Loop Ileostomy Morbidity: Timing

of Closure Matters
Rodrigo Oliva Perez, M.D., Angelita Habr-Gama, M.D., Ph.D., Victor E. Seid, M.D.,
Igor Proscurshim, M.S., Afonso H. Sousa Jr., M.D., Ph.D.,
Desidério R. Kiss, M.D., Ph.D., Marcelo Linhares, M.S., Manuela Sapucahy, M.D.,
Joaquim Gama-Rodrigues, M.D., Ph.D.
Institute of Colorectal Surgery, São Paulo, Brazil

PURPOSE: Diverting stomas are commonly performed
during ileoanal and coloanal anastomoses. We studied a
series of patients after loop ileostomy closure to determine
risk factors and the impact of the interval from primary
operation on morbidity. METHODS: Ninety-three consecu-
tive patients undergoing loop ileostomy closure at a single
institution after coloanal or ileoanal anastomosis were
retrospectively reviewed. Complications were classified as
medical or surgical according to its treatment require-
ments. Results were correlated to clinical and operative
features. RESULTS: Of the 93 patients, 43 were male and 50
were female with mean age of 56 years. Overall, complica-
tion rate was 17.2 percent. The most common complica-
tion was small-bowel obstruction. Complications required
operative management in 3.2 percent and medical manage-
ment alone in 14 percent. There was no mortality. There
was no correlation between complication occurrence and
age, gender, type of suture (manual or mechanical), and
operative time. Complications were significantly associated
with primary disease and shorter interval between primary
operation and ileostomy closure. Regarding the optimal
interval between primary surgery and ileostomy closure,
the cutoff value for increased risk of developing postoper-
ative complications was 8.5 weeks, below which the risk of
such occurrence was significantly higher with a sensitivity
rate of 88 percent. CONCLUSIONS: Diverting loop ileos-
tomy adds little cumulative morbidity to the primary
operation and is a safe option for diversion to protect a
low colorectal anastomosis. To further reduce morbidity,
Poster presentation at the meeting of The American Society of
Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to
May 5, 2005.
Correspondence to: Rodrigo Oliva Perez, M.D., Rua Manuel da
Nóbrega, 1564, São Paulo, SP 04001–005, Brazil, e-mail: rodrigo.
operez@gmail.com
Dis Colon Rectum 2006; 49: 1539–1545
DOI: 10.1007/s10350-006-0645-8
* The American Society of Colon and Rectal Surgeons
Published online: 08 August 2006
1539
the interval between primary operation and ileostomy
closure should be no shorter than 8.5 weeks. [Key words:
Diverting ileostomy; Complications; Morbidity]
T he high rates of anastomotic complications
associated with low colorectal and coloanal
anastomosis have driven surgeons to develop pro-
tective measures to diminish the severity of related
consequences.1–10 Diverting stomas are frequently
performed after these types of restorative proce-
dures. In fact, this strategy has had great impact on
surgical morbidity and mortality of restorative colo-
rectal surgery.2,6,11
However, several issues remain unresolved. First,
the choice between a loop ileostomy and colostomy is
controversial.5–7 Factors, such as metabolic conse-
quences and patient’s comfort, are crucial because
the most frequent indication for the primary proce-
dure is rectal cancer, and these patients often are in
their sixth or seventh decade of life. Furthermore,
when assessing the benefits of reducing primary
morbidity and mortality rates, consideration of the
morbidity of the protective loop stoma closure is
essential, especially in elderly patients.12
Therefore, the procedure related to this protective
stoma closure ideally should be associated with
minimal morbidity rates, allowing restoration of bowel
continuity for all of these patients and adding little
morbidity or even mortality to the primary procedure.
Otherwise, the performance of these protective loop
stomas could be considered a way to delay surgical
morbidity and mortality associated with the primary
1540 PEREZ ET AL
procedure shifting them to a later secondary operation.
Finally, the optimal interval between primary proce-
dure and ileostomy closure is not yet defined and may
be associated with the risk of developing postoperative
complications.
For these reasons, we decided to study the out-
comes of protective loop ileostomies performed for
low coloanal and ileoanal anastomosis in a large series
of patients to determine morbidity, mortality rates, and
factors associated with development of complications.
Identification of these factors could be useful in
choosing optimal management strategies.
PATIENTS AND METHODS
All patients requiring a protective loop ileostomy
for coloanal or ileoanal anastomosis in the period
between 1985 and 2005 in a single-center institution
(Habr-Gama Institute for Colorectal Surgery) were
retrospectively reviewed. Clinical and epidemiologic
data along with primary and ileostomy closure
operation were analyzed and correlated with the
occurrence of any complications within the first 30
postoperative days, requirement for reoperation, and
overall morbidity and mortality.
Patients were offered a clear liquid diet and 500 ml
of 10 percent Manitol the night before surgery.
Prophylactic intravenous antibiotics (second-genera-
tion cephalosporin) were administered on the day of
the procedure, during anesthesia induction. The
choice between stapled or manual anastomosis was
at the surgeon’s discretion. The same surgeons
performed operations in all cases. Ileostomy closure
was initially attempted by the stoma incision without
laparotomy in patients under general anesthesia. All
patients were offered a clear liquid diet on postop-
erative Day 1. Patients with adequate oral intake and
analgesia were discharged from the hospital. All
complications diagnosed within the first 30 days after
surgery were considered as postoperative, including
those specifically related to the operative procedure
and general complications. Complications were fur-
ther classified according to specific treatment re-
quirement (medical or surgical procedure) into
surgical and medical complications.
Statistical analysis included chi-squared test and
Fisher’s exact test for categorical variables, Student’s
t-test and Mann-Whitney test for continuous variables,
and receiver operating characteristic (ROC) curve to
determine optimal interval cutoff value. P < 0.05 was
considered significant.
Dis Colon Rectum, October 2006
RESULTS
Overall, 93 patients (50 females (53.8 percent) and 43
males (46.2 percent)) were eligible for the study. Mean
age was 56 (T15.3; range, 12–80) years. Primary disease
requiring protective loop ileostomy was rectal cancer in
67 patients (72 percent), inflammatory bowel disease
(IBD) in 17 patients (18.3 percent), and other benign
diseases (rectovaginal fistula, diverticular disease, and
others) in 9 patients (9.7 percent) (Table 1). There were
no complications specifically associated with the stoma
before closure, such as bleeding, peristomal abscess, or
significant prolapse.
Four patients with small-bowel obstruction before
ileostomy takedown required laparotomy for adhe-
sionlysis. In these patients, associated ileostomy closure
was performed during the same procedure (4.3 per-
cent). The remaining 89 patients had their stoma closure
after an interval determined by surgeon and patient’s
choice. Mean interval between creation of ileostomy
and closure was 14.3 (T16.8; range, 1–156) weeks. Mean
hospital stay was 6.8 (T7.2; range, 2–54) days. Mean
operation time for ileostomy closure was 100 (T53.4;
range, 40 – 300) minutes. Ileostomy closure was per-
formed by manual anastomosis in 81 patients (87.1
percent) and by stapled anastomosis in 12 patients (12.9
percent; Table 1).
Overall, 16 patients experienced some kind of
postoperative complication after ileostomy closure,
leading to an overall morbidity rate of 17.2 percent.
Eleven patients developed small-bowel obstruction or
prolonged postoperative ileus (11.8 percent). Of these,
three patients required reoperation (3.2 percent),
whereas the remaining eight patients (8.6 percent)
Table 1.
Characteristics of Patients Submitted to Ileostomy Closure
No. of patients 93
Mean age (yr) 56 T 15.3
Gender
Male 43 (46.2)
Female 50 (53.8)
Primary disease
Rectal cancer 67 (72)
Inflammatory bowel disease 17 (18.3)
Other benign disease 9 (9.7)
Mean interval between primary 14.3 T 16.8
surgery and ileostomy closure (wk)
Anastomosis
Handsewn 81 (87.1)
Stapled 12 (12.9)
Mean operative time (min) 100 T 53.4
Mean hospital stay (days) 6.8 T 7.2
Data are numbers with percentages in parentheses.
Vol. 49, No. 10 LOOP ILEOSTOMY MORBIDITY 1541

Table 2. oped deep venous thrombosis and was managed by

Postoperative Complications of Ileostomy Closures and
Their Management
Postoperative complications 16 (17.2)
Small-bowel obstruction 11 (11.8)
Wound infections 2 (2.1)
Enteric fistula 1 (1.1)
Deep venous thrombosis 1 (1.1)
Rectal bleeding 1 (1.1)
Management of complications
Surgicala 3 (3.2)
Medical 13 (14)
Data are numbers with percentages in parentheses.
a
Surgical interventions were for small-bowel obstruction.
were successfully managed by gastric decompression,
bowel rest, and intravenous hydration. During laparot-
omy, in one of these patients an enteric leak was
diagnosed and managed by segmental enterectomy
and reanastomosis without any protective stoma. One
other patient was found to have uncomplicated small-
bowel adhesions determining mechanical obstruction
and was managed by simple adhesionlysis, and the
remaining patient developed early anastomotic stric-
ture after a handsewn ileostomy closure. One patient
developed enteric fistula to the ileostomy incision (1.1
percent) and was successfully managed by antibiotics,
bowel rest, and total parenteral nutrition. There were
two wound infections managed by simple drainage
and oral antibiotics (2.1 percent). Finally, one patient
developed significant rectal bleeding, which required
blood transfusion on postoperative Day 1 (1.1 percent).
The bleeding ceased spontaneously and the patient
required no further treatment. One last patient devel-
anticoagulation therapy (1.1 percent; Table 2).
There was no association between overall, medical,
or surgical morbidity and age or gender distribution in
these patients (P = 0.2 and P = 0.3, respectively).
There was no statistical difference in terms of compli-
cation rates between patients with ileostomy closure
through laparotomy or peristomal incision (P = 0.6).
However, patients managed by laparotomy had signif-
icantly greater operative time (195 vs. 95 minutes; P =
0.046) and hospital stay (14 vs. 6.5 days; P = 0.017).
Interestingly, primary disease requiring protective
loop ileostomy was significantly associated with the
overall morbidity rate. Patients with primary IBD had
significantly higher complication rates compared
with patients with colorectal cancer and other benign
diseases (29.4 vs. 14.9 and 11.1 percent; P e 0.001).
Preoperative serum albumin level showed no statis-
tically significant differences between patients with IBD
(3.3 g/dl) and patients with non-IBD (3.8 g/dl; P = 0.18).
Also, preoperative serum albumin was not significantly
different between patients who did or did not develop
complications (3.6 vs. 3.6 g/dl; P = 0.8).
Mean interval period between ileostomy creation
and closure was 15.3 weeks (T18.3) for patients without
postoperative complications and 9.9 weeks (T4.7) for
patients with postoperative complications. This differ-
ence was statistically significant (P = 0.02). However,
when the type of complication was considered, this
association also was observed for complications of
medical management (P = 0.003) but not for compli-
cations requiring surgery (P = 0.32; Table 3).

Table 3.
Correlation Between Postoperative Complications and Patients’ Characteristics After Protective Ileostomy Closure
Noncomplicated (n = 77) Complicated (n = 16) P Value
Gender
Male 34 (44) 9 (56) 0.3
Female 43 (56) 7 (44)
Mean age (yr) 56.6 T 15.5 53.4 T 15.3 0.5
Primary disease
Rectal cancer 57 (74) 10 (62.3) e0.001
Inflammatory bowel disease 12 (15.6) 5 (31.3)
Other benign disease 8 (10.4) 1 (6.4)
Anastomosis
Handsewn 68 (88.3) 13 (81) 0.4
Stapled 9 (11.7) 3 (9)
Mean serum albumin (g/dl) 3.6 3.6 0.8
Mean interval between primary 15.3 T 18.3 9.9 T 4.7 0.02
surgery and ileostomy closure (wk)
Mean operative time (min) 95.2 T 51.5 122.7 T 58.8 0.09
Mean hospital stay (days) 5.8 T 4 11.6 T 14.4 0.01
Data are numbers with percentages in parentheses unless otherwise indicated.
1542 PEREZ ET AL
Figure 1. Receiver operating characteristic (ROC) curve
(interval between primary surgery and ileostomy closure).
Intervals shorter than 8.5 weeks were associated with
increased risk of postoperative complication with a
sensitivity of 88 percent and specificity of 44 percent
(ROC curve area, 0.68; P = 0.02).
Mean operative time was slightly higher in patients
who developed postoperative complications (122.7 T
58.8 minutes vs. 95.2 T 51.5 minutes); however, this
difference was not statistically significant (P = 0.09).
Furthermore, there were no differences between
groups in terms of operative time when the type of
complication was considered. Patients managed by
stapled ileostomy closure had a 25 percent compli-
cation rate compared with 16 percent for patients
with handsewn (P = 0.4). Mean hospital stay also was
significantly higher in patients who developed com-
plications (11.6 T 14.4 days vs. 5.8 T 4 days; P = 0.01).
Because there was a significant correlation be-
tween the time interval between ileostomy creation
and ileostomy closure and the occurrence of post-
operative complications, we decided to study wheth-
er there was any cutoff or critical interval period in
this series before which the risk of complications
would be significantly increased. Therefore, we
performed a ROC curve by using the interval periods
between primary surgery and ileostomy closure and
the absence of complication as the test variable. The
curve resulted in an area of 0.68 (P = 0.02), indicating
that intervals longer than 8.5 weeks between loop
ileostomy construction and closure may result in the
absence of postoperative complications with a sen-
Dis Colon Rectum, October 2006
sitivity rate of 88 percent and specificity of 44 percent
(Fig. 1). We then divided the patients into two
groups according to this 8.5 week cutoff (22 patients
< 8.5 weeks and 71 Q 8.5 weeks) and found that there
was a significant difference between the groups in
terms of overall complication rates (P = 0.04).
DISCUSSION
Loop ileostomies are frequently used in colorectal
surgery after ileoanal or coloanal anastomosis to
prevent complications associated with the anastomosis.
They are most frequently performed for distal rectal
cancer and IBD. Recently, the use of neoadjuvant
chemoradiation therapy has resulted in an increase in
sphincter-saving operations, leading to higher rates of
low colorectal or even coloanal anastomosis after this
treatment strategy.1,13,14 This decrease in the rates of
abdominoperineal resection in favor of sphincter-
saving operations may have led to an increase in the
indication for protective loop ileostomies. In fact, the
postoperative morbidity and mortality rates for these
low colorectal, coloanal, or even ileoanal anastomosis
alone are sufficiently high that fecal diversion has
become a routine recommendation.
Several factors have been associated with increased
risk of postoperative complications development after
ileostomy closure, such as the interval between primary
surgery and closure, the use of bowel preparation,
antibiotic prophylaxis, and technical strategies (stapled
vs. handsewn suture techniques).12,15–26 In our series,
timing of closure and primary disease were significant
factors contributing to ileostomy closure morbidity,
whereas age, gender, serum albumin, and type of
suture were not (Table 3).
One of the arguments in favor of creating a
diverting loop ileostomy is the reduction of the clinical
consequences of postoperative anastomotic compli-
cations. On the other hand, this may be counter-
balanced by the complication rates associated with the
stoma closure. Although they are rarely severe, these
complications are frequently managed by medical
management alone and are associated with minimal
mortality.
Since the first report of this procedure by Turnbull
and Weakley in 1966,27 loop ileostomies gained
increased popularity because of its technical simplic-
ity, lack of odor, liquid discharge, decreased rates of
parastomal hernia, and prolapse.1–10,28 Besides these
advantages, another factor that attracted surgeons to
the use of protective loop ileostomies as opposed to
Vol. 49, No. 10 LOOP ILEOSTOMY MORBIDITY
protective colostomies was the expected decreased
rates of morbidity and mortality associated with the
second operation for stoma takedown.1–10 Neverthe-
less, ileostomy closure is not by any means a
morbidity-free procedure. Reported overall complica-
tion rate of ileostomy closure range between 10 to 17
percent,15 and may reach up to 30 percent when
performed for diversion of ileoanal pouches.5,28 The
most frequent complication after ileostomy closure
seems to be small-bowel obstruction.5,29 Furthermore,
this complication has been particularly associated with
patients treated for IBD by proctocolectomy and ileal
pouch caused by extensive pelvic dissection involved
in the primary surgical procedure, distention of the
ileal vessels, and finally the inflammatory disease
affecting the remaining small bowel.5,28 The relatively
high rates associated with IBD has motivated studies
of the real benefits of protective fecal diversion in this
specific situation.5,10,29,30
Interestingly, in our series the overall rate of
postoperative morbidity was 16.7 percent concordant
with reported rates, considering that ileostomies
were performed for IBD only in 18 percent of the
cases. Primary disease (IBD) was associated with an
increased risk of developing postoperative compli-
cations. High-steroid intake and poor nutritional
status could possibly be responsible for this finding.
All of the patients with IBD had ulcerative colitis and
had been weaned off steroids shortly after the
primary operation. Therefore, in this subset of
patients, all were off steroids for approximately nine
weeks before ileostomy closure.
Nutritional status may have a role in postoperative
complications, although objective determination of
this influence may be methodologically difficult. In
the present study, serum albumin concentration was
not significantly different between patients with IBD
and noninflammatory diseases and was not associat-
ed with postoperative complications. The relatively
small proportion of patients with IBD could limit the
association between complications and poor nutri-
tional status, although patients experience significant
nutritional improvement after the primary operation.
Patients with distal rectal cancer (>70 percent of
our cases) were not associated with an increased risk
of developing complications. One could expect to
find higher complication rates in these patients, who
often are managed in advanced age and frequently
have associated comorbidities. Again, the most
frequent complication was small-bowel obstruction
and prolonged postoperative ileus occurring in 11.9
1543
percent of the cases (accounting for > 70 percent of
postoperative morbidity). Interestingly, a small group
of patients required reoperation (3.2 percent); how-
ever, none of them required stoma reconstruction.
The interval between primary surgery and ileos-
tomy closure has been considered a possible risk
factor for complication development. Possible
explanations for this association include complete
recovery by the patients after the initial procedure,
usually a major operation, which may take up to two
to three months.15,18 Also, longer intervals may avoid
the period of hypervascularization of adhesions,
which progressively become less firm. Finally, time
leads to increased vascularization and decreased
edema of the stoma border. On the other hand, poor
patient acceptance and compliance rates associated to
the cost burden of stoma care are arguments favoring
early stoma closure as opposed to late closure.15,18 In
fact, several reports have indicated the association
with complication development and early colostomy
closure in terms of postoperative infections and
anastomotic fistulas.18,31 Also, it has been reported
that excessively increased intervals (>6 months)
could be detrimental for loop ileostomy closure.16
In our series, patients who developed postopera-
tive complications had significantly shorter interval
periods between primary operation and ileostomy
closure (9.9 vs. 15.6 weeks). Although this informa-
tion was sufficient to acknowledge that early closure
would increase the morbidity rates of loop ileostomy
takedown, we searched for a critical interval period,
a cutoff that could have predicted a significant
decrease in the risk of complication development.
We found that an interval longer than 8.5 weeks
between primary surgery and ileostomy closure was
associated with a decreased risk of complication
development with a sensitivity of 88 percent and
specificity of 44 percent (ROC curve area, 0.68; P =
0.02). In fact, when comparing this series of patients
according to the cutoff interval of 8.5 weeks, we
confirmed this difference in terms of overall compli-
cations rates (P = 0.04). Other than surgeon and
patient’s choice, there were no specific reasons for
early stoma closure (<8.5 weeks) that could possibly
bias these results. The risk of complication occur-
rence may have a bimodal curve, with increased
rates in excessively short or long ileostomy takedown
periods. However, this fact could not be determined
in our study because 95 percent of the patients had
their stoma closed before 31 weeks from primary
surgery, indicating the narrow range of this interval.
1544 PEREZ ET AL
Patients experiencing postoperative complications
had significantly prolonged hospital stays. Therefore,
the costs associated with stoma maintenance during the
interval period may be outweighed by increased costs
associated with postoperative complications and in-
creased hospital stay when stomas are closed before
8.5 weeks in a large series of patients. Moreover, this
waiting period does not seem to be long enough to
affect patient’s stoma adaptation and compliance.
Finally, intraoperative technical aspects have been
reported to affect the rate of postoperative morbidity.
The recent introduction of ileostomy closure with the
use of linear staplers has been proposed to result in
decreased rates of postoperative small-bowel obstruc-
tion, although definitive data are not yet available. In
fact, this strategy has been considered to be more cost-
effective. This is supported by the idea that the
increased costs with the stapler itself could be
counterbalanced by a significant decrease in operative
time and therefore decreased operating room
costs.23,25,26 In our study, operative time did not affect
the rate of postoperative complication development,
possibly because of the narrow range of operative
time observed in our series (100 T 53 minutes). In our
series, patients managed by stapled ileostomy closure
had more complications than patients managed by
manual technique (25 vs. 16 percent respectively).
However, this difference was not significant and is
probably because of the small number of patients in
the former group.
CONCLUSIONS
Protective ileostomy closure is a procedure associ-
ated with low morbidity and mortality rates and
should be considered in high-risk low colorectal,
coloanal, and ileoanal anastomosis. Patients with IBD
may represent a subset of patients at increased risk
for the development of postoperative complications.
The interval between primary surgery and ileostomy
closure should be longer than 8.5 to lower the risk of
postoperative complications
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