Ileostomy reversal after rectal cancer surgery: Does timing matter?

In a systematic review and meta-analysis evaluating surgical outcomes in low rectal cancer patients who underwent early vs late ileostomy reversal, the former appears to be less beneficial than the latter in terms of surgical complications.

“A defunctioning ileostomy is commonly created to avert systemic sepsis associated with a tenuous anastomosis, particularly when the risk of anastomotic dehiscence is high … [I]it is believed that early closure may be beneficial for most patients than the standard practice of late closure,” said the researchers, led by Dr Dedrick Kok Hong Chan from the National University Hospital, Singapore.

“[This analysis shows that] early closure of defunctioning ileostomy in rectal cancer patients results in increased surgical complications vs late closure. [Hence,] caution must be undertaken in patients who have undergone early closure,” said Chan and colleagues.

The surgical complication rate was significantly higher with early vs late closure (11.3 percent vs 3.6 percent; odds ratio [OR], 2.63; 95 percent confidence interval [CI], 1.04–6.67; p=0.04). Surgical complications are operation-specific, such as bleeding, wound infection, or small bowel obstruction post-ileostomy reversal. [BMC Gastroenterol 2025;doi:10.1186/s12876-025-04090-9]

Statistical significance was not achieved when evaluating other outcomes such as overall morbidity (20 percent vs 12 percent; OR, 1.82; 95 percent CI, 0.97–3.31; p=0.06), reoperation (6.7 percent vs 1.6 percent; OR, 2.57; 95 percent CI, 0.72–9.14; p=0.14), and anastomotic dehiscence/leakage (OR, 3.75; 95 percent CI, 0.40–26.38; p=0.27).

“[However,] the magnitude of the increased risks as [reflected] by the ORs was high … [and] these were very close to approaching statistical significance,” the researchers pointed out.

“[As such,] surgeons must factor these potential complications when advising patients to consider early closure for the purported benefits of reducing complications and worse quality of life (QoL) whilst living with the ileostomy,” they said. Evidence shows that patients have reported decreased physical and role functioning with temporary ileostomy. [Dis Colon Rectum 2008;51:218-222]

A cautionary warning

The five randomized controlled trials included in the meta-analysis comprised 387 patients, with 195 participants in the early closure arm and 192 in the late closure arm. All participants underwent a defunctioning ileostomy for rectal cancer.

“We chose to include only rectal cancer patients in this review, as any complication occurring during this immediate post-reversal period may result in delays to chemotherapy delivery. Timely chemo delivery is associated with improved overall survival,” the researchers explained.

“Our meta-analysis … serves as a cautionary warning for the surgical community that early closure of ileostomy in rectal cancer, while technically feasible and potentially cost-saving from an institutional perspective, can result in an increased risk of surgical complications,” said Chan and colleagues.

The investigators recommended further studies that would aim to achieve a high level of scientific rigour using the appropriate sample size estimation, particularly for low-prevalence but clinically significant outcomes such as anastomotic dehiscence or reoperation, particularly in the control arms.

“We also encourage future trials to consider the importance of secondary outcomes related to health service delivery and post-closure QoL, as these indicators will be necessary for long-term cost-effectiveness analyses of early closure for the benefit of institutions,” they added.