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 research team, led by authors including Yudai Fukui, Koya Hida, Marie Hanaoka, and Yusuke Kinugasa, screened 438 records and ultimately synthesized 29 studies, comprising 20 observational investigations, four reports from randomized trials, and five systematic reviews or meta-analyses. Rather than pooling heterogeneous data into a single meta-analysis, which the authors argue would obscure clinically meaningful differences, they stratified the evidence by clinical setting, operative strategy, and patient risk profile. This framework allowed them to separate the true effects of the surgical approach itself from the powerful influence of patient selection, disease severity, and institutional expertise, factors that have long muddied comparisons between the two techniques.

The strongest evidence comes from the elective setting, where patients undergo planned sigmoid resection after recurrent episodes of diverticulitis. Randomized trials, including the landmark Dutch Sigma trial of 104 patients, demonstrated that laparoscopic sigmoidectomy reduced major morbidity, lessened early postoperative pain, shortened hospitalization, and sped recovery compared with open surgery. A Cochrane review of three randomized trials involving 392 patients confirmed that laparoscopy may reduce pain, though with low certainty and a notable trade-off: operative times ran nearly 50 minutes longer on average. Yet the review also highlights a sobering caveat. Mid- and long-term follow-up studies from these same trials found no clear differences in mortality, gastrointestinal function, or quality of life, and economic analyses from the Sigma trial showed that higher operative costs for laparoscopy were offset only to the point of comparable overall healthcare spending, not savings.

Large real-world database studies reinforce the short-term picture. Analyses of more than 124,000 elective colectomies in the Nationwide Inpatient Sample and nearly 7,700 cases in the American College of Surgeons NSQIP registry found lower postoperative morbidity, fewer wound complications, shorter hospital stays, and lower hospital charges with laparoscopy. For complicated diverticulitis specifically, a cohort of nearly 12,000 patients showed that the morbidity advantage was most pronounced among those receiving primary anastomosis. These observational findings are impressively consistent, but the authors caution that residual confounding by indication, the tendency to offer keyhole surgery to fitter patients with less severe disease, remains an unavoidable limitation of nonrandomized data.

The emergency setting is where the review delivers its most striking and clinically consequential findings. In one large NSQIP analysis of 9,194 emergent colectomies for diverticulitis, minimally invasive surgery was associated with significantly fewer major adverse events, 42.0 percent versus 56.4 percent, an adjusted odds ratio of 0.56, along with lower 30-day mortality of 4.1 percent versus 8.8 percent, dramatically lower ostomy formation at 35.8 percent versus 84.8 percent, fewer ileus cases, and shorter hospital stays of a median 7 versus 9 days. In selected cohorts, even operations that began laparoscopically and converted to open surgery were not associated with worse outcomes than planned open procedures, challenging the long-held assumption that conversion signals failure. Hospital volume emerged as a key modifier, with higher minimally invasive surgical volumes linked to lower conversion rates.

For perforated diverticulitis, the review’s most technically detailed domain, outcomes depended sharply on which operation was performed. In a propensity score-matched cohort of patients with purulent or fecal peritonitis, laparoscopic sigmoidectomy achieved lower overall morbidity of 44 percent versus 66 percent, shorter hospitalization of 7 versus 9 days, far fewer wound infections at 3 percent versus 29 percent, and a higher 12-month probability of being stoma-free among Hartmann procedure patients, 0.88 versus 0.64. By contrast, laparoscopic Hartmann procedures showed only limited advantages, chiefly reduced superficial surgical site infections, without consistent reductions in mortality or major complications. Most provocatively, the review concluded that laparoscopic lavage and drainage, a strategy of washing out the abdomen without removing the diseased segment, cannot be considered equivalent to laparoscopic resection, with comparative evidence suggesting lavage-based approaches may carry more frequent severe complications than open resection.

High-risk populations received special attention, and here the observational associations were among the most favorable. In cirrhotic patients undergoing colectomy for acute diverticulitis, laparoscopy was linked to lower mortality, shorter stays, and reduced costs. Among patients with respiratory comorbidities, hospital stays were dramatically shorter with laparoscopy, 5.3 versus 9.5 days in smokers, 6.8 versus 11.1 days in patients with dyspnea, and 7.4 versus 12.6 days in those with chronic obstructive pulmonary disease. In elderly patients, laparoscopic surgery reduced 30-day morbidity in both elective and non-elective settings, with odds ratios of 0.47 and 0.76 respectively, alongside fewer surgical site infections and shorter admissions. The authors repeatedly stress, however, that preferential selection of physiologically fitter patients for keyhole surgery may substantially inflate these apparent benefits.

Procedure-specific findings extended the favorable pattern to fistulizing disease and right-sided diverticulitis. A meta-analysis of diverticular colovesical fistulas, where the inflamed colon has eroded into the bladder, found fewer total postoperative complications with laparoscopy, an odds ratio of 0.55, and hospital stays nearly three days shorter, while mortality, anastomotic leak, and stoma rates remained comparable. A multicenter German study of fistulizing recurrent diverticulitis confirmed faster bowel recovery and shorter intensive care stays. For right-sided disease, a less common variant typically managed differently from sigmoid diverticulitis, NSQIP data showed comparable morbidity with shorter hospitalization after minimally invasive resection, and small comparative studies supported feasibility in selected complicated cases.

On the intraoperative front, the review found less to celebrate. Laparoscopic surgery consistently required longer operative time, with a matched perforated-disease cohort showing 127 versus 96.5 minutes, and while blood loss appeared numerically lower in several studies, evidence that laparoscopy reduces intraoperative complications remains insufficient. Questions about ureteral injury, a feared complication in inflamed diverticular fields, could not be answered definitively, though the authors note that fluorescence-guided ureter visualization techniques are attracting growing interest even as their protective value remains unproven.

The review’s ultimate contribution is a decision-making framework rather than a verdict. Laparoscopy offers its clearest and best-supported benefits in elective surgery, meaningful promise in selected emergency resections, perforated disease treated with resection rather than lavage, high-risk patients, fistulizing disease, and right-sided cases, while its role in Hartmann procedures and lavage-based strategies is far more uncertain. The authors emphasize that in emergency surgery, rapid and reliable source control of infection must take priority over completing a minimally invasive procedure, and that conversion to open surgery should be regarded as an appropriate safety decision rather than a technical failure. They also acknowledge their study’s limitations, including the absence of a formal risk-of-bias assessment, the exclusion of robotic surgery, and the reality that observational findings represent associations rather than causal proof. The choice of surgical approach, they conclude, should be driven not by technique alone but by the interplay of disease severity, patient condition, operative strategy, and institutional expertise, a conclusion that reframes the laparoscopic-versus-open debate as a question of matching the right operation to the right patient rather than crowning a single winner.

Subject of Research: Comparative outcomes of laparoscopic versus open surgery for colonic diverticular disease across elective, emergency, perforated, and high-risk clinical settings

Article Title: Laparoscopic Versus Open Surgery for Diverticular Disease: A Structured Review Across Clinical Settings and Operative Strategies

Article References: Hanaoka, M., Fukui, Y., Hida, K., Takeuchi, H., & Kinugasa, Y. (2026). Laparoscopic Versus Open Surgery for Diverticular Disease: A Structured Review Across Clinical Settings and Operative Strategies. Annals of Gastroenterological Surgery, Article ags3.70285. https://doi.org/10.1002/ags3.70285

Image Credits: AI Generated

DOI: 10.1002/ags3.70285

Keywords: diverticular disease, diverticulitis, laparoscopic surgery, open surgery, colectomy, sigmoidectomy, Hartmann procedure, laparoscopic lavage, emergency surgery, perforated diverticulitis, stoma creation, surgical outcomes