Abstract
Background and aims
Loop ileostomies are used currently in surgical practice to reduce the consequences of distal anastomotic failure following colorectal resection. It is often assumed that reversal of a loop ileostomy is a simple and safe procedure. However, many studies have demonstrated high morbidity rates following loop ileostomy closure. The aims of this systematic review were to examine all the existing evidence in the literature on morbidity and mortality following closure of loop ileostomy.
Method
A literature search of Ovid, Embase, the Cochrane database, Google Scholar™ and Medline using Pubmed as the search engine was used to identify studies reporting on the morbidity of loop ileostomy closure (latest at June 15th 2008), was performed. Outcomes of interest included demographics, the details regarding the original indication for operation, operative and hospital-related outcomes, post-operative bowel-related complications, and other surgical and medical complications.
Results
Forty-eight studies from 18 countries satisfied the inclusion criteria. Outcomes of a total of 6,107 patients were analysed. Overall morbidity following closure of loop ileostomy was found to be 17.3% with a mortality rate of 0.4%. 3.7% of patients required a laparotomy at the time of ileostomy closure. The most common post-operative complications included small bowel obstruction (7.2%) and wound sepsis (5.0%).
Conclusion
The consequences of anastomotic leakage following colorectal resection are severe. However, the consequences of stoma reversal are often underestimated. Surgeons should adopt a selective strategy regarding the use of defunctioning ileostomy, and counsel patients further prior to the original surgery. In this way, patients at low risk may be spared the morbidity of stoma reversal.
Similar content being viewed by others
References
Turnbull RB Jr, Hawk WA, Weakley FL (1971) Surgical treatment of toxic megacolon. Ileostomy and colostomy to prepare patients for colectomy. Am J Surg 122(3):325–331
Tilney HS, Sains PS, Lovegrove RE, Reese GE, Heriot AG, Tekkis PP (2007) Comparison of outcomes following ileostomy versus colostomy for defunctioning colorectal anastomoses. World J Surg 31(5):1142–1151
Bell SW, Walker KG, Rickard MJ et al (2003) Anastomotic leakage after curative anterior resection results in a higher prevalence of local recurrence. Br J Surg 90(10):1261–1266
Law WL, Choi HK, Lee YM, Ho JW, Seto CL (2007) Anastomotic leakage is associated with poor long-term outcome in patients after curative colorectal resection for malignancy. J Gastrointest Surg 11(1):8–15
Kanellos I, Blouhos K, Demetriades H et al (2004) The failed intraperitoneal colon anastomosis after colon resection. Tech Coloproctol 8(Suppl 1):s53–s55
Karanjia ND, Corder AP, Holdsworth PJ, Heald RJ (1991) Risk of peritonitis and fatal septicaemia and the need to defunction the low anastomosis. Br J Surg 78(2):196–198
Karanjia ND, Corder AP, Bearn P, Heald RJ (1994) Leakage from stapled low anastomosis after total mesorectal excision for carcinoma of the rectum. Br J Surg 81(8):1224–1226
Shellito PC (1998) Complications of abdominal stoma surgery. Dis Colon Rectum 41(12):1562–1572
Lertsithichai P, Rattanapichart P (2004) Temporary ileostomy versus temporary colostomy: a meta-analysis of complications. Asian J Surg 27(3):202–210 discussion 211–212
Kaidar-Person O, Person B, Wexner SD (2005) Complications of construction and closure of temporary loop ileostomy. J Am Coll Surg 201(5):759–773
Leung TT, MacLean AR, Buie WD, Dixon E (2008) Comparison of stapled versus handsewn loop ileostomy closure: a meta-analysis. J Gastrointest Surg 12(5):939–944
Garcia-Botello SA, Garcia-Armengol J, Garcia-Granero E et al (2004) A prospective audit of the complications of loop ileostomy construction and takedown. Dig Surg 21(5–6):440–446
Shea BJ, Grimshaw JM, Wells GA et al (2007) Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 7:10
Amin SN, Memon MA, Armitage NC, Scholefield JH (2001) Defunctioning loop ileostomy and stapled side-to-side closure has low morbidity. Ann R Coll Surg Engl 83(4):246–249
Bain IM, Patel R, Keighley MR (1996) Comparison of sutured and stapled closure of loop ileostomy after restorative proctocolectomy. Ann R Coll Surg Engl 78(6):555–6
Bakx R, Busch OR, van Geldere D, Bemelman WA, Slors JF, van Lanschot JJ (2003) Feasibility of early closure of loop ileostomies: a pilot study. Dis Colon Rectum 46(12):1680–1684
Barry M, Mealy K, Hyland J (1992) The role of the defunctioning ileostomy in restorative proctocolectomy. Ir J Med Sci 161(9):559–560
Bell C, Asolati M, Hamilton E et al (2005) A comparison of complications associated with colostomy reversal versus ileostomy reversal. Am J Surg 190(5):717–720
Berry DP, Scholefield JH (1997) Closure of loop ileostomy. Br J Surg 84(4):524
Carlsen E, Bergan AB (1999) Loop ileostomy: technical aspects and complications. Eur J Surg 165(2):140–143 discussion 144
Chen F, Stuart M (1996) The morbidity of defunctioning stomata. Aust N Z J Surg 66(4):218–221
Edwards DP, Leppington-Clarke A, Sexton R, Heald RJ, Moran BJ (2001) Stoma-related complications are more frequent after transverse colostomy than loop ileostomy: a prospective randomized clinical trial. Br J Surg 88(3):360–363
Fasth S, Hulten L, Palselius I (1980) Loop ileostomy—an attractive alternative to a temporary transverse colostomy. Acta Chir Scand 146(3):203–207
Feinberg SM, McLeod RS, Cohen Z (1987) Complications of loop ileostomy. Am J Surg 153(1):102–107
Fonkalsrud EW, Thakur A, Roof L (2000) Comparison of loop versus end ileostomy for fecal diversion after restorative proctocolectomy for ulcerative colitis. J Am Coll Surg 190(4):418–422
Gastinger I, Marusch F, Steinert R, Wolff S, Koeckerling F, Lippert H (2005) Protective defunctioning stoma in low anterior resection for rectal carcinoma. Br J Surg 92(9):1137–1142
Gooszen AW, Geelkerken RH, Hermans J, Lagaay MB, Gooszen HG (1998) Temporary decompression after colorectal surgery: randomized comparison of loop ileostomy and loop colostomy. Br J Surg 85(1):76–79
Gunnarsson U, Karlbom U, Docker M, Raab Y, Pahlman L (2004) Proctocolectomy and pelvic pouch—is a diverting stoma dangerous for the patient? Colorectal Dis 6(1):23–27
Haase O, Raue W, Bohm B, Neuss H, Scharfenberg M, Schwenk W (2005) Subcutaneous gentamycin implant to reduce wound infections after loop-ileostomy closure: a randomized, double-blind, placebo-controlled trial. Dis Colon Rectum 48(11):2025–2031
Hainsworth PJ, Bartolo DC (1998) Selective omission of loop ileostomy in restorative proctocolectomy. Int J Colorectal Dis 13(3):119–123
Hallbook O, Matthiessen P, Leinskold T, Nystrom PO, Sjodahl R (2002) Safety of the temporary loop ileostomy. Colorectal Dis 4(5):361–364
Hasegawa H, Radley S, Morton DG, Keighley MR (2000) Stapled versus sutured closure of loop ileostomy: a randomized controlled trial. Ann Surg 231(2):202–204
Hull TL, Kobe I, Fazio VW (1996) Comparison of handsewn with stapled loop ileostomy closures. Dis Colon Rectum 39(10):1086–1089
Ikeuchi H, Nakano H, Uchino M et al (2005) Safety of one-stage restorative proctocolectomy for ulcerative colitis. Dis Colon Rectum 48(8):1550–1555
Kaiser AM, Israelit S, Klaristenfeld D et al (2008) Morbidity of ostomy takedown. J Gastrointest Surg 12(3):437–441
Khoo RE, Cohen MM, Chapman GM, Jenken DA, Langevin JM (1994) Loop ileostomy for temporary fecal diversion. Am J Surg 167(5):519–522
Krand O, Yalti T, Berber I, Tellioglu G (2008) Early vs. delayed closure of temporary covering ileostomy: a prospective study. Hepatogastroenterology 55(81):142–145
Lahat G, Tulchinsky H, Goldman G, Klauzner JM, Rabau M (2005) Wound infection after ileostomy closure: a prospective randomized study comparing primary vs. delayed primary closure techniques. Tech Coloproctol 9(3):206–208
Law WL, Chu KW, Choi HK (2002) Randomized clinical trial comparing loop ileostomy and loop transverse colostomy for faecal diversion following total mesorectal excision. Br J Surg 89(6):704–708
Lewis P, Bartolo DC (1990) Closure of loop ileostomy after restorative proctocolectomy. Ann R Coll Surg Engl 72(4):263–265
Mala T, Nesbakken A (2008) Morbidity related to the use of a protective stoma in anterior resection for rectal cancer. Colorectal Dis 10(4):785–788
Mann LJ, Stewart PJ, Goodwin RJ, Chapuis PH, Bokey EL (1991) Complications following closure of loop ileostomy. Aust N Z J Surg 61(7):493–496
Mansfield SD, Jensen C, Phair AS, Kelly OT, Kelly SB (2008) Complications of loop ileostomy closure: a retrospective cohort analysis of 123 patients. World J Surg 32(9):2101–2106
Matthiessen P, Hallbook O, Rutegard J, Simert G, Sjodahl R (2007) Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 246(2):207–214
O’Toole GC, Hyland JM, Grant DC, Barry MK (1999) Defunctioning loop ileostomy: a prospective audit. J Am Coll Surg 188(1):6–9
Perez RO, Habr-Gama A, Seid VE et al (2006) Loop ileostomy morbidity: timing of closure matters. Dis Colon Rectum 49(10):1539–1545
Phang PT, Hain JM, Perez-Ramirez JJ, Madoff RD, Gemlo BT (1999) Techniques and complications of ileostomy takedown. Am J Surg 177(6):463–466
Platell C, Barwood N, Makin G (2005) Clinical utility of a de-functioning loop ileostomy. ANZ J Surg 75(3):147–151
Poon RT, Chu KW, Ho JW, Chan CW, Law WL, Wong J (1999) Prospective evaluation of selective defunctioning stoma for low anterior resection with total mesorectal excision. World J Surg 23(5):463–467 discussion 467–468
Rathnayake MM, Kumarage SK, Wijesuriya SR, Munasinghe BN, Ariyaratne MH, Deen KI (2008) Complications of loop ileostomy and ileostomy closure and their implications for extended enterostomal therapy: a prospective clinical study. Int J Nurs Stud 45(8):1118–1121
Rullier E, Le Toux N, Laurent C, Garrelon JL, Parneix M, Saric J (2001) Loop ileostomy versus loop colostomy for defunctioning low anastomoses during rectal cancer surgery. World J Surg 25(3):274–277 discussion 277–278
Sakai Y, Nelson H, Larson D, Maidl L, Young-Fadok T, Ilstrup D (2001) Temporary transverse colostomy vs loop ileostomy in diversion: a case-matched study. Arch Surg 136(3):338–342
Senapati A, Nicholls RJ, Ritchie JK, Tibbs CJ, Hawley PR (1993) Temporary loop ileostomy for restorative proctocolectomy. Br J Surg 80(5):628–630
Thalheimer A, Bueter M, Kortuem M, Thiede A, Meyer D (2006) Morbidity of temporary loop ileostomy in patients with colorectal cancer. Dis Colon Rectum 49(7):1011–1017
Tsunoda A, Tsunoda Y, Narita K, Watanabe M, Nakao K, Kusano M (2008) Quality of life after low anterior resection and temporary loop ileostomy. Dis Colon Rectum 51(2):218–222
van de Pavoordt HD, Fazio VW, Jagelman DG, Lavery IC, Weakley FL (1987) The outcome of loop ileostomy closure in 293 cases. Int J Colorectal Dis 2(4):214–217
Welten RJ, Jansen A, van de Pavoordt HD (1991) A future role for loop ileostomy in colorectal surgery? Neth J Surg 43(5):192–194
Wexner SD, Taranow DA, Johansen OB et al (1993) Loop ileostomy is a safe option for fecal diversion. Dis Colon Rectum 36(4):349–354
Williams NS, Nasmyth DG, Jones D, Smith AH (1986) De-functioning stomas: a prospective controlled trial comparing loop ileostomy with loop transverse colostomy. Br J Surg 73(7):566–570
Wong KS, Remzi FH, Gorgun E et al (2005) Loop ileostomy closure after restorative proctocolectomy: outcome in 1, 504 patients. Dis Colon Rectum 48(2):243–250
Williams LA, Sagar PM, Finan PJ, Burke D (2008) The outcome of loop ileostomy closure: a prospective study. Colorectal Dis 10(5):460–464
Rullier E, Laurent C, Garrelon JL, Michel P, Saric J, Parneix M (1998) Risk factors for anastomotic leakage after resection of rectal cancer. Br J Surg 85(3):355–358
Chambers WM, Mortensen NJ (2004) Postoperative leakage and abscess formation after colorectal surgery. Best Pract Res Clin Gastroenterol 18(5):865–880
Hallbook O, Sjodahl R (1996) Anastomotic leakage and functional outcome after anterior resection of the rectum. Br J Surg 83(1):60–62
McArdle CS, McMillan DC, Hole DJ (2005) Impact of anastomotic leakage on long-term survival of patients undergoing curative resection for colorectal cancer. Br J Surg 92(9):1150–1154
Guenaga KF, Lustosa SA, Saad SS, Saconato H, Matos D (2007) Ileostomy or colostomy for temporary decompression of colorectal anastomosis. Cochrane Database Syst Rev 1:CD004647
Guidelines for the Management of Colorectal Cancer. 3rd ed: The Association of Coloproctology of Great Britain and Ireland, 2007. A copy can be found at www.acpgbi.org.uk/assets/documents/COLO_guides.pdf
Huser N, Michalski CW, Erkan M et al (2008) Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery. Ann Surg 248(1):52–60
Weston-Petrides GK, Lovegrove RE, Tilney HS et al (2008) Comparison of outcomes after restorative proctocolectomy with or without defunctioning ileostomy. Arch Surg 143(4):406–412
70. Department_of_Health: Hospital Episode Statistics: Inpatient Data, Main Operations: 4 Character 2005–2006.
O’Leary DP, Fide CJ, Foy C, Lucarotti ME (2001) Quality of life after low anterior resection with total mesorectal excision and temporary loop ileostomy for rectal carcinoma. Br J Surg 88(9):1216–1220
Silva MA, Ratnayake G, Deen KI (2003) Quality of life of stoma patients: temporary ileostomy versus colostomy. World J Surg 27(4):421–424
Kairaluoma M, Rissanen H, Kultti V, Mecklin JP, Kellokumpu I (2002) Outcome of temporary stomas. A prospective study of temporary intestinal stomas constructed between 1989 and 1996. Dig Surg 19(1):45–51
Kanellos I, Zacharakis E, Christoforidis E, Demetriades H, Betsis D (2002) Low anterior resection without defunctioning stoma. Tech Coloproctol 6(3):153–156 discussion 156–157
Grobler SP, Hosie KB, Keighley MR (1992) Randomized trial of loop ileostomy in restorative proctocolectomy. Br J Surg 79(9):903–906
Law WI, Chu KW, Ho JW, Chan CW (2000) Risk factors for anastomotic leakage after low anterior resection with total mesorectal excision. Am J Surg 179(2):92–96
Makela JT, Kiviniemi H, Laitinen S (2003) Risk factors for anastomotic leakage after left-sided colorectal resection with rectal anastomosis. Dis Colon Rectum 46(5):653–660
Schrock TR, Deveney CW, Dunphy JE (1973) Factor contributing to leakage of colonic anastomoses. Ann Surg 177(5):513–518
Rudinskaite G, Tamelis A, Saladzinskas Z, Pavalkis D (2005) Risk factors for clinical anastomotic leakage following the resection of sigmoid and rectal cancer. Medicina (Kaunas) 41(9):741–746
Vignali A, Fazio VW, Lavery IC et al (1997) Factors associated with the occurrence of leaks in stapled rectal anastomoses: a review of 1, 014 patients. J Am Coll Surg 185(2):105–113
Kapiteijn E, Marijnen CA, Nagtegaal ID et al (2001) Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 345(9):638–646
Sauer R, Becker H, Hohenberger W et al (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351(17):1731–1740
Mealy K, Burke P, Hyland J (1992) Anterior resection without a defunctioning colostomy: questions of safety. Br J Surg 79(4):305–307
Parker MC, Wilson MS, van Goor H et al (2007) Adhesions and colorectal surgery—call for action. Colorectal Dis 9(Suppl 2):66–72
Ellis H (2004) Medicolegal consequences of adhesions. Hosp Med 65(6):348–350
Bakx R, Busch OR, Bemelman WA, Veldink GJ, Slors JF, van Lanschot JJ (2004) Morbidity of temporary loop ileostomies. Dig Surg 21(4):277–281
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Chow, A., Tilney, H.S., Paraskeva, P. et al. The morbidity surrounding reversal of defunctioning ileostomies: a systematic review of 48 studies including 6,107 cases. Int J Colorectal Dis 24, 711–723 (2009). https://doi.org/10.1007/s00384-009-0660-z
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00384-009-0660-z