Timing of diverting loop ileostomy closure after rectal resection: Commentary on recent findings

Abstract

The clinicians remain uncertain about the ideal timing for loop ileostomy reversal following rectal resection surgery. The common practice of waiting 8-12 weeks to protect from anastomotic complication, especially in patients who receive neoadjuvant chemoradiotherapy, would expose patients to dehydration, electrolyte disturbances, stoma related complications, and reduced quality of life. Randomized controlled trials have studied early reversal of ileostomy, with results ranging from improved outcomes in selected patients to increased morbidity when applied indiscriminately. Meta-analyses have also yielded heterogeneous findings, reflecting the need for careful patient selection. The study by Özcan and Düzgün used retrospective methods to show that patients who underwent early closure experienced similar complication rates to those who had late closure, but early closure were associated with better quality of life. Taken together, current evidence suggests that reversal within 2-4 weeks may be safe and beneficial in meticulously selected patients with an intact anastomosis and an uneventful postoperative course. Their study provides practical data supporting early closure. It is limited, however, by being retrospective with a short follow-up period, which may leave important concerns unaddressed. Multicenter randomized trials are required to help establish safe standardized criteria for early closure and long-term safety.

Key Words: Loop ileostomy; Ileostomy closure; Rectal cancer; Quality of life; Anastomotic leak

Core Tip: This commentary highlights that while traditional delayed closure protects the anastomosis, it imposes substantial patient burden. Recent retrospective data suggest that ultra-early (10-14 days) reversal may be safe and improve quality of life, but this aggressive strategy warrants cautious interpretation and prospective validation to define ideal candidates.

TO THE EDITOR

The use of temporary diverting loop ileostomies during advanced rectal cancer surgery has become standard, as it helps prevent complications from anastomotic leakage. On the other hand, it can lead to dehydration, electrolyte imbalances, stoma-related issues, and decreased quality of life that worsens with longer diversion periods[1]. Traditionally, closure has been delayed for 8-12 weeks after the index operation. Recently, however, the idea of early closure has provided an attractive concept supported by randomized controlled trials (RCTs) and meta-analysis[2,3]. Recent research indicates that patients with intact anastomoses who undergo early closure experience fewer stoma-related complications and better postoperative outcomes[4,5]. However, the safety of early anastomotic closure remains a concern, particularly with regard to the morbidity of postoperative complications and anastomotic leaks[2,6]. The retrospective cohort study by Özcan and Düzgün[7] adds important data to this discussion, demonstrating comparable complication rates between early and late closure while better psychosocial advantages of early reversal.

TIMING OF DIVERTING LOOP ILEOSTOMY REVERSAL AFTER RECTAL RESECTION

Traditionally, the closure of a protective diverting loop ileostomy following rectal resection has been delayed for 8 weeks to 12 weeks or longer to safeguard the distal anastomosis and minimize the risk of clinically significant leakage. This practice has been based on the principle that prolonged diversion provides sufficient time for anastomotic healing, thereby reducing the likelihood of pelvic sepsis and reoperation in the event of subclinical dehiscence[4]. Indeed, early randomized and prospective data suggested that a defunctioning stoma effectively reduces the rate of symptomatic anastomotic leakage and the need for surgical intervention compared to patients without diversion[4,8,9].

As a result, delayed stoma closure became incorporated into standard surgical pathways, particularly for rectal cancer patients undergoing low anterior resection or coloanal anastomosis, especially those who have received neoadjuvant chemoradiotherapy, where impaired tissue healing and higher risks of anastomotic leak are well recognized[10]. In this context, surgeons often favored late closure not only to protect the anastomosis, but also to accommodate adjuvant therapies, which could complicate perioperative management[10]. Although this approach minimized the immediate risk of catastrophic leakage, it committed patients to a prolonged period of diversion, with accumulating stoma-related complications and impaired quality of life, which ultimately sparked interest in evaluating earlier closure strategies[3,10].

While delayed closure of diverting ileostomies has been considered the safer strategy for protecting distal anastomoses, prolonged diversion exposes patients to a distinct set of complications that can significantly affect outcomes and quality of life. High-output stomas may lead to dehydration, electrolyte imbalance, and renal dysfunction, often necessitating readmission and sometimes critical care support[1]. In addition, patients are at risk of peristomal skin irritation, parastomal hernia, and small bowel obstruction, with reported overall morbidity rates ranging from 17% to 28%[10].

Beyond physical morbidity, delayed closure has also been shown to impair patient-reported outcomes. Studies have highlighted the psychological and social burdens associated with living with a stoma, including restrictions on physical activity, sexual health, and social interactions[3,10]. These challenges are exacerbated in patients who experience prolonged diversion for the duration of adjuvant therapy, with up to 25% of “temporary” ileostomies never get reversed[3].

Evidence from meta-analyses reinforces these concerns. Huang et al[10] demonstrated that delayed closure was associated with higher rates of skin irritation compared with early reversal, while O’Sullivan et al[11] reported an increased risk of postoperative ileus and reoperations in delayed groups. In a meta-analysis focused specifically on rectal cancer, Chan et al[3] observed that early closure was associated with an overall increase in surgical complications compared with late reversal. Taken together, these findings suggest that while delayed closure prolongs exposure to stoma-related morbidity and reduced quality of life, early closure may carry higher surgical risks if not restricted to carefully selected patients.

The recognition of morbidity associated with prolonged diversion has led to growing interest in early closure of diverting ileostomies. The premise is that by shortening the duration of diversion, patients may be spared complications such as dehydration, electrolyte imbalance, peristomal skin irritation, and reduced quality of life[1,10]. Several RCTs have examined this approach. Alves et al[4] conducted an early trial comparing closure within two weeks against conventional timing and demonstrated that early reversal was technically feasible, though concerns regarding septic complications were noted. Lasithiotakis et al[12] reported that early ileostomy closure was technically easier, faster to perform, and associated with reduced costs, without any increase in major complications. Kłęk et al[13] and Gallyamov et al[14] likewise confirmed that early closure can be safely implemented in rectal cancer patients, showing comparable morbidity rates to late closure while significantly reducing the duration of stoma and stoma-related burdens. In the multicenter EASY trial, Danielsen et al[5] further supported the safety of early closure in carefully selected patients, reporting fewer stoma-related complications and improved quality of life. In contrast, Bausys et al[2] observed higher morbidity rates with closure at 30 days, leading to early termination of their study. Fukudome et al[6] similarly reported increased surgical site infections when closure was attempted in the presence of asymptomatic leaks, emphasizing the risks of indiscriminate patient selection. Also, Elsner et al[15] found significantly higher rates of anastomotic leak and reintervention after early closure at two weeks, leading to premature termination of their trial. More recently, Ahmadi-Amoli et al[16] conducted a RCT including 104 patients comparing early and late ileostomy closure in rectal cancer and found no significant difference in postoperative complications, quality of life, or Low Anterior Resection Syndrome scores, although the study was limited by its single-center design and one-year follow-up.

Meta-analyses provide additional insight. Huang et al[10] suggested that early closure is feasible and associated with reduced skin irritation without an increase in overall morbidity. Clausen et al[1] and O’Sullivan et al[11] found no significant differences in major complications between early and late closure, though both identified trends toward increased reoperation or postoperative ileus in early groups. In a meta-analysis restricted to rectal cancer RCTs, Chan et al[3] noted a significant increase in surgical complications with early closure, reinforcing the need for caution in applying this strategy broadly. Collectively, these studies illustrate both the potential benefits and the ongoing controversies surrounding early ileostomy reversal, highlighting that outcomes are highly dependent on patient selection and perioperative conditions.

The recent retrospective cohort study by Özcan and Düzgün[7] provides valuable additional insight into the ongoing debate regarding the timing of ileostomy reversal. The authors compared patients whose stomas were closed in the late period (3-6 months, June 2016 to October 2022; group A) with those who underwent early closure at 10-14 days during a subsequent practice shift (October 2022 to October 2024; group B). This design reflects an institutional change in practice, with group A representing the traditional pathway of delayed closure and group B reflecting the strategy of early reversal.

In their analysis, no significant difference in perioperative or postoperative complication rates was observed between the two groups, supporting the technical feasibility and apparent safety of early closure. Importantly, readmissions due to dehydration and electrolyte imbalance were markedly reduced in the early closure cohort (0.7% vs 10.8%, P < 0.05), emphasizing the clinical relevance of minimizing the duration of diversion[7]. Beyond physical outcomes, the study highlighted psychological and social recovery, with significantly higher quality of life scores reported in the early closure group, consistent with the findings of the EASY trial[5,7].

However, the design also introduces several limitations. Because the two groups represent different periods of practice, there may be unmeasured confounders related to surgical technique, perioperative care, or patient selection criteria that evolved over time. The retrospective nature of the study further limits control for such variables. Additionally, risk stratification based on anastomotic integrity, comorbidities, or neoadjuvant therapy was not reported, and long-term outcomes such as anastomotic stricture or oncologic endpoints were not assessed. The study lacks essential data about oncologic follow-up after surgery which prevents us from evaluating how treatment timing affects chemotherapy schedules, disease recurrence and anastomotic complications that emerge after the initial recovery phase. Despite these limitations, this work provides timely real-world evidence that supports the feasibility of early ileostomy closure and underscores the psychosocial benefits of reducing diversion time. At the same time, the design highlights the ongoing need for prospective, contemporaneous RCTs to confirm these findings and guide standardized recommendations.

The study provides essential real-world data yet multiple methodological restrictions reduce the reliability of its findings. The study’s time difference between early and late cohorts (2016-2022 vs 2022-2024) creates a retrospective-design bias as surgical expertise, perioperative care protocols and patient optimization methods changed over time. The study design allows selection bias to occur as patients who received early closure might have been less sick or at lower risk. The observed decrease in readmissions could be due to enhanced recovery pathway improvements and nutritional optimization methods which were implemented during this period thus hiding potential adverse effects from early anastomosis. The study’s inability to conduct standardized long-term assessments of anastomotic and oncologic results restricts the applicability of its results.

The definition of early closure in published studies shows inconsistent patterns which creates a major research limitation. The definition of early reversal varies in the literature between 8-13 days in Alves et al[4] and Danielsen et al[5] randomized studies but other studies use a time frame of ≤ 30 days as seen in Chan et al[3] and Bausys et al[2]. The different time frames used in studies make it difficult to compare results between publications which leads to the observed discrepancies in research findings. The 10-14-day time frame established by Özcan and Düzgün[7] falls within the lower end of the spectrum which aligns with selected RCT protocols that proved early closure safety through careful patient selection.

When viewed in the context of existing randomized data, the results of Özcan and Düzgün[7] align most closely with the EASY trial and are consistent with other randomized studies, such as those by Lasithiotakis et al[12], Kłęk et al[13], and Gallyamov et al[14], which demonstrated that early closure can be performed safely in selected patients with comparable morbidity and improved recovery[5]. Their findings further reinforce the growing recognition that prolonged diversion contributes significantly to stoma-related complications, including dehydration and psychosocial distress. However, the contrasting outcomes observed in trials such as those by Bausys et al[2], Fukudome et al[6], and Elsner et al[15], as well as the increased surgical complications highlighted in the meta-analysis by Chan et al[3], emphasize that early closure is not universally safe and must be applied selectively. In this regard, the retrospective, practice-shift design of Özcan and Düzgün[7] provides supportive but not definitive evidence, emphasizing the continuing need for prospective RCTs to establish standardized criteria for timing of reversal.

CONCLUSION

The optimal timing of diverting loop ileostomy closure after rectal resection remains an important but unresolved question. While RCTs such as the EASY study have demonstrated that early reversal can be performed safely in carefully selected patients with significant gains in quality of life, other studies including those by Bausys et al[2] and Fukudome et al[6] highlight increased risks when this approach is applied indiscriminately. Meta-analyses further reflect this heterogeneity, with some reporting comparable morbidity between early and late closure and others noting higher surgical complication rates in the early cohorts. Within this context, the retrospective analysis by Özcan and Düzgün[7] contributes valuable real-world evidence, demonstrating reduced readmissions and psychosocial benefit without increased morbidity in patients undergoing early closure. The available data indicate that early closure of the stoma within 2-4 weeks appears to be both safe and beneficial for selected patients those with intact anastomosis and uneventful postoperative course and sufficient nutritional status. However, the limitations of its design and lack of long-term follow-up reinforce the fact that definitive conclusions cannot yet be drawn. Future prospective multicenter RCTs with rigorous patient selection, standardized quality of life measures, and extended follow-up are needed to guide evidence-based recommendations and optimize outcomes for patients.