Systematic reviews and randomized controlled trials8-10 have shown defunctioning loop ileostomies effectively reduce the rate of symptomatic anastomotic leaks and the need for reoperation in such cases. Restoration of gastrointestinal continuity by reversing loop ileostomies requires a second operation, the timing of which remains controversial. Furthermore, the morbidity rate following closure of ileostomy may be close to 20%,5 and systematic reviews and retrospective studies5,11,12 have shown mechanical small bowel obstruction, ileus, and wound-related problems are common complications.
Because the optimal timing of ileostomy closure remains unknown, interest has been growing in the assessment of the association between timing of closure and postoperative outcomes. Prospective and retrospective reports13-15 are available in the literature comparing ileostomy closures as early as 8 days following the primary operation to the traditionally timed closures at 12 weeks. Two (2) retrospective studies15-16 and 1 prospective randomized trial14 compared closures at various time intervals: 1 month to after 6 months, 3 months to after 6 months, and within 3 months to after 3 months, with variable conclusions (see Table 3).
The current study compares the outcomes of ileostomy closures within 6 months to those after 6 months, the first published comparison of outcomes at these specific time intervals. A key finding from the current data is that patients who underwent early closure had a significantly shorter length of hospital stay than patients who had late closure (4.5 days vs 9.4 days, respectively; P = .01). Similar findings were reported in a prospective randomized trial by Alves et al17 that compared outcomes in 186 patients randomized into 2 groups that underwent either early (within 8 days) or late closure (at 60 days) of a loop ileostomy. The reported length of stay in the early group was significantly lower than the late group (16 vs 18 days, respectively; P = .013). Similarly, a retrospective study of 93 patients by Omundsen et al18 that compared ileostomy closures within 10 days and at 90 days found length of hospital stay in the early group was significantly lower than in the late group (14 vs 17 days, respectively; P = .05).
The current study also found the mean number of complications was significantly lower in the early group as compared to the late group (0.33 vs 0.61, respectively; P = .04), findings supported by a randomized controlled trial of 112 patients by Danielsen et al19 in which significantly fewer complications occurred in the early group as compared to the late group (1.2 vs 2.9, respectively; P <.0001). A retrospective study by Rubio-Perez et al20 concluded the delay in ileostomy closure was associated with a significant increase in postoperative complications, specifically wound infections (13%; P = .007) and pseudomembranous colitis (4%; P = .003).
In the current study, the number of cases of ileus were higher in the late group (11) than the early group (4), but the difference was not statistically significant.
Williams et al13 analyzed the changes that occur in the distal, inactive limb of a loop ileostomy and found a significant reduction in the ileal smooth muscle contractility following a period of diversion of intestinal content. Based on this finding, the authors concluded such changes may result in reduced compliance and contractility of the defunctioned bowel segment, leading to the obstructive symptoms that may be observed following ileostomy closure. This may help explain the higher rate of ileus observed in the current late group, an observation also supported by the study by Alves et al.17
In order to objectively assess postoperative complications, study data were categorized according to the Clavien-Dindo classification (see Table 2). All postoperative complications were manually graded using the Clavien-Dindo grading tool as shown in Table 2. When comparing the 2 groups, the current authors found the late group had more grade I (14/35), II (16/35), III (3/35), and V (2/35) complications compared to the early group. However, these numbers were too small to determine statistical significance.
Some studies did not demonstrate significant differences in studied outcomes between early and late ileostomy closures. In their prospective controlled trial of ileostomy closures within 1 month and after 6 months, Zhen at al14 found rates of closure-related complications (20.9% vs 18.6%, respectively; P = .637) and length of hospital stay (7.94 vs 7.97 days, respectively; P = .588) were not statistically different between the early and late groups.
A prospective study by Zhou et al15 of early defunctioning ileostomy closure among 123 patients found no significant difference between the group that had ileostomy closure within 90 days and the group that underwent ileostomy closure after 180 days in relation to stoma-related complications (early group 10%, late group 16%; P = .387), anastomotic leakage (early group 1%, late group 2%; P = .691), ileus (early group 4%, late group 9%; P = .245), and peristomal hernia (early group 5%, late group 4%; P = .190).
A large retrospective study by Li and Ozuner16 on ileostomy reversal among 358 patients also reported no differences between the early (<3 months) and late (>3 months) ileostomy closure groups in terms of rates of ileus (12.3% vs 13.4%, respectively; P >.87), small bowel obstruction (15.6% vs 15.1%, respectively; P = .5), wound infection (2.2% vs 1.7%, respectively; P = .99), and surgery-related readmission rate (0.56% vs 0%, respectively; P = .85) (see Table 3).
The current study demonstrated that early ileostomy closure may lead to a significant reduction in length of hospital stay and average number of postoperative complications. These findings are supported by some of the aforementioned studies17,19-20 and could encourage surgeons to expedite reversal of loop ileostomies whenever possible. This study is the first to compare outcomes of ileostomy closure within these particular time intervals; larger prospective studies are required to confirm these findings and help guide practice.