Abstract
Background
Temporary loop ileostomy is a routine procedure to reduce the morbidity of restorative proctocolectomy. However, morbidity of ileostomy closure could reduce the benefit of this concept. The objective of this systematic review was to assess the risks of ileostomy closure after restorative proctocolectomy for ulcerative colitis or familial adenomatous polyposis.
Materials and Methods
Publications in English or German language reporting morbidity of ileostomy closure after restorative proctocolectomy were identified by Medline search. Two hundred thirty-two publications were screened, 143 were assessed in full-text, and finally 26 studies (reporting 2146 ileostomy closures) fulfilled the eligibility criteria. Weighted means for overall morbidity and mortality of ileostomy closure, rate of redo operations, anastomotic dehiscence, bowel obstruction, wound infection, and late complications were calculated.
Results
Overall morbidity of ileostomy closure was 16.5 %, there was no mortality. Redo operations for complications were necessary in 3.0 %. Anastomotic dehiscence occurred in 2.0 %. Postoperative bowel obstruction developed in 7.6 %, with 2.9 % of patients requiring laparotomy for this complication. Wound infection rate was 4.0 %. Hernia or bowel obstruction as late complications developed in 1.9 and 9.4 %, respectively.
Conclusion
The considerable morbidity of ileostomy reversal reduces the overall benefit of temporary fecal diversion. However, ileostomy creation is still recommended, as it effectively reduces the risk of pouch-related septic complications.
Similar content being viewed by others
References
Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. Br Med J 1978;2:85–88.
Weston-Petrides GK, Lovegrove RE, Tilney HS, Heriot AG, Nicholls RJ, Mortensen NJ, Fazio VW, Tekkis PP. Comparison of outcomes after restorative proctocolectomy with or without defunctioning ileostomy. Arch Surg 2008;143:406–412.
Hueting WE, Buskens E, van der Tweel I, Gooszen HG, van Laarhoven CJ. Results and complications after ileal pouch anal anastomosis: a meta-analysis of 43 observational studies comprising 9,317 patients. Dig Surg 2005;22:69–79.
Fazio VW, Kiran RP, Remzi FH, Coffey JC, Heneghan HM, Kirat HT, Manilich E, Shen B, Martin ST. Ileal pouch anal anastomosis: analysis of outcome and quality of life in 3707 patients. Ann Surg 2013;257:679–685.
Raval MJ, Schnitzler M, O′Connor BI, Cohen Z, McLeod RS. Improved outcome due to increased experience and individualized management of leaks after ileal pouch-anal anastomosis. Ann Surg 2007;246:763–770.
Heuschen UA, Allemeyer EH, Hinz U, Lucas M, Herfarth C, Heuschen G. Outcome after septic complications in J pouch procedures. Br J Surg 2002;89:194–200.
Sagap I, Remzi FH, Hammel JP, Fazio VW. Factors associated with failure in managing pelvic sepsis after ileal pouch-anal anastomosis (IPAA)--a multivariate analysis. Surgery 2006;140:691–703; discussion 703–694.
Farouk R, Dozois RR, Pemberton JH, Larson D. Incidence and subsequent impact of pelvic abscess after ileal pouch-anal anastomosis for chronic ulcerative colitis. Dis Colon Rectum 1998;41:1239–1243.
Tulchinsky H, Cohen CR, Nicholls RJ. Salvage surgery after restorative proctocolectomy. Br J Surg 2003;90:909–921.
Mennigen R, Senninger N, Bruwer M, Rijcken E. Impact of defunctioning loop ileostomy on outcome after restorative proctocolectomy for ulcerative colitis. Int J Colorectal Dis 2011;26:627–633.
Fajardo AD, Dharmarajan S, George V, Hunt SR, Birnbaum EH, Fleshman JW, Mutch MG. Laparoscopic versus open 2-stage ileal pouch: laparoscopic approach allows for faster restoration of intestinal continuity. J Am Coll Surg 2010;211:377–383.
Araujo SE, Nahas SC, Seid VE, Marchini GS, Torricelli FC. Laparoscopy-assisted ileal pouch-anal anastomosis: surgical outcomes after 10 cases. Surg Laparosc Endosc Percutan Tech 2005;15:321–324.
Grobler SP, Hosie KB, Keighley MR. Randomized trial of loop ileostomy in restorative proctocolectomy. Br J Surg 1992;79:903–906.
Heuschen UA, Hinz U, Allemeyer EH, Lucas M, Heuschen G, Herfarth C. One- or two-stage procedure for restorative proctocolectomy: rationale for a surgical strategy in ulcerative colitis. Ann Surg 2001;234:788–794.
Ikeuchi H, Nakano H, Uchino M, Nakamura M, Noda M, Yanagi H, Yamamura T. Safety of one-stage restorative proctocolectomy for ulcerative colitis. Dis Colon Rectum 2005;48:1550–1555.
Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6:e1000097.
Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, Porter AC, Tugwell P, Moher D, Bouter LM. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 2007;7:10.
Dolejs S, Kennedy G, Heise CP. Small bowel obstruction following restorative proctocolectomy: affected by a laparoscopic approach? J Surg Res 2011;170:202–208.
Selvaggi F, Sciaudone G, Limongelli P, Di Stazio C, Guadagni I, Pellino G, De Rosa M, Riegler G. The effect of pelvic septic complications on function and quality of life after ileal pouch-anal anastomosis: a single center experience. Am Surg 2010;76:428–435.
Gunnarsson U, Karlbom U, Docker M, Raab Y, Pahlman L. Proctocolectomy and pelvic pouch--is a diverting stoma dangerous for the patient? Colorectal Dis 2004;6:23–27.
Fonkalsrud EW, Thakur A, Roof L. Comparison of loop versus end ileostomy for fecal diversion after restorative proctocolectomy for ulcerative colitis. J Am Coll Surg 2000;190:418–422.
Dolgin SE, Shlasko E, Gorfine S, Bekov K, Leleiko N. Restorative proctocolectomy in children with ulcerative colitis utilizing rectal mucosectomy with or without diverting ileostomy. J Pediatr Surg 1999;34:837–840.
Edwards DP, Chisholm EM, Donaldson DR. Closure of transverse loop colostomy and loop ileostomy. Ann R Coll Surg Engl 1998;80:33–35.
Bain IM, Patel R, Keighley MR. Comparison of sutured and stapled closure of loop ileostomy after restorative proctocolectomy. Ann R Coll Surg Engl 1996;78:555–556.
Khoo RE, Cohen MM, Chapman GM, Jenken DA, Langevin JM. Loop ileostomy for temporary fecal diversion. Am J Surg 1994;167:519–522.
Seow-Choen F, Ho YH, Goh HS. The ileo-anal reservoir: results from an evolving use of stapling devices. J R Coll Surg Edinb 1994;39:13–16.
Braun J, Schumpelick V. [Direct ileum pouch-anal anastomosis in ulcerative colitis. Technique and complications]. Chirurg 1992;63:361–367.
Poppen B, Svenberg T, Bark T, Sjogren B, Rubio C, Drakenberg B, Slezak P. Colectomy-proctomucosectomy with S-pouch: operative procedures, complications, and functional outcome in 69 consecutive patients. Dis Colon Rectum 1992;35:40–47.
de Silva HJ, de Angelis CP, Soper N, Kettlewell MG, Mortensen NJ, Jewell DP. Clinical and functional outcome after restorative proctocolectomy. Br J Surg 1991;78:1039–1044.
Sugerman HJ, Newsome HH, Decosta G, Zfass AM. Stapled ileoanal anastomosis for ulcerative colitis and familial polyposis without a temporary diverting ileostomy. Ann Surg 1991;213:606–617; discussion 617–609.
Sutter PM, Schuppisser JP, Ackermann C, Herzog U, Tondelli P. [Early and long-term results following ileum-anal pouch anastomosis]. Schweiz Med Wochenschr 1991;121:741–743.
Lewis P, Bartolo DC. Closure of loop ileostomy after restorative proctocolectomy. Ann R Coll Surg Engl 1990;72:263–265.
Matikainen M, Santavirta J, Hiltunen KM. Ileoanal anastomosis without covering ileostomy. Dis Colon Rectum 1990;33:384–388.
Wexner SD, Wong WD, Rothenberger DA, Goldberg SM. The ileoanal reservoir. Am J Surg 1990;159:178–183; discussion 183–175.
Feinberg SM, McLeod RS, Cohen Z. Complications of loop ileostomy. Am J Surg 1987;153:102–107.
Harms BA, Hamilton JW, Yamamoto DT, Starling JR. Quadruple-loop (W) ileal pouch reconstruction after proctocolectomy: analysis and functional results. Surgery 1987;102:561–567.
Nasmyth DG, Williams NS, Johnston D. Comparison of the function of triplicated and duplicated pelvic ileal reservoirs after mucosal proctectomy and ileo-anal anastomosis for ulcerative colitis and adenomatous polyposis. Br J Surg 1986;73:361–366.
Metcalf AM, Dozois RR, Kelly KA, Beart RW, Jr., Wolff BG. Ileal "J" pouch-anal anastomosis. Clinical outcome. Annals of surgery 1985;202:735–739.
Nicholls RJ, Pezim ME. Restorative proctocolectomy with ileal reservoir for ulcerative colitis and familial adenomatous polyposis: a comparison of three reservoir designs. Br J Surg 1985;72:470–474.
de Montbrun SL, Johnson PM. Proximal diversion at the time of ileal pouch-anal anastomosis for ulcerative colitis: current practices of North American colorectal surgeons. Dis Colon Rectum 2009;52:1178–1183.
Tulchinsky H, Hawley PR, Nicholls J. Long-term failure after restorative proctocolectomy for ulcerative colitis. Ann Surg 2003;238:229–234.
Cohen Z, McLeod RS, Stephen W, Stern HS, O′Connor B, Reznick R. Continuing evolution of the pelvic pouch procedure. Ann Surg 1992;216:506–511; discussion 511–502.
Tjandra JJ, Fazio VW, Milsom JW, Lavery IC, Oakley JR, Fabre JM. Omission of temporary diversion in restorative proctocolectomy--is it safe? Dis Colon Rectum 1993;36:1007–1014.
Williamson ME, Lewis WG, Sagar PM, Holdsworth PJ, Johnston D. One-stage restorative proctocolectomy without temporary ileostomy for ulcerative colitis: a note of caution. Dis Colon Rectum 1997;40:1019–1022.
Aberg H, Pahlman L, Karlbom U. Small-bowel obstruction after restorative proctocolectomy in patients with ulcerative colitis. Int J Colorectal Dis 2007;22:637–642.
Remzi FH, Fazio VW, Gorgun E, Ooi BS, Hammel J, Preen M, Church JM, Madbouly K, Lavery IC. The outcome after restorative proctocolectomy with or without defunctioning ileostomy. Dis Colon Rectum 2006;49:470–477.
Kiran RP, da Luz Moreira A, Feza H. Remzi FH, Church JM, Lavery I, Hammel J, Fazio VW. Factors Associated With Septic Complications After Restorative Proctocolectomy. Ann Surg 2010;251:442–446.
Davies M, Hawley PR. Ten years experience of one-stage restorative proctocolectomy for ulcerative colitis. Int J Colorectal Dis 2007;22:1255–1260.
Lovegrove RE, Symeonides P, Tekkis PP, Goodfellow PB, Shorthouse AJ. A selective approach to restorative proctocolectomy without ileostomy: a single centre experience. Colorectal Dis 2008;10:916–924.
Chow A, Tilney HS, Paraskeva P, Jeyarajah S, Zacharakis E, Purkayastha S. The morbidity surrounding reversal of defunctioning ileostomies: a systematic review of 48 studies including 6,107 cases. Int J Colorectal Dis 2009;24:711–723.
Luglio G, Pendlimari R, Holubar SD, Cima RR, Nelson H. Loop ileostomy reversal after colon and rectal surgery: a single institutional 5-year experience in 944 patients. Arch Surg 2011;146:1191–1196.
van Westreenen HL, Visser A, Tanis PJ, Bemelman WA. Morbidity related to defunctioning ileostomy closure after ileal pouch-anal anastomosis and low colonic anastomosis. Int J Colorectal Dis 2012;27:49–54.
D′Haeninck A, Wolthuis AM, Penninckx F, D′Hondt M, D′Hoore A. Morbidity after closure of a defunctioning loop ileostomy. Acta Chir Belg 2011;111:136–141.
Akesson O, Syk I, Lindmark G, Buchwald P. Morbidity related to defunctioning loop ileostomy in low anterior resection. Int J Colorectal Dis 2012;27:1619–1623.
Gessler B, Haglind E, Angenete E. Loop ileostomies in colorectal cancer patients--morbidity and risk factors for nonreversal. J Surg Res 2012;178:708–714.
El-Hussuna A, Lauritsen M, Bulow S. Relatively high incidence of complications after loop ileostomy reversal. Dan Med J 2012;59:A4517.
Peacock O, Law CI, Collins PW, Speake WJ, Lund JN, Tierney GM. Closure of loop ileostomy: potentially a daycase procedure? Tech Coloproctol 2011;15:431–437.
Baraza W, Wild J, Barber W, Brown S. Postoperative management after loop ileostomy closure: are we keeping patients in hospital too long? Ann R Coll Surg Engl 2010;92:51–55.
Mennigen R, Senninger N, Bruewer M, Rijcken E. Pouch function and quality of life after successful management of pouch-related septic complications in patients with ulcerative colitis. Langenbecks Arch Surg 2012;397:37–44.
Selvaggi F, Pellino G, Canonico S, Sciaudone G. Is omitting pouchography before ileostomy takedown safe after negative clinical examination in asymptomatic patients with pelvic ileal pouch? An observational study. Tech Coloproctol 2012;16:415–420.
Loffler T, Rossion I, Bruckner T, Diener MK, Koch M, von Frankenberg M, Pochhammer J, Thomusch O, Kijak T, Simon T, Mihaljevic AL, Kruger 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, Buchler MW, Weitz J. HAnd Suture Versus STApling for Closure of Loop Ileostomy (HASTA Trial): results of a multicenter randomized trial (DRKS00000040). Ann Surg 2012;256:828–835; discussion 835–826.
Hiranyakas A, Rather A, da Silva G, Weiss EG, Wexner SD. Loop ileostomy closure after laparoscopic versus open surgery: is there a difference? Surg Endosc 2013;27:90–94.
Royds J, O′Riordan JM, Mansour E, Eguare E, Neary P. Randomized clinical trial of the benefit of laparoscopy with closure of loop ileostomy. Br J Surg 2013;100:1295–1301.
Funding
There was no funding for this study.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Mennigen, R., Sewald, W., Senninger, N. et al. Morbidity of Loop Ileostomy Closure after Restorative Proctocolectomy for Ulcerative Colitis and Familial Adenomatous Polyposis: a Systematic Review. J Gastrointest Surg 18, 2192–2200 (2014). https://doi.org/10.1007/s11605-014-2660-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11605-014-2660-8