For patients with Crohn’s disease, the creation of a surgical stoma—an opening on the abdominal wall that diverts intestinal contents into a collection bag—is sometimes a necessary intervention when anorectal complications overwhelm the bowel. Yet the long-term fate of these stomas, and the patients who live with them, has remained remarkably poorly documented. A new retrospective cohort study published in Annals of Gastroenterological Surgery now offers one of the most detailed long-range pictures to date, following 422 patients who underwent stoma creation at a single Japanese institution over more than four decades, from September 1974 through December 2017. The findings carry sobering implications for how gastroenterologists and surgeons counsel patients facing fecal diversion, particularly those whose stomas stem from progressive anorectal disease.
The research team drew on a prospectively maintained institutional database at Hyogo Medical University, where 1,440 patients with Crohn’s disease underwent intestinal surgery during the study window. Of these, 422 adults required at least one stoma for a Crohn’s-related indication, meaning that nearly three in ten surgical patients—29.3 percent—faced diversion at some point in their disease course. The cohort reflected the notoriously aggressive biology of the disease: the median age at Crohn’s diagnosis was just 21 years, disease at diagnosis was classified as penetrating or stricturing in the vast majority of cases under the Montreal classification, and 321 patients—76.1 percent—had anorectal lesions such as perianal fistulas, abscesses, or strictures. This high rate of anorectal involvement, which reaches nearly 49 percent in some Japanese prospective cohorts compared with 4 to 14 percent in Western series, is a defining feature of Crohn’s disease in Asian populations and shapes much of what the study found.
At the initial operation, three quarters of the patients received what surgeons hoped would be a temporary stoma, while a quarter underwent permanent diversion, typically in conjunction with abdominoperineal resection—the removal of the anus, rectum, and sphincter complex. Among the temporary stomas, small-intestinal stomas predominated, accounting for 86 percent of initial diversions, while permanent stomas were more evenly split between small-intestinal and colonic origins. The reasons behind temporary diversion proved to be the study’s most consequential variable. Progression of anorectal lesions drove stoma creation in 224 patients, or 71.1 percent of the temporary group. Poor intestinal conditions—severe malnutrition, complicated abscesses or perforations, or bowel-wall edema so pronounced that a safe anastomosis was deemed impossible—accounted for 23.8 percent. Anastomotic leakage necessitated diversion in just 4.4 percent of cases, and two patients were diverted for rare causes, including fistulas arising from an ileal pouch in individuals initially misclassified as having ulcerative colitis.
When the researchers traced each indication forward through time, a stark divergence emerged. Among patients diverted because of refractory anorectal disease, 87 percent ultimately ended up with a permanent stoma over long-term follow-up. Only 19 percent of this group ever achieved stoma closure at all, and even among those successes, five patients later required abdominoperineal resection and eight needed re-creation of a stoma. By contrast, patients diverted because of poor intestinal conditions fared far better: 61 percent achieved closure, and bowel continuity was maintained in 56 percent of the entire group. Those diverted for anastomotic leakage occupied an intermediate position, with 57 percent achieving closure and 43 percent ultimately keeping their continuity intact. The message for clinical practice is unambiguous—a stoma created to rest an inflamed but structurally salvageable bowel behaves very differently from one created to sidestep a fistulizing, destroyed perineum.
The overall numbers tell a similarly granular story. Of the 315 patients with temporary stomas, 98—31 percent—achieved closure, but 13 percent of those later required re-creation, and among patients whose re-created stomas again failed, only one ever achieved a second durable closure. Over the long run, 92 of the 315 temporarily diverted patients, or 29.2 percent, ended with abdominoperineal resection, and a further 133 lived with stomas that were never closed. Stoma-related complications requiring reoperation arose in 23 patients, and the investigators noted that the most common problem—stenosis adjacent to the stoma, seen in 19 cases—was attributed to Crohn’s disease lesions at the stoma site rather than to technical failure of the stoma itself, a distinction that underscores how the underlying inflammation pursues patients even after diversion.
Quantifying the population-level burden, the team used Kaplan–Meier analysis from the time of Crohn’s diagnosis. Stoma-free survival—freedom from any diversion, temporary or permanent—was 94.9 percent at five years, 88.4 percent at ten years, 81.5 percent at fifteen years, and 75.4 percent at twenty years. Freedom from permanent stoma was considerably higher among the full cohort of 1,440 surgical patients: 98.2 percent at five years, 94.8 percent at ten years, 89.5 percent at fifteen years, and 82.7 percent at twenty years. These cumulative figures, the authors note, exceed some previously published rates, likely because the study defined permanent stomas as those unclosed for more than 24 months and focused on surgically treated patients with a heavy load of anorectal disease followed for decades rather than years.
One of the study’s most provocative findings concerns the era in which patients were treated. Infliximab, the first anti-tumor necrosis factor biologic approved for Crohn’s disease in Japan, entered routine clinical practice in the mid-2000s, and the researchers used 2005 as a cutoff to compare outcomes before and after the biologics era. Permanent stoma-free survival was significantly better in the later group: twenty-year rates reached 86.5 percent in the biologic era versus 79.3 percent before it, a statistically significant difference with a p-value of 0.032. This suggests that the arrival of potent immunologic therapies has meaningfully reduced the long-term risk of losing the rectum and sphincters. Yet the data also temper enthusiasm. Population-based studies cited by the authors show that the early risk of stoma creation after diagnosis has not substantially declined despite wider biologic use, and in this surgically referred cohort, patients with advanced anorectal damage continued to progress to permanent diversion at high rates. Biologics, in other words, appear to change the trajectory of earlier disease but cannot reverse irreversible perineal destruction.
The study also casts light on a less-discussed hazard: malignancy arising in diseased or diverted bowel. Thirteen percent of the cohort developed cancer related to anorectal disease, and the investigators identified two cases of cancer developing in diverted or excluded rectal segments after stoma creation—a scenario that arises because the excluded rectum escapes routine endoscopic surveillance. Surveillance for Crohn’s-associated cancer remains fraught, the authors point out, since strictures and pain often make endoscopy technically difficult, and standardized screening programs comparable to those established for ulcerative colitis simply do not exist for Crohn’s disease. They argue that patients with anorectal disease need regular perianal examination, evaluation under anesthesia when necessary, and continued monitoring of diverted rectal segments, ideally within a framework of close collaboration between gastroenterologists and colorectal surgeons.
The authors acknowledge the limitations inherent in their design: the analysis was retrospective and single-center, conducted at a tertiary inflammatory bowel disease referral center likely enriched with severe and refractory cases; management evolved dramatically across the 43-year study period; and the precise onset of anorectal disease could not always be established, particularly in patients referred from elsewhere. Median follow-up, however, was an extraordinary 19.5 years, with observations extending to 50 years, giving the study a temporal depth that few cohorts in inflammatory bowel disease can match. Within those constraints, the conclusions are clear and clinically actionable. Temporary diversion for Crohn’s disease is far more likely to become permanent when created for anorectal disease than for mechanical reasons such as leakage or poor bowel condition, a reality that should shape preoperative counseling and the timing of closure attempts. For patients and clinicians alike, the findings reinforce that aggressive, early, and coordinated control of perianal inflammation—combining surgical drainage techniques such as seton placement with immunomodulators, biologics, and antibiotics before irreversible damage accumulates—remains the best defense against a lifetime with a permanent stoma.
Subject of Research: Long-term outcomes of stoma creation in patients with Crohn’s disease
Article Title: Long‐Term Outcomes After Stoma Creation in Crohn’s Disease: A Retrospective Cohort Study of 422 Patients
Article References: Nagano, K., Kuwahara, R., Tomoo, Y., Kusunoki, K., Horio, Y., Kimura, K., Kataoka, K., Ikeda, M., Uchino, M., & Ikeuchi, H. (2026). Long‐Term Outcomes After Stoma Creation in Crohn’s Disease: A Retrospective Cohort Study of 422 Patients. Annals of Gastroenterological Surgery, 10(5), 1463-1469. https://doi.org/10.1002/ags3.70219
Image Credits: AI Generated
DOI: 10.1002/ags3.70219
Keywords: Crohn’s disease, stoma creation, anorectal disease, abdominoperineal resection, inflammatory bowel disease, biologic therapy, infliximab, stoma closure, permanent stoma, perianal fistula, retrospective cohort study, colorectal surgery
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Ophelia Keating. (September 23, 2026). When Crohn’s Stomas Become Permanent: 40-Year Study Tracks Long-Term Outcomes in 422 Patients. Scienmag. https://scienmag.com/when-crohns-stomas-become-permanent-40-year-study-tracks-long-term-outcomes-in-422-patients/
Ophelia Keating. “When Crohn’s Stomas Become Permanent: 40-Year Study Tracks Long-Term Outcomes in 422 Patients.” Scienmag, 23 September 2026, https://scienmag.com/when-crohns-stomas-become-permanent-40-year-study-tracks-long-term-outcomes-in-422-patients/. Accessed 23 September 2026.
Ophelia Keating. “When Crohn’s Stomas Become Permanent: 40-Year Study Tracks Long-Term Outcomes in 422 Patients.” Scienmag. September 23, 2026. https://scienmag.com/when-crohns-stomas-become-permanent-40-year-study-tracks-long-term-outcomes-in-422-patients/
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Tags: abdominoperineal resectionanorectal diseasebiologic therapycolorectal surgeryCrohn’s disease anorectal complicationsCrohn’s disease intestinal surgeryCrohn’s disease stoma long-term outcomesCrohn’s disease surgical managementCrohn’s diseasedemographic and clinical characteristics of Crohn’sfecal diversion in Crohn’s patientsimpact of Crohn’s stomas on quality of lifeinflammatory bowel diseaseinfliximablong-term follow-up of Crohn’s stoma patientslong-term prognosis of Crohn’s stomasperianal fistulapermanent Crohn’s stoma studypermanent stomaretrospective cohort studystoma closurestoma creationsurgical decision-making in Crohn’s disease
