Surgical fecal diversion vs non-diversion in perineal necrotizing soft tissue infections: A systematic review and meta-analysis

doi:10.5492/wjccm.v15.i2.117985

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World Journal of Critical Care Medicine

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2220-3141

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Meta-Analysis

Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Crit Care Med. Jun 9, 2026; 15(2): 117985
Published online Jun 9, 2026. doi: 10.5492/wjccm.v15.i2.117985

Surgical fecal diversion vs non-diversion in perineal necrotizing soft tissue infections: A systematic review and meta-analysis

Marcelo Augusto Fontenelle Ribeiro Junior, Sharon M Henry, Husna Irfan Thalib, Sariya Khan, Agata Grochowska-Krystman, Lucas Fontenelle Vieira, Sachin Reddi, Rafael Dib Possiedi

Marcelo Augusto Fontenelle Ribeiro Junior, Sharon M Henry, Rafael Dib Possiedi, Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD 21201, United States

Marcelo Augusto Fontenelle Ribeiro Junior, Department of Surgery, Pontifical Catholic University of São Paulo - Campus Sorocaba, Sorocaba 18030070, Sao Paulo, Brazil

Husna Irfan Thalib, Sariya Khan, General Medicine Practice Program, Batterjee Medical College, Jeddah 21442, Makkah al Mukarramah, Saudi Arabia

Agata Grochowska-Krystman, Faculty of Medicine, Medical University of Lodz, Lodz 90419, Poland

Lucas Fontenelle Vieira, Department of Surgery, Florida Atlantic University Charles E Schmidt College of Medicine, Boca Raton, FL 33431, United States

Sachin Reddi, School of Medicine, California University of Science and Medicine, Colton, CA 92324, United States

Rafael Dib Possiedi, Department of Surgery, Médecins Sans Frontières, Brussels 1050, Brussels-Capital Region, Belgium

Rafael Dib Possiedi, Department of Surgery, UK-Med, Manchester M3 3WD, United Kingdom

Co-first authors: Marcelo Augusto Fontenelle Ribeiro Junior and Rafael Dib Possiedi.

Author contributions: Fontenelle Ribeiro Junior MA, Henry SM and Dib Possiedi R designed the study; Irfan Thalib H, Khan S, Grochowska-Krystman A, Fontenelle Vieira L, Reddi S and Dib Possiedi R contributed to article search, data extraction, and quality assessment of the studies; Fontenelle Ribeiro Junior MA served as the adjudicator for conflicts and “maybe” classifications during study selection in Rayyan; Dib Possiedi R performed data analyses; Fontenelle Ribeiro Junior MA, Henry SM, Dib Possiedi R, Irfan Thalib H, Khan S, Grochowska-Krystman A, Fontenelle Vieira L and Reddi S participated in the drafting of the article; Fontenelle Ribeiro Junior MA and Henry SM reviewed the article independently and made revisions after consulting with Dib Possiedi R. All authors have read and approved the final version of the manuscript for submission. This manuscript, including the related data, figures, and tables, has not been published previously. All the authors have read and approved the final manuscript. Dib Possiedi R and Fontenelle Ribeiro Junior MA contributed equally to this work and shared first authorship.

Conflict-of-interest statement: The authors declare no competing interests.

PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.

Corresponding author: Marcelo Augusto Fontenelle Ribeiro Junior, MD, PhD, Director, FACS, Full Professor, Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, 22 S Greene St-Baltimore, Baltimore, MD 21201, United States. drmribeiro@gmail.com

Received: December 22, 2025
Revised: January 8, 2026
Accepted: January 27, 2026
Published online: June 9, 2026
Processing time: 152 Days and 12 Hours

Abstract

BACKGROUND

Perineal necrotizing soft tissue infections (P-NSTI) are aggressive and potentially fatal conditions. Surgical fecal diversion (SFD) is often used to reduce contamination, but whether non-diversion provides comparable outcomes remains uncertain. We hypothesized that non-diversion does not confer worse outcomes than SFD.

AIM

To evaluate clinical outcomes of non-diversion compared with SFD in adults with P-NSTI.

METHODS

Systematic review and meta-analysis following PRISMA and Cochrane standards. PubMed, EMBASE, Scopus, Web of Science and Cochrane Library were searched without date restrictions. Adults with P-NSTI comparing non-diversion vs SFD were included when outcomes were numerically extractable. Outcomes were mortality, hospital length of stay (LOS), number of surgical procedures and intensive care unit (ICU) admission. Random-effects models were used. Risk of bias was assessed with ROBINS-I and certainty of evidence with GRADE (PROSPERO CRD420251241839).

RESULTS

Thirty-six studies including 1751 patients were analyzed. In studies with reconstructed groups, mortality favored non-diversion, whereas no difference was observed in studies with predefined groups. Overall pooled analysis showed lower mortality with non-diversion (odds ratio 0.65; 95% confidence interval: 0.46-0.91; P = 0.01; I² = 24%), limited by serious confounding by indication. Hospital LOS showed substantial heterogeneity; excluding one outlier study favored non-diversion. ICU admission and number of surgical procedures did not differ. Certainty of evidence was very low for all outcomes.

CONCLUSION

No consistent outcome differences are demonstrated between non-diversion and SFD, and apparent mortality differences likely reflect baseline severity rather than treatment effect, with insufficient evidence to define superiority.

Keywords: Nonsurgical fecal diversion; Perianal sepsis; Flexible fecal management system; Flexi-seal; Colostomy, surgical fecal diversion; Fournier’s gangrene; Fecal incontinence catheter; Evacuation management; Necrotizing fasciitis

Core Tip: This systematic review and meta-analysis of thirty-six studies found no consistent differences between non-diversion and surgical fecal diversion (SFD) in mortality, intensive care unit admission or the number of surgical procedures. Hospital length of stay showed significant heterogeneity, with sensitivity analysis favoring non-diversion after exclusion of one outlier study. Overall certainty of evidence was very low, mainly due to confounding by indication and inconsistent group definitions. These findings do not demonstrate a clear overall advantage of routine SFD and support the need for standardized criteria and prospective studies in Perineal necrotizing soft tissue infections.