Predictors of clinically significant complications after stoma reversal: A prospective analytical study

Abstract

BACKGROUND

Stoma reversal is often considered a low-risk elective procedure; however, postoperative morbidity remains clinically significant. Evidence identifying predictors of meaningful complications, particularly from resource-limited settings, is limited.

AIM

To identify risk factors associated with Clavien-Dindo grade II and above complications following stoma reversal surgery.

METHODS

This prospective analytical study was conducted at a tertiary care center between February 2024 and June 2025. Adult patients undergoing elective stoma reversal were included and followed for 30 days postoperatively. Demographic, clinical, and operative variables-including age, etiology, type of index surgery, timing of reversal, type of anastomosis, and anastomosis time-were analyzed. Postoperative complications were graded using the Clavien-Dindo classification. Secondary outcomes included postoperative ileus and length of hospital stay.

RESULTS

Clinically significant complications were observed in a substantial proportion of patients. Advanced age and longer anastomosis time were significantly associated with Clavien-Dindo grade ≥ II complications, postoperative ileus, and prolonged hospital stay. In contrast, type of stoma and anastomotic technique were not independent predictors of high-grade complications.

CONCLUSION

Stoma reversal carries a measurable risk of morbidity and should not be regarded as a minor procedure. Patient-related factors and operative complexity play a greater role in determining outcomes than technical variations alone. Careful patient selection, preoperative optimization, and strategies to minimize anastomosis time are essential to improve postoperative outcomes.

Key Words: Stoma reversal; Ileostomy closure; Postoperative complications; Clavien-Dindo classification; Postoperative ileus

Core Tip: Stoma reversal is frequently perceived as a minor elective procedure, yet it carries a significant risk of postoperative morbidity. In this prospective study, advanced age and longer anastomosis time emerged as the strongest predictors of clinically significant (Clavien-Dindo grade ≥ II) complications, postoperative ileus, and prolonged hospital stay, whereas type of stoma and anastomotic technique were not independent risk factors. These findings emphasize that stoma reversal should be approached as a major abdominal operation, with careful patient selection, preoperative optimization, and operative strategies aimed at minimizing anastomosis time to improve outcomes.

INTRODUCTION

Temporary faecal diversion is frequently employed in the management of gastrointestinal pathologies where restoration of bowel continuity is unsafe at the initial operation. Such situations commonly arise in perforation peritonitis, bowel resection surgeries, and abdominal trauma[1]. The etiological profile leading to gastrointestinal discontinuity differs markedly between Western and tropical regions. In developed countries, small bowel perforations are uncommon and are typically related to malignancy, diverticular disease, Crohn’s disease, adhesions, or foreign bodies[2]. In contrast, in India and other tropical regions, infectious causes such as typhoid fever and tuberculosis remain predominant. Studies from North India have identified typhoid fever as the most common cause of intestinal perforation, followed by tuberculosis, often resulting in delayed presentation, diffuse peritonitis, sepsis, and malnutrition. Under these conditions, creation of a temporary ileostomy or colostomy is frequently required to reduce operative risk and prevent anastomotic failure[3].

The epidemiological profile of intestinal stoma varies considerably across geographic regions. In Western populations, stomas are predominantly created electively for colorectal malignancy and inflammatory bowel disease. In contrast, studies from Asian countries, including China, report a higher proportion of emergency stomas due to infectious etiologies, trauma, and obstruction. Recent Chinese cohort studies have highlighted tuberculosis, colorectal malignancy, and anastomotic leak as leading causes of stoma formation, with postoperative complication rates ranging from 15%-35%. Despite these regional variations, data evaluating predictors of morbidity after stoma reversal in Asian populations remain limited.

Stoma formation is a well-established surgical strategy used in both emergency and elective settings. In emergencies, stomas are created when primary anastomosis is contraindicated due to hemodynamic instability, faecal contamination, or multiorgan dysfunction[4]. Electively, defunctioning stomas are commonly used to protect low colorectal or pelvic anastomoses in rectal cancer, inflammatory bowel disease, diverticular disease, and familial adenomatous polyposis. Among the various stoma types, loop ileostomies are preferred over colostomies because they are less bulky, associated with fewer prolapse-related issues, and generally have lower morbidity at the time of reversal. Consequently, stoma reversal is often perceived as a minor and low-risk procedure[5].

However, accumulating evidence demonstrates that stoma reversal is associated with a significant rate of postoperative complications. Physiologically, reversal is ideally performed once inflammation has resolved and the distal bowel has healed, typically between 9 and 12 weeks after the initial surgery. In clinical practice, this interval is frequently prolonged due to chemotherapy, pelvic sepsis, or patient-related comorbidities. Complications following stoma closure include surgical site infection, postoperative ileus, anastomotic leak, fistula formation, and incisional hernia, with a notable proportion of patients requiring reintervention or higher-level postoperative care[6].

The incidence and severity of complications are influenced by multiple patient-related and surgical factors, including advanced age, malnutrition, diabetes mellitus, chronic systemic illness, type of stoma, method of anastomosis, and timing of reversal. Importantly, 30%-40% of temporary stomas are never reversed, particularly among elderly and medically compromised patients, resulting in long-term quality-of-life impairment and increased healthcare utilization[7]. Despite these concerns, most existing studies originate from Western cohorts and focus primarily on surgical technique rather than patient-specific and intraoperative predictors. There is limited standardized evidence addressing risk factors for complications following stoma reversal in the Indian population. Therefore, there remains a need for prospective analyses in diverse populations to better identify clinically meaningful predictors of severe postoperative complications. The lack of uniform complication grading further limits comparison across studies. These gaps highlight the need for systematic evaluation of risk factors influencing outcomes after stoma reversal surgery in resource-limited settings.

MATERIALS AND METHODS

This prospective analytical study was conducted in the Department of Surgery at Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, over a period from 1 February 2024 to 30 June 2025. All patients were followed for 30 days postoperatively, with the final recruitment completed on 31 May 2025. Institutional Review Board approval was obtained [No. TP (MD/MS) (177/2024)/IEC/ABVIMS/RMLH/177] prior to commencement of the study, and written informed consent was secured from all participants before enrolment.

Adult patients undergoing elective stoma reversal surgery during the study period were screened for eligibility. Inclusion criteria comprised all adult patients presenting for reversal of a temporary ileostomy or colostomy in the Department of Surgery. Patients were excluded if stoma reversal was performed for stoma-related complications such as gangrene, prolapse, or parastomal hernia, or if patients had more than one stoma or an associated enterocutaneous fistula. Eligible patients included those with loop, double-barrel, or end ileostomy and colostomy.

Preoperative assessment included detailed clinical evaluation, documentation of demographic parameters, comorbidities, indication for the initial stoma, type of index operation, and time interval between stoma creation and planned reversal. Haematological and biochemical investigations were recorded, including hemogram, renal and liver function tests, blood glucose levels, coagulation profile, and viral markers. Nutritional status was assessed using body mass index (BMI). All patients underwent a contrast study, typically a loopogram, to confirm distal bowel patency prior to surgery.

Stoma reversal was performed once patients were deemed fit for surgery following standard preoperative optimization. Intraoperative details including surgical approach (circumstomal incision or laparotomy), type of anastomosis (hand-sewn or stapled), need for bowel resection, total operative duration, and specific time taken for anastomosis were recorded. Fascial closure was performed using interrupted polypropylene sutures, and skin was closed with interrupted nylon sutures.

Postoperatively, patients were monitored daily for clinical parameters including vital signs, return of bowel sounds, bowel movements, abdominal distension, nausea, vomiting, fever, wound discharge, and signs of ileus or obstruction. Surgical site evaluation was conducted on postoperative days 1, 3, 5, 7, 10, 14, 20, and 30. Any wound discharge suggestive of infection was sent for culture and sensitivity testing, and antibiotics were modified accordingly. Complications such as paralytic ileus, anastomotic leak, surgical site infection, intra-abdominal collections, fistula formation, and need for reoperation were documented.

Postoperative complications were classified using the Clavien-Dindo classification system, with grade II and above complications considered clinically significant outcomes. Primary outcome measures included the occurrence of Clavien-Dindo grade II or higher complications. Secondary outcomes included postoperative ileus and length of hospital stay.

Sample size was calculated using study by Climent et al[8] which was based on the rule of at least 10 outcome events per independent variable included in multivariate logistic regression (event-to-variable ratio 10:1). Assuming an anticipated rate of clinically significant (Clavien-Dindo ≥ II) complications of approximately 30% based on prior literature, and inclusion of up to five independent predictors in the final model, a minimum of 50-60 patients was required. The final cohort of 115 patients provided adequate power for regression analysis.

Statistical analysis was performed using descriptive and inferential methods. Continuous variables were expressed as mean, median, and standard deviation, while categorical variables were summarized as frequencies and percentages. Associations between variables were analyzed using χ² tests for categorical data and t-tests for continuous data. A P-value of less than 0.05 was considered statistically significant.

Multivariate regression models were constructed using the Enter method to adjust for clinically relevant confounders identified in univariate analysis (P < 0.10) and variables with biological plausibility. Variance inflation factor (VIF) was calculated to assess multicollinearity, and no significant collinearity (VIF < 5) was observed.

Propensity score analysis was not performed, as the study did not compare predefined exposure groups but rather evaluated independent predictors of outcomes within a single cohort. Continuous variables were tested for normality using the Shapiro-Wilk test. Non-normally distributed variables were analyzed using appropriate non-parametric methods. Multivariate regression was performed using the Enter method with predefined clinically relevant covariates.

Although the Clavien-Dindo classification is an ordinal scale, linear regression was used to model complication severity as a continuous outcome to allow evaluation of incremental changes across grades. This approach has been adopted in prior surgical outcomes research when the number of high-grade events is limited, permitting greater statistical stability compared to categorical or ordinal logistic regression models. Given the relatively small number of severe complications in this cohort, linear modeling was considered a pragmatic and statistically feasible strategy.

RESULTS

This prospective analytical study included 115 adult patients undergoing elective stoma reversal surgery during the study period. All enrolled patients completed a minimum follow-up of 30 days and were included in the final analysis. The primary outcome assessed was the occurrence of Clavien-Dindo grade II or higher postoperative complications, while secondary outcomes included postoperative ileus and length of hospital stay.

Baseline characteristics of the study population

The demographic and baseline clinical characteristics of the study population are summarized in Table 1. The cohort comprised patients across a wide age range, with a predominance of younger adults. The median age was 32 years (range 13-70 years). Both ileostomy and colostomy reversals were included, performed for a variety of underlying aetiologies. Most patients had undergone stoma creation in an emergency setting. Nutritional status, assessed using BMI, varied across the cohort, and a subset of patients had associated medical comorbidities.

Table 1 Baseline demographic, clinical, operative characteristics (n = 115), n (%)/mean ± SD/median (interquartile range).

Variable
Demographic characteristics
Age (years)	34.7 ± 15.0
Median age	32 (13-70)
Age group distribution (years)
< 20	23 (20.0)
20-29	30 (26.1)
30-39	18 (15.7)
40-49	20 (17.4)
50-59	15 (13.0)
≥ 60	9 (7.8)
Sex
Male	71 (61.7)
Female	44 (38.3)
BMI (kg/m2)	20.0 ± 2.1
Median BMI	19.4 (15.2-27.2)
Aetiology of index surgery
Tuberculosis	49 (42.6)
Typhoid perforation	33 (28.7)
Others	12 (10.4)
Large bowel obstruction	8 (7.0)
Appendicular perforation	7 (6.1)
Trauma	6 (5.2)
Type of stoma
Loop ileostomy	63 (54.8)
Double-barrel ileostomy	36 (31.3)
End ileostomy	9 (7.8)
Colostomy	7 (6.1)
Type of anastomosis
Single-layer extra mucosal	24 (20.9)
Double-layer	69 (60.0)
Stapled	22 (19.1)

BMI: Body mass index.

Predictors of hospital stay

On univariate linear regression analysis, anastomosis time was the only statistically significant predictor of hospital stay (β = 0.05, P = 0.0007; 95%CI: 0.02-0.08; R² = 0.10), indicating that each additional minute spent on anastomosis increased hospital stay by approximately 0.05 days (Table 2). Stoma type, aetiology, waiting time to reversal, and type of anastomosis were not significantly associated with duration of hospitalization, although waiting time to reversal demonstrated a trend toward significance (P = 0.08).

Table 2 Univariate analysis of operative predictors of hospital stay.

Variable	Coefficient (β)	SE	t value	P value	95%CI	R2
Stoma type (complexity)	0.18	0.12	1.52	0.13	-0.05 to 0.41	0.02
Etiology	0.03	0.08	0.32	0.75	-0.14 to 0.19	0.00
Waiting time to reversal (months)	0.11	0.06	1.75	0.08	-0.01 to 0.24	0.03
Anastomosis time (minute)	0.05	0.01	3.47	0.0007	0.02 to 0.08	0.10
Type of anastomosis	-0.14	0.16	-0.87	0.39	-0.46 to 0.18	0.01

When patient-related variables were analysed separately, older age (β = 0.033, P = 0.012) and lower preoperative haemoglobin (β = -0.571, P = 0.0085) were significantly associated with longer hospital stay, while BMI, sex, and preoperative albumin were not significant predictors (Table 3).

Table 3 Univariate analysis of patient-related predictors of hospital stay.

Variable	Coefficient (β)	SE	t value	P value	95%CI	R2
Age (years)	0.033	0.013	2.55	0.012	0.007 to 0.059	0.054
BMI (kg/m2)	-0.159	0.095	-1.67	0.098	-0.347 to 0.030	0.024
Sex (male = 1)	-0.794	0.414	-1.92	0.057	-1.614 to 0.025	0.032
Pre-op hemoglobin (g/dL)	-0.571	0.213	-2.68	0.0085	-0.994 to -0.149	0.060
Pre-op albumin (g/dL)	-1.372	1.110	-1.24	0.219	-3.571 to 0.827	0.013

BMI: Body mass index.

On multivariate analysis, stoma complexity (β = 0.48, P = 0.047) and anastomosis time (β = 0.08, P = 0.018) remained independent predictors of prolonged hospital stay. Aetiology, waiting time to reversal, and type of anastomosis were not independently associated with hospital stay (Table 4).

Table 4 Multivariate analysis of predictors of hospital stay.

Variable	Coefficient (β)	SE	P value	95%CI
Stoma type (complexity)	0.48	0.24	0.047	0.01-0.96
Etiology	-0.26	0.17	0.144	-0.60 to 0.09
Waiting time to reversal (months)	0.19	0.14	0.167	-0.08 to 0.46
Anastomosis time (minute)	0.08	0.03	0.018	0.01-0.15
Type of anastomosis	0.24	0.37	0.525	-0.50 to 0.98

Predictors of Clavien-Dindo complication severity

On univariate analysis, both stoma type (β = 0.0635, P = 0.043) and anastomosis time (β = 0.0107, P = 0.005) were significantly associated with increasing Clavien-Dindo scores, indicating greater complication severity (Tables 5 and 6). Etiology, waiting time to reversal, and type of anastomosis did not demonstrate significant associations.

Table 5 Predictors of postoperative morbidity-univariate analysis of predictors of Clavien-Dindo score.

Variable	Coefficient (β)	SE	P value	95%CI	R2
Stoma type (complexity)	0.0635	0.0311	0.043	0.0018-0.1252	0.036
Etiology	0.0235	0.0219	0.286	-0.0199 to 0.0669	0.010
Waiting time to reversal	0.0088	0.0168	0.599	-0.0245 to 0.0421	0.003
Anastomosis time (minute)	0.0107	0.0037	0.005	0.0033-0.0180	0.070
Type of anastomosis	-0.0218	0.0430	0.613	-0.1068 to 0.0632	0.002

Table 6 Predictors of postoperative morbidity-multivariate analysis of predictors of Clavien-Dindo score.

Variable	Coefficient (β)	SE	P value	95%CI
Anastomosis time (minute)	0.051	0.018	0.004	0.017-0.086
Stoma type	0.15	0.12	0.227	-0.09 to 0.39
Etiology	-0.05	0.09	0.561	-0.23 to 0.13
Waiting time to reversal	0.04	0.07	0.547	-0.10 to 0.18
Type of anastomosis	0.15	0.19	0.417	-0.22 to 0.53

However, on multivariate regression analysis, anastomosis time emerged as the only independent predictor of higher Clavien-Dindo grades (β = 0.051, P = 0.004; 95%CI: 0.017-0.086), while the effect of stoma type lost statistical significance after adjustment for confounders.

High-grade (Clavien-Dindo ≥ III) complications

Univariate analysis identified age as the strongest predictor of high-grade complications (β = 0.0098, P = 0.0001; R² = 0.12), with each additional year of age increasing the risk of severe complications by approximately 1%. Lower preoperative haemoglobin showed a trend toward significance (P = 0.064), while BMI, sex, and preoperative albumin were not significantly associated with high-grade morbidity.

Postoperative ileus, surgical site infection, and mortality

Logistic regression analysis demonstrated that age was the only significant predictor of postoperative ileus or subclinical bowel obstruction [odds ratio (OR) = 1.05, P = 0.006; 95%CI: 1.01-1.09]. No patient- or procedure-related variable showed a significant association with surgical site infection on univariate analysis.

Mortality analysis revealed lower BMI as the only significant predictor (OR = 0.27, P = 0.031; 95%CI: 0.08-0.89), while age, sex, aetiology, and waiting time to reversal were not associated with mortality.

DISCUSSION

Stoma reversal is frequently perceived as a technically straightforward elective procedure; however, contemporary evidence consistently demonstrates that it carries a substantial risk of postoperative morbidity and, in selected patients, mortality. Large cohort analyses report overall complication rates ranging from 11% to 36%, with mortality up to 3% in some series[9,10]. National database studies further confirm that both major complications and death are not uncommon after colostomy reversal, particularly in high-risk populations[11]. Against this background, the present prospective analytical study reinforces that stoma reversal should not be regarded as a minor procedure, especially in settings where many stomas are created under emergency circumstances.

The findings of this study should be interpreted within the context of its single-center design. The study population reflects a tertiary-care setting in which a substantial proportion of stomas were created in emergency conditions with a predominance of infectious etiologies. As such, extrapolation to populations with different disease profiles, healthcare infrastructure, or elective surgical patterns should be made with caution. These results therefore define context-specific risk relationships rather than universally generalizable predictors. Future multicenter studies involving diverse geographic and clinical settings are required to validate the external applicability and reproducibility of these findings. Prolonged operative duration has similarly been associated with increased morbidity in large database analyses, where longer operative time independently predicted postoperative complications after elective ileostomy closure[12].

Although the cohort was relatively young overall, patients aged ≥ 60 years demonstrated significantly higher rates of high-grade complications and postoperative ileus, indicating that advancing age-even within a predominantly young population—remains a clinically relevant risk factor. While age did not independently predict overall complication frequency after adjustment, it significantly influenced complication severity. This distinction is consistent with large National Surgical Quality Improvement Program analyses demonstrating age > 70 years as an independent predictor of major complications and mortality following colostomy reversal[11]. Earlier cohort data also identified age as a determinant of survival after stoma closure[9]. Collectively, these data reinforce that advancing age primarily modifies physiological reserve and recovery capacity rather than merely increasing complication incidence, underscoring the need for careful perioperative risk stratification in elderly patients.

Stoma type demonstrated a nuanced relationship with outcomes. In the present study, increasing stoma complexity correlated with higher Clavien-Dindo scores on univariate analysis and independently predicted prolonged hospital stay. Comparative analyses have shown that stoma type influences both stoma-related and reversal-related morbidity. For instance, loop ileostomy has been associated with higher rates of dehydration and ileus, whereas loop colostomy carries a different profile of wound-related complications[13]. Similarly, prospective comparisons have demonstrated significantly higher reversal-related complications in ileostomy compared with transverse colostomy[14]. These findings suggest that stoma type may influence perioperative recovery dynamics and resource utilization, even when not directly driving severe complications.

Contrary to traditional assumptions, the type of anastomosis did not independently influence hospital stay, complication severity, postoperative ileus, or mortality in the present study. Broader colorectal literature evaluating anastomotic configuration has shown differences in leak rates in primary rectal surgery[15], but such technical variation appears less determinative in the context of stoma reversal when standard surgical principles are maintained. This supports the concept that patient-related and global operative factors outweigh specific anastomotic technique in predicting short-term reversal outcomes.

The timing of stoma reversal remains a debated determinant of postoperative risk. In our cohort, waiting time was not an independent predictor of adverse outcomes, despite a trend toward longer hospital stay with increasing delay. However, multiple contemporary studies have demonstrated that delayed reversal is associated with increased morbidity. Although timing of reversal did not independently predict postoperative morbidity in this study, optimal scheduling should be individualized based on patient condition. Early reversal (< 6 months) has been linked to lower postoperative ileus and fewer 30-day complications[16], while delayed closure has independently predicted higher complication rates in multicenter analyses[17] and institutional cohorts[18]. After Hartmann’s procedure, early reversal has likewise been associated with fewer complications and shorter hospitalization[19]. Moreover, time to reversal has been identified as an independent predictor of stoma-related complications[10] and infectious morbidity, including Clostridioides difficile infection[20]. Thus, although timing did not reach independent significance in our model, cumulative evidence suggests that unnecessary delay may contribute to increased postoperative risk.

Nutritional and physiological reserve also play a critical role. Lower preoperative haemoglobin in the present study was associated with prolonged hospitalization and a trend toward higher-grade complications, emphasizing the importance of preoperative optimization. Hypoalbuminemia has been identified as an independent predictor of overall complications after ileostomy reversal[10], while high BMI independently predicts stoma-related complications[10] and major morbidity in national analyses[11]. Functional dependence, smoking, steroid use, and severe comorbidities have likewise emerged as strong predictors of adverse outcomes[11]. These data collectively highlight the modifiable nature of several risk domains.

Postoperative ileus in our cohort was most strongly associated with advancing age. External data support the association between delayed reversal and increased postoperative ileus[16], reinforcing the interplay between patient age, bowel physiology, and surgical timing. Surgical site infection did not demonstrate independent associations in our model; however, SSI remains one of the most common complications after stoma reversal, with rates up to 36% and identifiable predictors including prior fascial dehiscence, colostomy, and increased subcutaneous fat thickness[21].

Mortality in the present series was infrequent. Nonetheless, national data confirm that mortality after colostomy reversal is influenced by advanced age, high BMI, severe comorbidities, and open surgical approach[11]. In our cohort, lower BMI emerged as a predictor, underscoring the deleterious impact of poor nutritional reserve—an observation biologically consistent with the broader literature.

Taken together, both the present findings and contemporary multicenter and national data emphasize that stoma reversal should be approached as a major abdominal procedure rather than a minor elective intervention. Advanced age, comorbidity burden, nutritional status, operative duration, stoma type, and timing of reversal all contribute to postoperative risk. Careful patient selection, optimization of haemoglobin and nutritional parameters, minimization of operative complexity and anastomosis time, and avoidance of unnecessary delay are likely to play a pivotal role in improving outcomes after stoma reversal[22-24]. Table 7 summarizes similar studies.

Table 7 Summary of studies on small intestinal perforation and ileostomy reversal.

Ref.	Study design, number of cases	Objective	Results	Remarks
Kang et al[7], 2020	Retrospective multicenter cohort; 437 HP, 127 reversals	Evaluate rate of Hartmann’s reversal and predictors of post-reversal complications	35.9% post-reversal of Hartmann’s procedure complications. Interval > 6 months associated with lower complication rate. Age > 70, ASA III-IV, malignancy predicted non-reversal	Delay > 6 months may reduce complications; patient comorbidity critical
Pokorny et al[9], 2005	Retrospective cohort; 533 closures	Identify predictors of mortality and complications after stoma closure	Mortality 3%; complication rate 20%. Age predicted mortality; silicone drain use predicted complications	Age significant predictor; drain use associated with morbidity
Liang et al[21], 2013	Retrospective; 128 reversals	Identify predictors of SSI after stoma reversal	SSI rate 36%. Independent predictors: Fascial dehiscence (OR = 16.9), colostomy, thicker subcutaneous fat	Strong predictive model for SSI risk stratification
de Paula et al[12], 2020	ACS-NSQIP database analysis	Identify predictors of morbidity after elective ileostomy closure	Significant morbidity; operative time and patient factors predictive	Large database; risk-adjusted predictors identified
McCain et al[11], 2026	NSQIP database analysis	Identify predictors of major complications and mortality after colostomy reversal	Predictors: Age > 70, BMI ≥ 40, smoking, COPD, dependent status, steroid use, dialysis. Open approach ↑ complications (OR 1.67)	Robust national data; highlights modifiable risk factors
Lv et al[10], 2024	Retrospective; 439 patients	Identify predictors of overall and stoma-related complications after ileostomy reversal	Overall complications 11.4%. Low albumin → overall complications. High BMI and longer interval → stoma-related complications	Nutritional status and delay are key predictors
Khoo et al[16], 2021	Retrospective cohort; 251 patients	Assess impact of timing of reversal on outcomes	Early (< 6 months) reversal had lower POI (13.5% vs 38.1%) and fewer 30-day complications	Delay increases morbidity; supports early reversal
Rubio-Perez et al[18], 2014	Institutional retrospective study	Assess impact of delayed protective ileostomy closure	Delayed closure associated with increased postoperative complications	Timing is modifiable risk factor
Munshi et al[17], 2025	Multicenter retrospective cohort	Evaluate effect of delay on 90-day complications	Delayed reversal independently associated with higher complication rates	Multicenter validation of timing effect
Popazu et al[19], 2025	Retrospective; 148 HP reversals	Compare early vs delayed Hartmann reversal	Early (45-120 days) → fewer complications, shorter stay. Late reversal independently associated with complications	Supports early reversal when feasible
Oriel et al[22], 2017	Retrospective cohort; 114 reversals	Identify incidence and risk factors for hernias after stoma reversal	Incisional hernia 317%; risk factors: BMI, ASA ≥ 3, radiotherapy, deep SSI	Hernia risk stratification important for long-term outcomes
Tirelli et al[20], 2023	Retrospective; 126 patients	Identify predictors of Clostridium difficile infection after stoma reversal	CDI 4.8%; delayed reversal associated with higher CDI risk	Timing influences infectious morbidity
Peltrini et al[23], 2023	Retrospective; 145 patients	Evaluate postoperative morbidity after loop ileostomy reversal	Significant morbidity; risk influenced by urgency of primary surgery	Differentiates elective vs urgent index surgery
Abdulmohaymen[14], 2020	Prospective; 70 patients	Compare loop ileostomy vs loop colostomy complications including reversal	Higher reversal-related complications in ileostomy group (45.4% vs 13.5%)	Stoma type impacts reversal morbidity
Özcan et al[24], 2025	Retrospective cohort	Compare early vs late ileostomy closure complications	Evaluates complication rates based on timing	Adds evidence on timing-related morbidity

SSI: Surgical site infection; ACS-NSQIP: American College of Surgeons National Surgical Quality Improvement Program; COPD: Chronic obstructive pulmonary disease; BMI: Body mass index; ASA: American Society of Anesthesiologists; OR: Odds ratio; POI: Postoperative ileus; CDI: Clostridium difficile infection.

The findings of this study should be interpreted within the context of its single-center design. The study population reflects a tertiary-care setting in which a substantial proportion of stomas were created in emergency conditions with a predominance of infectious etiologies. As such, extrapolation to populations with different disease profiles, healthcare infrastructure, or elective surgical patterns should be made with caution. These results therefore define context-specific risk relationships rather than universally generalizable predictors. Future multicenter studies involving diverse geographic and clinical settings are required to validate the external applicability and reproducibility of these findings.

Limitations

This study has several limitations. First, it was conducted at a single tertiary-care center with a modest sample size, which may limit the generalizability of the findings to broader populations. Second, the follow-up period was limited to 30 days, potentially underestimating late postoperative complications such as incisional hernia or adhesive bowel obstruction. Third, although data were collected prospectively and multivariate adjustment was performed, residual confounding from unmeasured intraoperative or patient-related variables cannot be completely excluded.

Furthermore, the study population was relatively young (median age 32 years), with a limited proportion of patients aged ≥ 60 years. While stratified analyses were performed, the small number of elderly patients may restrict the precision of conclusions regarding advanced age as a risk factor for severe complications. Larger multicenter studies with a broader age distribution are required to validate these findings.

Finally, although logistic regression was applied for selected binary outcomes, overall complication severity was primarily analyzed using linear regression modeling of Clavien-Dindo grades. While this approach permits assessment of incremental severity changes, future studies with larger event numbers may benefit from fully adjusted logistic regression models for clinically significant complications to enhance interpretability and robustness.

CONCLUSION

Stoma reversal is associated with clinically significant postoperative morbidity and should not be regarded as a minor procedure. In this prospective study, increasing age and longer anastomosis time were associated with a higher risk of Clavien-Dindo grade II and above complications, postoperative ileus, and prolonged hospital stay, while type of stoma and anastomotic technique did not independently influence major outcomes; however, given the relatively young study population, this finding should be interpreted as reflecting a risk gradient across the adult age spectrum rather than being limited to elderly patients alone.

These findings emphasize that patient-related factors and operative complexity play a greater role in determining postoperative risk than technical variations alone. Given the predominance of emergency stoma creation in the Indian setting, this study provides context-specific evidence using standardized Clavien-Dindo reporting. Careful patient selection, preoperative optimization, and operative strategies aimed at reducing anastomosis time are essential to improve outcomes. Stoma reversal should be approached as a major surgical procedure, particularly in older or high-risk patients.