Early Versus Late Preventive Ileostomy Closure Following Colorectal Surgery: Systematic Review and Meta-analysis With Trial Sequential Analysis of Randomized Controlled Trials.

Abstract

Most preventive ileostomy following colorectal surgery requires a closure procedure. The intervals between primary surgery and ileostomy closure remain controversial. This study aimed to compare early versus late closure of preventive ileostomy following colorectal surgery. A systematic literature search was performed in conference papers, MEDLINE, EMBASE, the Cochrane Library, and the Clinicaltrials.gov database. Randomized clinical trials published through October 2019 comparing early versus late closure of ileostomy following colorectal surgery were selected. Morbidity, leak of the primary anastomosis, reoperation, surgical site infection, small-bowel obstruction/postoperative ileus, total operative time, and postoperative length of hospital stay were measured. Results were synthesized using meta-analysis and were rated as firm or weak evidence by trial sequential analysis. A total of 6 randomized controlled trials were included. Firm evidence from trial sequential analysis demonstrated that the early closure of ileostomy after colorectal surgery reduced the incidence of small-bowel obstruction/postoperative ileus and required less total operative time, but increased the incidence of surgical site infection, compared with late closure of ileostomy; postoperative length of hospital stay tended to be longer with early versus late closure of ileostomy. Weak evidence showed that there was no difference between early and late closure in morbidity, reoperation, or leak of the primary anastomosis. The study was limited by some evidence rated as weak from trial sequential analysis, combined analysis of small-bowel obstruction and postoperative ileus, and exclusion of the influence of chemo- or radiotherapy. In selected patients, early closure of ileostomy after colorectal surgery can be considered, with a lower incidence of postoperative small-bowel obstruction/postoperative ileus and less total operative time, but a relatively high surgical site infection rate. PROSPERO registration number: CRD42020160989.