Introduction: diverting loop ileostomies are widely used in col-
orectal surgery to protect low rectal anastomoses. However, they
may have various complications, among which are those associated
with the subsequent stoma closure. The present study analyses our
experience in a series of patients undergoing closure of loop
Method: retrospective study of all the patients undergoing ileosto-
my closure at our hospital between 2006-2010. There were 89
patients: 56 males (63%) and 33 females (37%) with a mean age
of 55 (38-71) years. The most common indication for ileostomy
was protection of a low rectal anastomosis, 81 patients (91%). The
waiting time until stoma closure, type and frequency of the compli-
cations, length of hospital stay and mortality rate are analysed.
Results: waiting time before surgery was 8 (1-25) months. Forty-
one patients (45,9%) developed some type of complication, three
were reoperated (3.37%) and one patient died (1.12%). The most
important complications were intestinal obstruction (32.6%), diar-
rhoea (6%), surgical wound infection (6%), enterocutaneous fistula
(4.5%), rectorrhagia (3.4%) and anastomotic leak (1.12%). The
mean length of patient stay was 7.54 (2-23) days.
Conclusions: protective ostomies in low rectal anastomoses
have proved to be the only preventive measure for reducing the
morbidity and mortality rates for anastomotic leakage. However,
creation means subsequent closure, which must not be considered
a minor procedure but an operation with possibly significant com-
plications, including death, as has been shown in publications on
the subject and in our own series.
Key words: Loop Ileostomy. Clousure of ileostomies. Complica-
tions of ileostomies.
Diverting ileostomies are widely used in colorectal surgery
to protect low rectal anastomoses, especially in techniques
such as low anterior resection and restorative protocolectomy.
Although their presence does not reduce the total incidence
of anastomotic leakage, it does reduce related morbidity and
therefore the need for reoperation as well as the mortality
rate of these patients (1).
However, ileostomies are not without their drawbacks
as they represent a reduction in the patients’ quality of life
(2)and may present various complications, such as hydro-
electrolytic alterations, bowel obstruction, infection of soft
parts, incisional hernias, etc. But it is stoma closure that
carries the highest rates of morbidity and mortality (3).
We believe that the closure of diverting ileostomies
should not be considered a complication-free minor surgical
procedure; for this same reason we analyse our experience
in a series of patients undergoing closure of diverting loop
ileostomies between 2006-2010.
PATIENTS AND METHODS
Retrospective study including all the patients undergoing
ileostomy closure at the José María Morales Meseguer Hos-
pital in Murcia, Spain between January 1st, 2006 and De -
Data were collected retrospectively and entered into a
database created for this purpose. The study population was
Protective ileostomy: complications and mortality associated with
Mónica Mengual-Ballester1, José Andrés García-Marín2, Enrique Pellicer-Franco1,
María Pilar Guillén-Paredes2, María Luisa García-García2, María José Cases-Baldó2
and José Luis Aguayo-Albasini3
1Department of General Surgery and Digestive Diseases. School of Medicine. Universidad de Murcia. Spain.
2Department of General Surgery and Digestive Diseases. Hospital General Universitario Morales Meseguer. Murcia,
Spain. 3Universidad de Murcia. Spain
REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS
Copyright © 2012 ARÁN EDICIONES, S. L.
REV ESP ENFERM DIG (Madrid)
Vol. 104. N.° 7, pp. 350-354, 2012
Correspondence:Mónica Mengual Ballester. Department of General Surgery.
Hospital Universitario “Morales Meseguer”. Avda. Marqués de los Vélez,
s/n. 30008 Murcia, Spain
Mengual-Ballester M, García-Marín JA, Pellicer-Franco E, Guillén-
Paredes MP, García-García ML, Cases-Baldó MJ, Aguayo-Albasini
JL. Protective ileostomy: complications and mortality associated
with its closure. Rev Esp Enferm Dig 2012;104:350-354.
Vol. 104. N.° 7, 2012 PROTECTIVE ILEOSTOMY: COMPLICATIONS AND MORTALITY ASSOCIATED WITH ITS CLOSURE 351
REV ESP ENFERM DIG 2012; 104 (7): 350-354
selected from a historical archive of patients receiving pro-
grammed surgery in the General Surgery department; this
archive allows identification of the process for which the
patient undergoes surgery and is ordered chronologically.
The series is made up of 89 patients: 56 males (63%)
and 33 females (37%), with a mean age of 55 (38-71) years.
The most common diagnosis for previous surgery was
rectal neoplasia in 70 patients (78.65%), followed by pan-
colitis in 8 cases (9%), familial adenomatous polyposis
in 5 (78.65%), 2 dehiscences of previous anastomoses
(2.25%), perianal Crohn’s disease in 2 patients (2.25%),
recto-vaginal fistula in 1 (1.12%) and sigmoid divertic-
ulitis in 1 patient (1.12%).
All the patients are carrying of loop ileostomia; the osto-
my was performed in most patients as a programmed oper-
ation; only 7 cases received emergency surgery: 3 patients
with anastomotic dehiscence (2 ileocolic and 1 colorectal),
one case of pancolitis in an ulcerative colitis with haemo-
dynamic involvement and 2 colonic perforations secondary
to obstructive neoplastic processes.
As for the anesthesic-surgical risk according to ASA’S
classification (American Society of Anesthesiologists): 44
patients (49.4%) were ASA III, 32 (36%) ASA I and only
13 (14.6%) ASA III.
The surgical technique performed together with the
ileostomy was low or ultra-low anterior resection in 64
cases (72%), restorative proctocolectomy with a ”J” reser-
voir in 13 patients (14.5%), subtotal colectomy in 7 cases
(7.9%), diverting ileostomy as a single technique in 3
patients (3.4%) and finally a high anterior resection in
2 patients (2.2%).
The most common indication for ileostomy was to pro-
tect a low anastomosis, in a total of 81 patients (91%),
including those with an ileal J-pouch reservoir. The rest
consisted in protection of the anastomosis in the context of
a peritonitis (n = 5) and in 3 patients with the intention
of temporarily diverting transit.
Of all the patients undergoing ileostomy closure, 91%
had a preoperative imaging test to confirm the integrity and
proper calibre of the anastomosis and to ensure the absence
of any process that might contraindicate closure of the
stoma. The most commonly chosen test was abdominal
computed tomography with oral contrast and gastrograffin
enema, performed in 64.2% of the cases, followed by
colonoscopy in 32% and finally by opaque enema in 3.8%
of the patients.
All the patients were given antibiotic prophylaxis with
ceftriaxone prior to surgery and rachideal anaesthesia. The
approach was via a peristomal incision; the ileostomy was
pulled out and the edges refreshed. The anastomosis was per-
formed manually in 87 cases and mechanically with GIA 60
in 2 cases. Those done manually were end-to-end, with slow-
absorption monofilament suture (Byosin®), 73% with loose
extramucous sutures and the remaining 27% with two inter-
Later there was realized closing of the abdominal wall
by planes by running suture of material monofilament of
slow-absorption, and closing of cellular subcutaneous by
interrupted suture of monofilament.
Quantitative variables are expressed as mean ± standard
deviation and the qualitative variables as percentages with
their 95% confidence intervals. Comparison between the
2 groups was made with the Pearson Chi-squared test or
Fisher exact test for qualitative variables. Statistical signif-
icance was considered for a p-value of < 0.05.
Waiting time before surgery
The mean waiting time between creation of the ileostomy
and closure was 8 months (1-25). Here there are significant
differences between patients who had adjuvant chemother-
apy after construction of the ileostomy (37%) and those
who did not (63%). The mean waiting time was 9.81
months in the former group but 6.91 months in the latter
(p = 0.003).
Forty-one (45.9%) of the 89 patients developed some
type of complication and even 14.6% developed several
The most common was intestinal obstruction, that hap-
pened in 29 patients(32.6%), which was resolved in all cases
with conservative treatment; in second place was diarrhoea
and surgical wound infection, which occurred in 5 patients
(6%) in both cases. In third place, enterocutaneous fistula,
with a frequency of 4.5%, any of which required surgery
after being resolved with conservative treatment.
Other less common complications were rectorrhagia in
3 patients (3.4%) and one anastomotic leak (1.12%), which
was treated with radiological drainage. Minor events includ-
ed two cases of phlebitis (2.24%), an infection of the urinary
tract (1.14%) and an episode of paroxysmal auricular fib-
Three of the total patients (3.37%) required reoperation,
two as a result of dehiscence of the ileostomy suture. It was
necessary in both cases to resect the anastomosis and create
a new ileostomy, terminal in these cases. The third reoper-
352 M. MENGUAL-BALLESTER ET AL. REV ESP ENFERM DIG (Madrid)
REV ESP ENFERM DIG 2012; 104 (7): 350-354
ation was performed in a patient who developed an ischemia
of the anastomosis; this was the only death in our series,
caused by septic shock secondary to peritonitis on day 7
after the second operation.
The relation between the classification of the anesthesic-
surgical risk according to the ASA and the complications
developed by the patients has been analyzed, not finding
relation between both variables, so that the group that devel-
oped more complications was that of risk ASA II, 24 patients
(54.5% of this group), opposite to 12 patients (37.5%) of
ASA I and 5 patients of ASA III (38.46%), with p = 0.289.
Also the relation between the chemotherapy received by
the patients before the closing of ileostomía and the devel-
opment of complications has been studied, not finding rela-
tion between both variables; this way of 33 patients who
received chemotherapy, 11 developed complications
(33.3%), opposite to 30 patients (53.57%) who did not
receive adjuvant treatment, with one p = 0,064.
Mean length of stay
The mean length of patient stay was 7.54 days (2-23). It
increased significantly for those developing postoperative
complications, compared to those who were complication-
free, such that the mean postoperative length of stay was
4.58 days for the latter group, rising to 11 days for those
who had complications (p < 0.005).
Complications in colorectal surgery have decreased in
recent years due to the creation of specialised units (4);
however, when they occur they associate high rates of mor-
bidity and mortality, especially the feared anastomotic
dehiscence. Protective ostomies in low anastomoses (after
low anterior resection or restorative procrocolectomy) have
proved to be the only preventive measure for reducing the
morbidity and mortality with dehiscences of this type of
anastomosis; although they do not prevent them they do
reduce their impact and the number of reoperations (5,6).
Despite existing beneficial evidence, there is no estab-
lished indication for performing protective ostomies. There-
fore, creating an ostomy or deciding on which type to do
is left at the surgeon’s criterion and based on factors such
as type and locoregional conditions of the anastomosis, dif-
ficulties arising during surgery, associated patient morbidity,
etc. Moreover, the surgeon must take into account on the
one hand the potential benefit of the ileostomy in protecting
the anastomosis, and on the other hand the drawbacks
involved, such as the reduced life quality of ostomy patients
(2) and the morbidity and mortality associated with the
future closure of the ostomy.
One of the controversial points is the optimum time inter-
val between the creation of the ileostomy and the time of
closure. There are groups that incline towards an early stoma
closure during hospital admission with a view to improving
the patients’ quality of life and preventing possible stomal
complications, such as Alves et al. (7) and de Mengaux et
al.(8), who perform early closure on postoperative days 8
and 10 with good results. However, most groups favour a
late closure, between 8.5 weeks and six months after surgery;
they encounter a higher morbidity rate both in closures done
before 8.5 weeks (9), due to oedema of the ileostomy and
still-firm intraabdominal adhesions, and in closures per-
formed after the sixth month postoperatively (9,10). Delayed
closure of the ileostomy is often related to the adjuvant
chemotherapy that many of these patients receive, as occurs
in our series, in which the mean waiting time increases in
the chemotherapy group, compared to those not receiving
adjuvant treatment (6.91 vs. 9.81 months).
Although in the literature groups as of the Thalmeir et
al. (2) show a higher morbidity rate with ileostomy closure
in patients receiving adjuvant treatment, In our series we
could not confirm this relationship, and have not demon-
strated the relation between the preperative ASA and the
complications either; probably these results are due to our
series is not very large.
During this pre-closure waiting period an imaging test
is usually performed to check the integrity of the anasto-
mosis and diagnose the presence of fistulas or stenosis,
although it is not clear if it is strictly necessary in all cases.
On the one hand, the use of gastrograffin enemas in the
immediate postoperative period is not recommended in
patients with no clinical suspicion of dehiscence, as the
increase in pressure on the anastomosis may lead to a dis-
ruption, or to a bacteraemia in the event of a subclinical
local septic process; it should therefore not be done before
itive rates of 6.4% and false negative rates of 3.5% have
been observed (12). Enema is only recommended therefore
in those with a suspected anastomotic complication, as rou-
tine administration is highly questioned (11-13). The use
of computed tomography with rectal contrast demonstrates
the same drawbacks as gastrograffin enema, although it has
the advantage of being able to evaluate possible local septic
On the other hand, evaluation of the anastomosis using
rigid or flexible sigmoidoscopy in the hands of experts has
proved to be safe after the first 24 hours postoperatively
(15). Exploration of a low anastomosis using rectal palpa-
tion allows identification of anastomotic defects without
the need for enema; however, it does not allow good assess-
ment of the presence of fistulas (12). On the basis of this
evidence, Matthew (13) recommends conducting a digital
and endoscopic examination of the anastomosis between
motic complication is suspected carrying out a radiological
test to confirm it.
Another of the points for discussion is the type of anas-
tomosis to perform in the ileostomy closure. There are
groups that favour a lower rate of complications associated
with a mechanical rather than a manual anastomosis, espe-
thweek postoperatively (11); moreover, false pos-
thweek postoperatively and only if an anasto-
Vol. 104. N.° 7, 2012 PROTECTIVE ILEOSTOMY: COMPLICATIONS AND MORTALITY ASSOCIATED WITH ITS CLOSURE 353 Download full-text
REV ESP ENFERM DIG 2012; 104 (7): 350-354
cially bowel obstruction (16,17). However, other studies,
such as the meta-analysis conducted by Leung, find no sig-
nificant differences between the two modes of reconstruc-
tion (18). Our group performed manual anastomosis in
97.7% of the patients, which means we cannot offer data
on which type of anastomosis is better.
The rates of closure-related mortality are very varied in
the studies published, ranging from 0.06% (3) to 6.4% (19):
the mortality rate in our series was 1.12%, due to the death
of a patient presenting with an anastomotic ischaemia.
As for morbidity, we had a 45.9% rate of complications,
the most common being intestinal obstruction. Our series
coincides with the most common closure-related compli-
cations published in the literature: intestinal obstruction,
surgical wound infection, intraabdominal infections, ente-
rocutaneous fistula and anastomotic dehiscence (3,20). We
had a high complication rate, compared to other series
reporting morbidities of 11.4 (3) or 33.8% (19), probably
due to a more exhaustive data collection. Most of our com-
plications were solved conservatively and the reoperation
rate was just 3.37%, compared to rates of 7.4% (1) pub-
lished in the literature.
In conclusion, the creation of diverting loop ileostomies
implies paying the price associated with the complications
of the future surgical closure. The decision, therefore, to
create and subsequently close an ileostomy should not be
considered a minor surgical process and the surgeon should
take into account which patients will really benefit from it
(cases of low anastomoses, presence of adverse conditions
for healing of the anastomosis, etc.) and compensate for
the risks involved with closure.
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