Abstract
OBJECTIVES: Perianal fistulizing Crohn's disease (pfCD) is a severe type of inflammatory bowel disease resulting in significant patient morbidity. Despite advancements in treatments, pfCD remains challenging to manage with low healing rates. Fecal diversion (FD) has previously demonstrated clinical improvement for patients with refractory disease. Our meta-analysis aimed to explore the clinical response to FD, rates of successful restoration of bowel continuity after FD, rates of re-diversion, and factors affecting the success of FD in pfCD. METHODS: A systematic review and meta-analysis was carried out of adult patients who had undergone FD for pfCD, with detailed patient outcome data. Studies were identified through a literature search of six bibliographic databases and one trial register, all run on February 28, 2025, including MEDLINE ALL, EMBASE, Emcare, APA PsycInfo, CINAHL, Cochrane Library, and Clinicaltrials.gov. RESULTS: Seventeen studies encompassing 714 adult pfCD patients were included. FD resulted in a 65% clinical improvement rate, yet considerable heterogeneity existed in study methodologies and outcome definitions. While 29% of patients achieved bowel restoration within a median follow-up of 58.2 months, challenges in sustaining the effects were evident, with 10% requiring repeat diversion and a 37% overall proctectomy/proctocolectomy rate. Factors associated with diversion success included the absence of rectal involvement and quiescent luminal disease, with biologic use showing no impact on outcomes. CONCLUSIONS: FD offers symptom control in pfCD, although restoration rates remain low. These findings emphasize the need for individualized patient counseling. Future research should strive for uniform measures and refined approaches to enhance pfCD management.