Loop Ileostomy Closure After

Restorative Proctocolectomy:
Outcome in 1,504 Patients
Kutt-Sing Wong, M.D., F.R.C.S.,1 Feza H. Remzi, M.D., F.A.S.C.R.S.,1
Emre Gorgun, M.D.,1 Susana Arrigain, M.A.,2 James M. Church, M.B.B.Ch., F.R.A.C.S.,1
Miriam Preen, R.N., B.S.N.,1 Victor W. Fazio, M.B., M.S.1
1
Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio
2
Department of Biostatistics and Epidemiology, The Cleveland Clinic Foundation, Cleveland, Ohio

PURPOSE: Routine use of a temporary loop ileostomy for
diversion after restorative proctocolectomy is controversial
because of reported morbidity associated with its creation
and closure. This study intended to review our experience
with loop ileostomy closure after restorative proctocolec-
tomy and determine the complication rates. In addition,
complication rates between handsewn and stapled closures
were compared. METHODS: Our Department Pelvic Pouch
Database was queried and charts reviewed for all patients
who had ileostomy closure after restorative proctocolec-
tomy from August 1983 to March 2002. RESULTS: A total of
1,504 patients underwent ileostomy closure after restora-
tive proctocolectomy during a 19-year period. The median
length of hospitalization was three (range, 1–40) days and
the overall complication rate was 11.4 percent. Complica-
tions included small-bowel obstruction (6.4 percent),
wound infection (1.5 percent), abdominal septic complica-
tions (1 percent), and enterocutaneous fistulas (0.6 per-
cent). Handsewn closure was performed in 1,278 patients
(85 percent) and stapled closure in 226 (15 percent). No
significant differences in complication rates and length of
hospitalization were found between handsewn and stapled
closure techniques. CONCLUSIONS: Our results demon-
Read at the meeting of The American Society of Colon and Rectal
Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.
Correspondence to: Feza H. Remzi, M.D., F.A.S.C.R.S., Depart-
ment of Colorectal Surgery, The Cleveland Clinic Foundation, 9500
Euclid Avenue, Desk A30, Cleveland, Ohio 44195, email:
remzif@ccf.org
Dis Colon Rectum 2005; 48: 243–250
DOI: 10.1007/s10350-004-0771-0
© The American Society of Colon and Rectal Surgeons
Published online: 7 February 2005
243
strated that ileostomy closure after restorative proctocolec-
tomy can be achieved with a low morbidity and a short
hospitalization stay. In addition, we found that complica-
tion rates and length of hospitalization were similar be-
tween handsewn and stapled closures. [Key words: Ileosto-
my; Ileostomy closure; Restorative proctocolectomy; Pelvic
abscess; Anastomotic dehiscence; Enterocutaneous fistula;
Bowel obstruction; Wound infection]
A relatively high risk of anastomotic dehiscence
after restorative proctocolectomy has led to the
frequent use of a defunctioning loop ileostomy.1,2 For
a defunctioning ileostomy to have any clinical utility,
ileostomy-related complications including those per-
taining to ileostomy closure must be less than the risk
and complications related to anastomotic dehiscence.
However, reports of high complication rates of ileos-
tomy closure after restorative proctocolectomy have
discouraged the routine use of a defunctioning ileos-
tomy.3–8 Furthermore, there is concern about the
need for a second operation with time in the hospital
and off work.
This study intended to determine the outcome and
complication rates of a large series of ileostomy clo-
sures after restorative proctocolectomy. In addition,
this study was designed to compare the outcome and
complication rates between handsewn and stapled
techniques of ileostomy closure.
244 WONG ET AL
METHODS
We queried our Institution Review Board-approved
Pelvic Pouch Database for all patients who underwent
ileostomy closure after restorative proctocolectomy in
our department from August 1983 to March 2002 in-
clusive. Hospital and clinic charts of patients who had
incomplete data were reviewed. We noted patient de-
mographics, length of hospitalization, incision used
for closure, closure technique, complications, and
time interval from ileostomy construction to closure.
Statistical Analysis
To assess differences in complication rates by inci-
sion used and technique of closure, we used chi-
squared and Fisher’s exact tests as appropriate. We
assessed the relationship between incision and length
of stay, using Kruskal-Wallis test and Dunn’s multiple
comparison procedure. We assessed the relationship
of age and gender with closure technique using Wil-
coxon rank-sum and chi-squared tests respectively.
To assess the relationship between closure tech-
nique and length of stay, we used a negative binomial
generalized linear model, adjusting for the year of
closure because there was a trend toward earlier pa-
tient discharge in more recent years. Because length
of stay was measured in days, a positive discrete vari-
able, a number of appropriate generalized linear
models were explored. A negative binomial model
offered much lower deviance and hence a substan-
tially improved fit compared with a Poisson model.
To assess the relationship between timing of ileos-
tomy closure and development of complications, we
used logistic regression analysis. Because of the dis-
tribution of the interval between ileostomy construc-
tion and closure, we took the log base 2 of months to
closure to model the odds of developing a complica-
tion. This transformation increased the goodness-of-
fit for all logistic regression models.
We used the median time of ileostomy closure to
divide patients into early and late closure groups and
tested differences in the proportion of complications
before and after that time using chi-squared tests. All
complications are mentioned in the RESULTS, al-
though wound infection had the only significant dif-
ference.
Statistics were generated using SAS 8 software (SAS
Institute Inc., Cary, NC) and S-PLUS 6.1 (Insightful
Inc., Seattle, WA). P < 0.05 was considered statistically
significant.
Dis Colon Rectum, February 2005
Technical Considerations
Before ileostomy closure, the majority of patients
had a Gastrografin enema performed to demonstrate
free flow of contrast into the ileostomy bag (indicating
the absence of distal obstruction) and the absence of
leakage from the pelvic pouch and the pouch-anal
anastomosis.
Ileostomy closure was generally approached via a
circumstomal incision and mobilization of the stoma
performed down to the fascia and peritoneal cavity.
When difficulty was encountered during mobilization,
the incision was extended vertically. A midline inci-
sion was used in patients in whom mobilization was
impossible despite extension of the circumstomal in-
cision, or sometimes in patients who had obstructive
symptoms or concurrent ventral midline hernias be-
fore closure. After mobilization, the integrity of the
afferent and efferent limbs was routinely checked
with instillation of air and saline/Betadine.
For handsewn closure, after the ileostomy had been
fully mobilized, the everted edges of the afferent limb
were freed and thickened bowel edges trimmed. In
general, handsewn closure was performed with a
single-layer interrupted serosubmucosal Vicryl® (Ethi-
con, Inc., Somerville, NJ) sutures. In some cases, clo-
sure was performed in two layers.
For stapled closure, a 6-cm linear cutter stapler was
inserted into each bowel limb followed by firing a
linear stapler across both limbs below the previous
stoma. This resulted in a side-to-side functional, end-
to-end anastomosis.
After ileostomy closure, the anterior fascia was
closed with 1-0 Vicryl®, PDS® (Ethicon, Inc.), or
Prolene® (Ethicon, Inc.) sutures, depending on sur-
geon preference. The majority of circumstomal inci-
sions were left partially or completely open. Midline
wounds were closed in the standard fashion: mass
closure with PDS® or Prolene® followed by staples to
skin.
Definition of Complications
Small-bowel obstruction was defined by a combi-
nation of the following findings: abdominal disten-
tion, abdominal pain, vomiting, or the presence of
multiple air-fluid levels on a plain abdominal radio-
graph in the postoperative period. Wound infection
was defined by the presence of purulent wound dis-
charge, wound erythema, and induration. Abdominal
septic complications were defined by the presence of
Vol. 48, No. 2 OUTCOME OF ILEOSTOMY CLOSURE
Table 1.
Overall Postoperative Complications in 1,504 Patients
Complication No. of Patients
Small-bowel obstruction 97 (6.4)
Wound infection 23 (1.5)
Abdominal septic complications 15 (1)
Enterocutaneous fistula 9 (0.6)
Stoma-site incisional hernia 17 (1.1)
Postoperative hemorrhage 2 (0.1)
Respiratory 6 (0.4)
Renal 1 (0.06)
Cardiac 1 (0.06)
Mortality 1 (0.06)
Total 172 (11.4)
Data are numbers with percentages in parentheses.
a pelvic abscess confirmed on a CT scan or clinical
peritonitis with or without anastomotic dehiscence af-
ter ileostomy closure.
RESULTS
Between August 1983 and March 2002, 1,504 pa-
tients (889 males; median age, 36.8 (range, 7–89)
years) underwent loop ileostomy closure after restor-
ative proctocolectomy The median time interval from
ileostomy construction to closure was 3.2 months
(range, 9 days to 38.8 months). The median length of
hospitalization stay overall was three (range, 1–40;
interquartile range, 2–5) days.
The majority of ileostomy closures were performed
using a circumstomal incision (n = 1221; 81.2 per-
cent). This incision was extended in 203 patients (13.5
percent) because of dense adhesions and difficulties
in dissecting the stoma from the abdominal wall. A
midline incision was used in 80 patients (5.3 percent).
The reasons for using a midline incision were adhe-
sions (n = 57), obstructive symptoms before closure
(n = 17), and concurrent repair of ventral hernias
(n = 6).
A total of 1,278 patients (85 percent) underwent
handsewn ileostomy closure and 226 patients (15 per-
cent) underwent stapled closure. The handsewn and
stapled groups were not significantly different in their
age or gender distribution. Handsewn closure was
performed in one interrupted layer in 992 patients (66
percent) and in two layers in 286 (19 percent).
Wounds were left open at skin level in 731 patients
(48.6 percent), partially closed in 579 (38.5 percent),
and completely closed in 194 (12.9 percent).
Complications occurred in 172 patients (11.4 per-
cent; Table 1), which included 1 mortality (0.06 per-
245
cent). The cause of the mortality was an acute myo-
cardial infarction in a 64-year-old patient, which
occurred four days after loop ileostomy closure.
Small-Bowel Obstruction
Small-bowel obstruction (SBO) was the most com-
mon complication after ileostomy closure after restor-
ative proctocolectomy (n = 97; 6.4 percent), 83 (85.6
percent) in the early postoperative period (up to 30
days). The remaining 14 cases (14.4 percent) occurred
more than 30 days after closure. The majority of cases
were managed successfully with conservative man-
agement (n = 72; 74.2 percent) but surgery was
needed in 25 patients (25.8 percent). Adhesions were
the main cause of obstruction found at surgery (n =
23). The other causes were an anastomotic stricture in
one patient and an intramural hematoma at the clo-
sure site in another. Both these patients had previ-
ously undergone handsewn closure. Operations per-
formed for adhesion-obstruction included lysis of
adhesions and small-bowel resection. When obstruc-
tion rates were compared based on anastomotic tech-
nique, there was no significant difference between
handsewn and stapled techniques (85/1,278 = 6.7
percent vs. 12/226 = 5.3 percent; P value = 0.45).
Wound Infection
The second most common complication after ileos-
tomy closure was wound infection (n = 23; 1.5 per-
cent). All settled with conservative management,
which included laying open of a closed wound, regu-
lar wound dressing and, in some cases, oral antibiot-
ics. Other complications that needed surgery, besides
bowel obstruction, were abdominal sepsis, enterocu-
taneous fistulas, and incisional hernias at the stoma
site.
Abdominal Sepsis
There were 15 cases (1 percent) of septic compli-
cations. Five cases of pelvic abscesses were success-
fully managed nonoperatively with percutaneous
drainage. Of the ten cases operated on, there were six
anastomotic leaks, one enterotomy that went unde-
tected during ileostomy closure, one leak from an
enterotomy that was repaired during ileostomy clo-
sure, and two cases for which no apparent source was
found. Four of the six cases of anastomotic leaks un-
246 WONG ET AL
derwent small-bowel resection and the other two had
resuturing of the anastomosis and proximal loop ile-
ostomy with subsequent uncomplicated closure. The
patient with the undetected enterotomy underwent a
primary closure, whereas the patient with a leak from
the enterotomy repair underwent small-bowel resec-
tion. Exploratory laparotomies were performed for
the remaining two patients who had no apparent
source.
Enterocutaneous Fistula
There were nine cases (0.6 percent) of enterocuta-
neous fistulae (ECF). Six closed after octreotide
therapy and a prolonged period of total parenteral
nutrition. Two patients with anastomotic dehiscence
manifesting as ECF were operated on: one underwent
small-bowel resection and the other had resuturing of
the anastomosis. The third patient who underwent
surgery for an ECF was found to have a previously
undetected enterotomy. This was repaired and a re-
peat proximal defunctioning ileostomy constructed.
Closure of the repeat ileostomy was uncomplicated.
Other Complications
Incisional herniation at the stoma site was managed
without surgery in 2 of 17 patients. Two patients un-
derwent mesh repair and 13 underwent anatomic re-
pair.
Two patients bled per rectum two and four weeks
after closure respectively. These bleeding episodes
were self-limiting and did not require any interven-
tion. One of them was thought to be warfarin-related.
One patient had undergone a handsewn closure and
the other a stapled closure.
Six patients developed infectious respiratory com-
plications, which were treated with chest therapy,
deep breathing exercises, and antibiotics. One patient
had a rising serum creatinine level that normalized
after hydration and diuretic therapy. Besides the only
mortality from an acute cardiac event, the other car-
diac complication was that of supraventricular tachy-
cardia, which resolved with verapamil.
The proportion of wound infections was signifi-
cantly lower (P < 0.001) for patients with open (0.4
percent) and partially open wounds (0.4 percent)
compared with those with closed wounds (9.3 per-
cent; Table 2). The incidence of SBO was not signifi-
cantly different among midline (8.8 percent), circum-
Dis Colon Rectum, February 2005
Table 2.
Wound Infection Rate in Closed, Open, and Partially
Open Wounds After Ileostomy Closure After
Restorative Proctocolectomy
No Wound Wound
Infection Infection
Wound Disposition (n = 1,481) (n = 23) P Valuea
Closed (n = 194) 176 (90.7) 18 (9.3) <0.001
Open (n = 731) 728 (99.6) 3 (0.4)
Partially open 577 (99.6) 2 (0.4)
(n = 579)
Data are numbers with percentages in parentheses un-
less otherwise indicated.
a
Chi-squared test.
stomal (6.8 percent), and extended circumstomal (4
percent) incisions (P = 0.23; Table 3). We found no
significant differences in rates of bowel obstruction,
wound infection, and anastomotic complications be-
tween handsewn and stapled ileostomy closure tech-
niques (Table 4).
Length of Stay
The median length of hospitalization stay was 4
(range, 1–36; interquartile range, 3–5) days for hand-
sewn closure and 3 (range 1–40; interquartile range
2–4) days for stapled closure. However, the majority
of stapled closures were performed after 1993 and
patients were generally discharged earlier in more re-
cent years. Therefore, we used a negative binomial
generalized linear model to adjust for the year of op-
eration and found no significant difference in length
of stay between the two techniques (P = 0.85; Fig. 1).
We found that the length of stay for patients with
midline incisions (median, 7 days) was significantly
higher (P < 0.001) than the length of stay for patients
with circumstomal (median, 3 days) and extended cir-
cumstomal incisions (median, 4 days).
Time to Closure
The odds ratios for developing small-bowel ob-
struction, enterocutaneous fistulas, abdominal septic
complications, and wound infections for each twofold
increase in time to closure are presented in Table 5.
An odds ratio higher than 1 means that with an in-
crease in the time to closure, the odds of developing
that particular complication increase. Conversely, an
odds ratio lower than 1 means that with an increase in
Vol. 48, No. 2 OUTCOME OF ILEOSTOMY CLOSURE 247

Table 3.
Incidence of Small-Bowel Obstruction by Incision Type
Small-Bowel
No Small-Bowel Obstruction
Incision Obstruction (n = 1,407) (n = 97) P Valuea
Midline (n = 80) 73 (91.3) 7 (8.87) 0.23
Circumstomal (n = 1,214) 1,132 (93.3) 82 (6.8)
Extended circumstomal (n = 201) 193 (96) 8 (4)
Data are numbers with percentages in parentheses unless otherwise indicated.
a
Chi-squared test.

Table 4. with low colorectal or coloanal anastomoses.3–8 As a

Complication Rates for Handsewn and Stapled
Ileostomy Closures After Restorative Proctocolectomy
Handsewn Stapled
Complication (n = 1,278) (n = 226)
Bowel obstruction 85 (6.7) 12 (5.2)
Wound infection 20 (1.6) 3 (1.3)
Anastomotic 22 (1.7) 2 (0.9)
complications
Data are numbers with percentages in parentheses un-
less otherwise indicated.
a
Fisher’s exact test.
b
Chi-squared test.
the time to closure, the odds of developing that par-
ticular complication decrease. We found that the odds
ratios of developing the aforementioned complica-
tions decrease with an increase in time to closure, but
the relationship is only significant in the case of
wound infection. For example, in the case of wound
infection rates, for each doubling in time to closure,
the odds of wound infection are 0.39 times as high
(P = 0.017).
When we compared the complication rates on ile-
ostomy closure at or after 3.2 months (median time to
closure) vs. closure before 3.2 months, we found no
significant differences in the proportion of SBO or
anastomotic complications. However, we found that
2.2 percent of ileostomy closure before 3.2 months
(early closure) and 0.7 percent of ileostomy closure at
or after 3.2 months (late closure) developed wound
infections (P = 0.015; Table 6).
DISCUSSION
Overall complication rates after ileostomy closure
have been reported to be in the range of 10 to 30
percent.3–11 In addition, some authors have reported
a higher morbidity after ileostomy closure associated
with restorative proctocolectomy than that associated
result, a selective approach to the use of a defunc-
tioning loop ileostomy after restorative proctocolec-
P tomy has been advocated.
Value
Our experience with loop ileostomy closure was
0.45b first reported in 1987 by Van de Pavoordt et al.3 In that
0.99a
0.56a
study, the outcome of ileostomy closure after restor-
ative proctocolectomy and other colorectal opera-
tions performed for indications like low rectal cancer
and diverticulitis was reviewed. Like most other re-
ports in the literature, the results from that study in
1987 led to the conclusion that complication rates of
ileostomy closure after restorative proctocolectomy
(and ileal pouch-anal anastomoses) were higher than
those after left-sided colectomy/proctectomy (and co-
lorectal/coloanal anastomoses). With 142 cases of
loop ileostomy closure after restorative proctocolec-
tomy, that study remained the largest series ever re-
ported for more than a decade until 1999 when Phang
et al.11 reported on their experience in 235 cases.
Overall complication rates for the reports by Van de
Pavoordt et al. and Phang et al. were 17 and 28 per-
cent respectively. However, because loop ileostomy
closure after operations other than restorative procto-
colectomy were included in both reports, the true
complication rates for loop ileostomy closure after
restorative proctocolectomy could not be determined.
Our study showed a complication rate of 11.4 per-
cent after ileostomy closure and restorative procto-
colectomy. To capture a true figure of the morbidity
associated with ileostomy closure, we included all
medical and surgical complications so that we could
determine the acceptability of a staged procedure in
restorative proctocolectomy.
Small-bowel obstruction accounted for almost one-
half of the complications (56.4 percent; SBO/total
complications, 97/172 = 56.4 percent). This finding
was similar to other reports in the literature.3,10 It has
been suggested that the high incidence of small-
bowel obstruction after ileostomy closure in these pa-
248 WONG ET AL Dis Colon Rectum, February 2005

Figure 1. Length of stay and

year of procedure for
handsewn and stapled.
Gaussian kernel smooth with
three-year bandwidth.

Table 5.
Timing of Closure and Complications
Odds Ratio Per
No. of Mean No. of Months Doubling in Time
Complication Level Patients to Closure (SD) to Closure (95% CI) P Valuea
Small-bowel obstruction No 1,407 3.6 (1.9) 0.94 (0.62–1.42) 0.78
Yes 97 3.7 (2.3)
Enterocutaneous fistula/abdominal No 1,480 3.6 (2) 0.73 (0.32–1.7) 0.47
septic complications Yes 24 3.4 (1.2)
Wound infection No 1,481 3.6 (2) 0.39 (0.18–0.85) 0.017
Yes 23 3 (1.1)
SD = standard deviation; CI = confidence intervals.
a
Logistic regression analysis. All odds ratios were calculated using the log2 of months to closure.

tients compared with patients who had previous co- Table 6.

lorectal/coloanal anastomosis could be a result of the Wound Infection Rate in Early and Late Ileostomy
extensive dissection and mobilization required in re- Closure Using Median Time of Closure (3.2 months) as
storative proctocolectomy, thus encouraging forma- a Cutoff
tion of adhesions.3,4 This possibility is corroborated in No Wound Wound
this present study, because 23 of 25 patients who Infection Infection P
needed surgery for obstruction had intra-abdominal Time of Closure (n = 1,481) (n = 23) Valuea
adhesions as a cause of obstruction. More than 70 <3.2 months (n = 799) 781 (97.8) 18 (2.2) 0.015
ⱖ3.2 months (n = 705) 700 (99.3) 5 (0.7)
percent of patients who had midline incisions had
obstructive symptoms before closure and yet the in- Data are numbers with percentages in parentheses un-
less otherwise indicated.
cidence of SBO was not significantly different among a
Chi-squared test
the different incision types after closure. Therefore, in
patients with more than one episode of small-bowel
obstruction before ileostomy closure, a case may be Edema at a narrowed anastomosis has been
made for performing a midline laparotomy with a thought to be another cause of obstruction after ile-
view to lysis of adhesions at the time of closure. ostomy closure. Advocates have suggested that a
Vol. 48, No. 2 OUTCOME OF ILEOSTOMY CLOSURE
stapled closure may result in a lower incidence of
bowel obstruction than a handsewn closure,12,13 be-
cause a larger bowel lumen is created, although this
was not borne out in another comparative study.14
Our study did not show any significant difference in
bowel obstruction between handsewn and stapled
closures.
Reported wound infection rates after ileostomy clo-
sure ranged from 0 to 14.5 percent.4,6,9,10,11,12,13,14,15
Closed wounds were reported to have higher infec-
tion rates than wounds left partially or completely
open.10,11 Phang et al.11 reported a wound infection
rate of 14.2 percent in their series in which the ma-
jority of their wounds were closed primarily. Like-
wise, Mann et al.10 reported a wound infection rate of
14 percent in which 68 percent of their patients had
primary wound closure. In contrast, our study had a
low wound infection rate of 1.5 percent, which may
be ascribed to our practice of leaving the majority of
our wounds partially open at least. We have shown
that wounds left partially or completely open have a
significantly lower incidence of wound infection than
closed wounds. We thus recommend that ileostomy
closure wounds should not be closed primarily, espe-
cially in patients who are obese, diabetic, or immu-
nocompromised in any way and in the presence of
peristomal skin excoriation at the time of closure.
Anastomotic complications after loop ileostomy
closure, including pelvic abscesses and ECF, had a
low incidence (1.4 percent) in this study. Others have
reported anastomotic complication rates after loop il-
eostomy closure of 0 to 3 percent.3,6,8,11 Compar-
atively, anastomotic leak rates after restorative proc-
tocolectomy without diversion have been reported to
be up to 14 percent.1,2,16,17 In addition, our study did
not show any significant difference in anastomotic
complications between handsewn and stapled clo-
sures. This was similar to the findings of other reports
in the literature.11,13,14,15 Moreover, like these studies,
we did not find any significant difference in the length
of hospitalization stay between handsewn and
stapled ileostomy closures.
The relationship between timing of loop ileostomy
closure and the development of surgical complica-
tions has not been studied in previous reports in the
literature. Nonetheless, most centers traditionally
schedule ileostomy closure in three months because it
is believed that earlier closure is fraught with difficul-
ties caused by adhesions and bowel friability.10,12,14
The results from the present study provide supporting
evidence for this practice.
249
CONCLUSIONS
Loop ileostomy closure after restorative procto-
colectomy is associated with an acceptable complica-
tion rate of 11.4 percent and a short median hospital-
ization length of stay of three days, especially if
performed after at least a three-month interval. Be-
cause of our low wound infection rates (1.5 percent)
after ileostomy closure, which may be explained by
our practice of leaving the majority of our wounds
unclosed, we believe that ileostomy closure wounds
should not be closed primarily. Complication rates
and length of stay are similar between handsewn and
stapled closures.
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