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

The retrospective cohort study was conducted at the Cancer Institute Hospital of the Japanese Foundation for Cancer Research in Tokyo, one of Japan’s leading oncology centers. The investigators reviewed consecutive patients who underwent definitive rectal cancer surgery between January 2011 and December 2024. To keep the population homogeneous, they included only patients who had sphincter-preserving rectal resection with double-stapling technique reconstruction and a diverting stoma, all following radiation-based neoadjuvant treatment. Patients with Stage IV disease at surgery, those undergoing additional major procedures, and those with other reconstructive methods were excluded. Treatment strategy for each patient was determined at a multidisciplinary team conference, reflecting real-world institutional practice rather than trial protocol conditions.

The cohort was divided into two treatment eras of evolving intensity. A total of 168 patients received radiotherapy without additional preoperative systemic chemotherapy — the non-TNT group — comprising 135 patients treated with long-course chemoradiotherapy and 33 with short-course radiotherapy alone. Another 128 patients received total neoadjuvant therapy, or TNT, in which systemic chemotherapy is delivered before surgery, either before or after radiotherapy: 94 with a long-course chemoradiotherapy-based regimen and 34 with a short-course radiotherapy-based approach. TNT has become increasingly standard for locally advanced rectal cancer because Phase III trials have shown higher pathological complete response rates and, in selected patients, the possibility of organ preservation. The median patient age was 61 years, about 70 percent were men, and 71 percent had clinical Stage III disease.

The results on closure itself were encouraging. Stoma closure was achieved in 287 of 296 patients, a rate of 97 percent, and only five of those 287 patients — 1.7 percent — needed a stoma again within 30 days, a signal of an anastomotic problem missed during pre-closure assessment. That left 282 patients with what the researchers defined as initially successful closure. Before every closure, patients underwent contrast enema and endoscopic examination of the anastomosis, and surveillance computed tomography was added when more than six months had elapsed since the original operation. Closure proceeded only when no leakage, fistula, sinus, severe stenosis, or recurrence was evident. Even with this careful gating, the story did not end there.

During a median follow-up of 63 months after closure, 25 of the 282 patients — 8.9 percent — required delayed re-stoma creation more than 30 days after closure. The Kaplan-Meier estimates of delayed re-stoma-free survival were 93.3 percent at three years and 90.3 percent at five years. At the final follow-up, 258 of all 296 patients, or 87.2 percent, were stoma-free, while 12.8 percent lived with a permanent stoma. Strikingly, the timing and cause of re-stoma creation followed two distinct patterns that carry different clinical implications, the authors report.

Structural anastomotic complications were the leading cause, accounting for 14 of the 25 delayed events. These included delayed leakage, pelvic abscess, fistula, chronic sinus, and clinically significant stenosis — objectively confirmed anatomical failures severe enough to demand renewed fecal diversion. The median interval from closure to re-stoma in this group was 11 months. The researchers attribute these late failures to a convergence of mechanisms: persistent pelvic sepsis, impaired tissue healing, and progressive radiation-related tissue changes such as fibrosis and microvascular injury. Radiation, while essential for tumor control, leaves behind tissue that is fibrotic, poorly vascularized, and slow to repair itself — a hostile environment for an anastomosis that must remain intact for decades. A delayed leak may represent either an occult abnormality that became apparent only after bowel continuity was restored or a genuinely new failure of the irradiated tissue.

The second pathway was quieter and slower. Seven patients required re-stoma creation because of severe functional bowel dysfunction — defecatory impairment so disabling that patients elected fecal diversion despite having no structural abnormality on endoscopy or imaging. In these cases the median interval was 44 months, nearly four years after closure, and all seven stomas were permanent. This pattern echoes long-term randomized trial data showing that preoperative radiotherapy is associated with a higher prevalence of major low anterior resection syndrome even 14 years after surgery. Anatomical continuity, the study makes clear, does not guarantee functional success. One patient additionally developed dysmotility-related megacolon 46 months after closure, and three patients required re-stomas because of tumor recurrence at a median of 11 months.

Importantly, the intensification of treatment did not appear to worsen long-term stoma outcomes. Delayed re-stoma-free survival did not differ significantly between the non-TNT and TNT groups (log-rank p = 0.176), nor between long-course and short-course radiotherapy schedules within TNT. In an exploratory comparison, male sex was the only characteristic significantly associated with delayed re-stoma creation — 88 percent of re-stoma patients were men versus 67.7 percent of those who remained stoma-free (p = 0.040) — a finding the authors attribute cautiously to the narrower male pelvis and greater technical difficulty of deep pelvic reconstruction, while emphasizing it is hypothesis-generating given the small number of events. Age, diabetes, tumor height, anastomotic height, surgical approach, and lateral lymph node dissection showed no significant associations.

The study has limitations the authors acknowledge candidly. It was retrospective and conducted at a single high-volume center where treatment strategies evolved over 14 years. The number of delayed events was small, limiting statistical power, and the primary endpoint captured only clinically consequential deterioration requiring diversion — not the full spectrum of delayed anastomotic abnormalities or functional decline that patients may endure without a new stoma. Patient-reported bowel, urinary, and sexual function were not systematically collected, and the decision to create a re-stoma inevitably involves physician judgment and patient preference. Even so, the central message stands: approximately 90 percent of patients were ultimately stoma-free after radiation-based neoadjuvant treatment and sphincter-preserving surgery, and TNT was not associated with worse long-term stoma outcomes. The authors argue that sustained stoma-free status should be recognized as a clinically meaningful endpoint in its own right, tracked well beyond the day the diverting stoma is closed — with careful pre-closure imaging, continued vigilance for late anastomotic failure, and standardized assessment of bowel function in future studies.

Subject of Research: Long-term stoma-free outcomes after diverting stoma closure in rectal cancer patients treated with radiation-based neoadjuvant therapy

Article Title: Long‐Term Stoma‐Free Outcomes After Diverting Stoma Closure Following Radiation‐Based Neoadjuvant Treatment for Rectal Cancer

Article References: Ichikawa, H., Matsui, S., Sato, K., Noguchi, T., Sakamoto, T., Mukai, T., Yamaguchi, T., & Akiyoshi, T. (2026). Long‐Term Stoma‐Free Outcomes After Diverting Stoma Closure Following Radiation‐Based Neoadjuvant Treatment for Rectal Cancer. Annals of Gastroenterological Surgery, Article ags3.70279. https://doi.org/10.1002/ags3.70279

Image Credits: AI Generated

DOI: 10.1002/ags3.70279

Keywords: rectal cancer, diverting stoma, stoma closure, total neoadjuvant therapy, anastomotic complications, sphincter-preserving surgery, radiotherapy, low anterior resection syndrome, surgical outcomes, colorectal surgery, Long, Term