The feasibility and safety of early ileostomy reversal: a systematic review and meta‐analysis

Abstract

Background Recent evidence supports the safety of early reversal of a temporary stoma, within 14 days of construction. The aim of this systematic review and meta‐analysis was to evaluate the post‐operative morbidity and overall feasibility of early stoma reversal. Methods Medline and Cochrane databases were searched for studies up to June 2019 that investigated the outcomes of early stoma reversal (EC, defined as closure ≤14 days from the index operation) versus late stoma reversal (LC, ≥8 weeks from the index operation). Meta‐analysis was performed on the respective rates of post‐operative morbidity, anastomotic leak, wound infection, bleeding, sepsis, small bowel obstruction and ileus. Results Nine studies were included (667 patients analysed). Meta‐analysis showed no significant difference in the post‐operative morbidity rate, anastomotic leak rate, rates of small bowel obstruction, bleeding and ileus between EC and LC. However, the wound infection rate was significantly higher after EC than LC; relative difference 0.10 (95% confidence interval 0.00–0.19, P = 0.047). The stoma‐related complication rate was significantly higher after LC than EC; relative difference −0.28 (95% confidence interval ‐0.45 to −0.11, P = 0.001). Conclusion The concept of early stoma reversal is appealing, and this meta‐analysis confirms the safety of early stoma closure with an associated reduction in stoma‐related complications despite higher wound infection rates. However, the results need to be interpreted with caution due to the heterogeneity of the studies included, especially in respect of the definition of complications that were used. Further well‐designed prospective studies are required prior to confident adoption of early stoma closure into clinical practice.

Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project

“…Ng et al [ 217 ], in their pooled analysis of 667 patients from nine studies, confirmed the safety of EC, with an associated reduction in stoma-related complications (8.4% vs. 33.4%, RD = − 0.28, P = 0.001) despite a higher wound infection rate (18.6% vs. 7.1%, RD = 0.10, P = 0.047). The meta-analysis showed no significant difference in the postoperative morbidity rate, anastomotic leak rate, rates of small bowel obstruction, bleeding, and ileus between EC and LC.…”

“…To improve QoL, early stoma closure within 2 weeks from the index operation has been proposed. Six randomized controlled trials [ 204 , 210 – 214 ] published over the past 10 years, and four systematic reviews with meta-analysis published over the past 2 years [ 202 , 215 – 217 ] were evaluated by the meta-analysis team.…”

Temporary impairment of renal function in patients with rectal cancer treated with diverting ileostomy

“…For patients with a high risk of renal function damage who require a temporary diverting stoma, more rigorous monitoring of fluids, electrolytes, and renal function is needed. Moreover, other preventative methods such as colostomy instead of ileostomy to reduce water and electrolyte loss (30), as well as shortening the time to stoma closure, might help to decrease the occurrence of renal function impairment in high-risk patients (31).…”

Early versus delayed defunctioning ileostomy closure after low anterior resection for rectal cancer: a meta-analysis and trial sequential analysis of safety and functional outcomes

“…Some recent meta-analyses have suggested that early ileostomy closure is effective and safe in selected patients [21][22][23][24]. However, others reported that early closure increased the rate of post-operative complications [25].…”