Evidence - Ileostomy closure

Studies indicate that a temporary ileostomy can be safely reversed early and no later than 12 weeks after it was fashioned. However, the latency between stoma construction and closure is often significantly longer and may be as long as 6 months, and it is not uncommon (9-57%) for stomas not to be taken down at all.[1-4] Reasons for failure to close a stoma include advanced patient age, low body mass index, presence of a terminal stoma, and neoadjuvant radiotherapy.[2, 5, 6] Other reasons include progressive malignancy, initial surgery with complications, and, in particular, anastomotic failure.[1, 7]

There are hardly any recommendations in the literature for ideal timing of ileostomy reversal, and management varies greatly from hospital to hospital.[8]

In 2021, a study was published with a high level of evidence that investigated postoperative complications after early closure of a diverting stoma ("early closure" [EC] ≤ 6 weeks vs. standard closure [SC] > 6 weeks) following rectal resection with unremarkable postoperative course.[9] Early closure was not associated with a higher rate of postoperative complications. However, the condition for early reversal is that patients do not have to undergo postoperative or adjuvant chemotherapy after initial surgery (rectal resection with diverting stoma).

In terms of anastomotic technique, manual and stapled suture lines are equivalent with respect to morbidity. Stapled anastomoses speed up the operating time and reduce the postoperative obstruction rate [10], but they are also incur higher costs.[11] When comparing manually sutured end-to-end anastomoses with side-to-end anastomoses, the former increases morbidity and length of stay in hospital.[12]

The body of studies on skin closure after ileostomy takedown shows a significant benefit for purse-string over linear skin closure in terms of septic wound complications [13], while there do not appear to be any differences in the rates of incisional hernia, operating time, inpatient length of stay, and patient quality of life.[14]

Early Ileostomy Closure Following Restorative Proctectomy for Rectal Cancer Patients: A North American Multicenter Randomized-Controlled Trial

Prevention of Incisional Hernia With Biosynthetic Mesh at the Site of Temporary Ileostomy Closure

Efferent Loop Stimulation Previous to Ileostomy Closure. Ileostim Trial.

Timing Evaluation of Stoma Closure (TIMES). Early vs Late Closure of Stoma After Rectal Cancer Surgery.

The Efficacy of Purse-string Skin Closure With Negative Pressure Wound Therapy (NPWT) on Wound Recovery After Ileostomy Reversal: A Prospective Randomized Clinical Trial

1. Floodeen H, Lindgren R, Matthiessen P (2013) When are defunctioning stomas in rectal cancer

surgery really reversed? Results from a population-based single center experience. Scand J Surg 102:246–250.

2. David GG, Slavin JP, Willmott S, Corless DJ,Khan AU, Selvasekar CR (2010) Loop ileostomy following

anterior resection: is it really temporary? Colorectal Dis 12:428–432.

3. Gessler B, Haglind E, Angenete E (2012) Loop ileostomies in colorectal cancer patients—morbidity

and risk factors for nonreversal. J Surg Res 178:708–714.

4. Sier MF, van Gelder L, Ubbink DT, BemelmanWA, Oostenbroek RJ (2015) Factors affecting timing of

closure and non-reversal of temporary ileostomies. Int J ColorectalDis 30:1185–1192.

5. den Dulk M, Smit M, Peeters KCMJ, Kranenbarg EM-K, Rutten HJT,Wiggers T, Putter H, van de Velde CJH,Dutch Colorectal Cancer Group(2007) A multivariate analysis of limiting factors for stoma reversal in patients with rectal cancer entered into the total mesorectal excision (TME) trial: a retrospective study. Lancet Oncol 8:297–303.

6. Lindgren R, Hallböök O, Rutegård J, Sjödahl R, Matthiessen P (2011) What is the risk for a permanent stoma after low anterior resection of the rectum for cancer? A six-year follow-up of a multicenter trial. Dis Colon Rectum 54:41–47.

7. Mohammed Ilyas MI, Haggstrom DA, Maggard-Gibbons MA, Wendel CS, Rawl S, Schmidt CM,

Ko CY, Krouse RS (2018) Patients with temporary ostomies: veterans administration hospitals multiinstitutional retrospective study. JWound Ostomy Continence Nurs 45:510–515.

8. Ostomy Guidelines Task Force, Goldberg M, Aukett LK, Carmel J, Fellows J, Folkedahl B, Pittman J, Palmer R (2010) Management of the patient with a fecalostomy: best practice guideline

for clinicians. J Wound Ostomy Continence Nurs 37:596–598.

9. Clausen FB et al (2021) Safety of early ileostomy closure: a systematic review and metaanalysis of randomized controlled trials. Int J Colorect Dis 36(2):203–212.

10. Löffler T, Rossion I, Bruckner T, Diener MK, Koch M, von Frankenberg M, Pochhammer J, Thomusch O, Kijak T, Simon T, Mihaljevic AL, Krüger M, Stein E, Prechtl G, Hodina R, Michal W, Strunk R, Henkel K, Bunse J, Jaschke G, Politt D, Heistermann HP, Fußer M, Lange C, Stamm A, Vosschulte A, Holzer R, Partecke LI, Burdzik E, Hug HM, Luntz SP, Kieser M, Büchler MW, Weitz J, HASTA Trial Group (2012) HAnd Suture Versus STApling for Closure of Loop Ileostomy (HASTA Trial): results of a multicenter randomized trial (DRKS00000040). Ann Surg 256:828–835.

11. Nemeth ZH,Bogdanovski DA,Hicks AS,Paglinco SR, Sawhney R, Pilip SA, Stopper PB, Rolandelli RH (2018) Outcome and cost analysis of hand-sewn and stapled anastomoses in the reversal of loop Ileostomy. Am Surg84:615–619.

12. Prassas D, Ntolia A, Spiekermann J-D, Rolfs T-M, Schumacher F-J (2018) Reversal of diverting loop Ileostomy using hand-sewn side-to-side versus end-to-end anastomosis after low anterior resection for rectal cancer: a single center experience.Am Surg84:1741–1744.

13. Gachabayov M, Lee H, Chudner A, Dyatlov A, Zhang N, Bergamaschi R (2019) Purse-string vs. linear skin closure at loop ileostomy reversal: a systematic review and meta-analysis. Tech Coloproctol 23:207–220.

14. Rausa E, Kelly ME, Sgroi G, Lazzari V, Aiolfi A, Cavalcoli F, Bonitta G, Bonavina L (2019) Quality of life following ostomy reversal with purse-string vs linear skin closure: a systematic review. Int J Colorectal Dis 34:209–216.