease. An ileostomy, created from the ileum (the end of the small intestine), is the most common type for CD patients.
The output from an ileostomy is typically liquid or paste-like and occurs frequently because the colon, which absorbs water, has been bypassed or removed. In contrast, a colostomy is formed from the large intestine, resulting in output that is more solid and less frequent. Surgeons generally favor an ileostomy when the disease involves the colon, rectum, or perianal area to completely divert the fecal stream.
Stomas are also classified by their intended duration: temporary or permanent. A temporary stoma, often a loop ileostomy, is created to divert waste and protect a surgical connection further down the intestine, allowing it to heal without contamination. A permanent stoma, or end ostomy, is necessary when the diseased section, such as the rectum, must be fully removed, or when severe perianal disease makes successful bowel reconnection impossible.
Factors Influencing the Need for an Ostomy
The primary factor dictating the need for an ostomy is the location and behavior of the Crohn’s disease. Disease that affects the rectum and perianal area is a strong predictor for the need for a permanent stoma. Complex perianal fistulas, abscesses, and severe inflammation in the rectum often lead to the removal of this section, making a permanent stoma necessary.
Patients whose disease exhibits a penetrating or fistulizing behavior are more likely to require an ostomy compared to those with strictly inflammatory or stricturing disease. This complicated disease phenotype is often unresponsive to maximum medical therapy, including advanced biologic drugs. Furthermore, the age of disease onset is a factor, as those diagnosed at an older age may have a higher risk of requiring a stoma within the first few years.
The failure to respond adequately to advanced medical therapies, such as anti-tumor necrosis factor (TNF) agents, also increases the likelihood of surgical intervention and ostomy creation. For these patients, a stoma can offer immediate and sustained relief from debilitating symptoms, often leading to improved quality of life after years of chronic disease activity.