Meta-analysis of early versus late closure of a temporary ileostomy after proctectomy

Abstract

Background: A temporary ileostomy is frequently constructed to reduce the risk of symptomatic anastomotic leakage. An ostomy is a heavy burden on both patient and society, and early closure is therefore desirable to counteract increased morbidity. The optimal time for stoma closure has been investigated in some studies, although it remains controversial. Methods: We conducted a literature search of PubMed, Wiley, Web of Science, and the Cochrane Library to identify studies published till 2017 that focused on perioperative complications and details related to early(<4 weeks) and late(>4weeks) closure of temporary ileostomies after proctectomy. Results: Six studies (three randomized controlled trials, two prospective nonrandomized trials, and one retrospective trial) satisfied our inclusion criteria, and the outcomes of 767 patients (356 early closures and 411 late closures) were analyzed. There was a significantly lower prevalence of skin irritation (p=0.0002) in the early group, but no worse morbidity outcomes were observed between the early and late closure groups. Hospital stay length after an ileostomy closure was not prolonged following early closure, suggesting that the increased wound infection risk did not significantly delay discharge. Also, the overall hospital stay length, when time since admission for the original operation was included in the late closure group, showed no significantly longer duration in the early closure group (p = 0.02). Conclusions: We found that early closure of a temporary ileostomy after proctectomy was feasible in selected patients, with some advantages and disadvantages that need to be weighed by the patient and surgeon.

Post-operative Complications in Patients Undergoing Early Closure Compared to Delayed Closure of Ileostomy: A Meta-Analysis

“…12 Khan, et al even stated that delayed closure of ileostomy may be abandoned completely. 11 Aside from the 8 RCT's analyzed for this study, current review of literature also revealed two meta-analysis 4,15 attempting to summarize these findings. One unpublished study 4 concluded that early closure of a temporary ileostomy after proctectomy at 4 weeks shows no significantly increased morbidity, except an increased wound infection rate.…”

“…1 Gastrointestinal continuity is restored after a period of 6-12 weeks but it can be longer if the patient is on adjuvant chemotherapy or due to low priority given to this procedure. 2 It has been proven by a few RCT's 3 and one unpublished meta-analysis 4 that early stoma closure (EC) within 4 weeks after proctectomy is feasible and has some advantages in selected patients. It was also stated that early closure of a temporary ileostomy after proctectomy at 4 weeks showed no significantly increased morbidity, except for an increased wound infection rate.…”

“…It was also stated that early closure of a temporary ileostomy after proctectomy at 4 weeks showed no significantly increased morbidity, except for an increased wound infection rate. 4,15 In 21-28% of cases, defunctioning stomas are not reversed, becoming permanent. 5 Reasons for not reversing a stoma include advanced cancer stage and anastomotic leakage.…”

“…9 Early closure of ileostomy is often defined in majority of trials as closure of stoma within 4 weeks after initial bowel surgery. 4 In one study, early closure was defined as early closure done after the 8th day of initial surgery. 3 Compared to traditional closure, early closure has only been in practice since the early 2000's as described by current available literature.…”