Outcomes of Early versus Standard Closure of Diverting Ileostomy after Proctectomy

Abstract

Objective: We aimed to compare outcomes of early and standard closure of diverting loop ileostomy (DLI) after proctectomy and determine risk factors for anastomotic leak (AL) and complications. Summary Background Data: Formation of DLI has been a routine practice after proctectomy to decrease the incidence and potential adverse sequela of AL. Methods: PubMed, Scopus and Web of Science were searched for randomized controlled trials (RCTs) that compared outcomes of early versus standard closure of DLI after proctectomy. Main outcome measures were postoperative complications, AL, ileus, surgical site infection (SSI), reoperation, readmission, and hospital stay following DLI closure. Results: Eleven RCTs (932 patients; 57% male) were included. Early closure group included 474 patients and standard closure 458 patients. Early closure was associated with higher odds of AL (OR: 2.315, P=0.013) and similar odds of complications (OR: 1.103, P=0.667), ileus (OR: 1.307, P=0.438), SSI (OR:1.668, P=0.079), reoperation (OR: 1.896, P=0.062) and readmission (OR: 3.431, P=0.206). Hospital stay was similar (WMD: 1.054, P=0.237). Early closure had higher odds of AL than standard closure when early closure was done ≤2 weeks (OR: 2.12, P=0.047) but not within 3-4 weeks (OR: 2.98, P=0.107). Factors significantly associated with complications after early closure were diabetes mellitus, smoking, and closure of DLI ≤2 weeks whereas factors associated with AL were ≥ASA II classification and diabetes mellitus. Conclusions: Early closure of DLI after proctectomy has a higher risk of AL, particularly within two weeks of DLI formation. On the basis of this study, routine early ileostomy closure cannot be recommended.