The Outcome After Restorative Proctocolectomy With or Without Defunctioning Ileostomy

TLDR

There is controversy over whether omitting a diverting ileostomy in restorative proctocolectomy increases septic complications. The authors aimed to determine whether omitting a diverting ileostomy during restorative proctocolectomy affects postoperative complications, functional outcomes, and quality of life. The study used a consecutive series of 1,725 patients with ileostomy and 277 without, applying strict omission criteria (stapled, tension‑free anastomosis, intact tissue rings, good hemostasis, no air leaks, no malnutrition, toxicity, anemia, or prolonged steroids) and recorded demographics, operative details, and complications. The analysis showed no increase in septic complications or mortality with ileostomy omission, although early postoperative ileus was more frequent in the one‑stage group, and quality of life and functional outcomes were comparable between groups, supporting safe omission in carefully selected patients.

Abstract

Controversy exists regarding the safety for omission of diverting ileostomy in restorative proctocolectomy because of fears of increased septic complications. This study was designed to evaluate the outcomes of restorative proctocolectomy in a consecutive series of patients by comparing postoperative complications, functional results, and quality of life in patients with and without diverting ileostomy.Data regarding demographics, length of stay, surgical characteristics, and complications were reviewed and recorded according to the presence (n= 1,725) or absence (n = 277) of a diverting ileostomy at the time of pelvic pouch surgery. Criteria for omission of ileostomy included: stapled anastomosis, tension-free anastomosis, intact tissue rings, good hemostasis, absence of airleaks, malnutrition, toxicity, anemia, and prolonged consumption of steroids. Functional outcome and quality of life indicators were prospectively recorded and compared.Patients in the ileostomy group had greater body surface area and older mean age at time of surgery, were taking greater doses of steroids preoperatively, and required more blood transfusions at the time of surgery compared with the one-stage (P < 0.05). There were no differences between the two groups in septic complications (P > 0.05). Early postoperative ileus was more common in the one-stage group (P < 0.001). There were no differences between the groups in quality of life and functional outcomes.For carefully selected patients undergoing restorative proctocolectomy with ileal pouch-anal anastomosis, omission of diverting ileostomy is a safe procedure that does not lead to an increase in septic complications or mortality. Quality of life and functional results are similar to those who undergo ileal pouch-anal anastomosis with diversion, provided that certain selection factors are considered.