Comparison of outcomes after restorative proctocolectomy with or without defunctioning ileostomy

Objective: To evaluate postoperative adverse events and functional outcomes of patients undergoing restorative proctocolectomy with or without proximal diversion. Data Sources: The literature was searched by means of MEDLINE, Embase, Ovid, and Cochrane databases for all studies published from 1978 through July 15, 2005. Study Selection: Comparative (randomized and non-randomized) studies evaluating outcomes after restorative proctocolectomy with or without ileostomy were included. Data Extraction: Three authors independently extracted data by using operative variables, early and late adverse events, and functional outcomes between the 2 groups. Trials were assessed by means of the modified Newcastle-Ottawa Score. Random-effects meta-analytical techniques were used for analysis. Data Synthesis: The review included 17 studies comprising 1486 patients (765 without ileostomy and 721 with ileostomy). There were no significant differences in functional outcomes between the 2 groups. The development of pouch-related leak was significantly higher in the no-ileostomy group (odds ratio, 2.37; P=.002). Small-bowel obstruction was more common in the stoma group but was not statistically significant (odds ratio, 0.65). The development of anastomotic stricture favored the nostoma group (odds ratio, 0.31; P=.045). On sensitivity analysis, pelvic sepsis was significantly less common in patients whose ileostomies were defunctioned; however, this finding was not mirrored by a significant difference in ileal pouch failure in this subgroup. Conclusions: Restorative proctocolectomy without a diverting, ileostomy resulted in functional outcomes similar to those of surgery with proximal diversion but was associated with an increased risk of anastomotic leak. Diverting ileostomy should be omitted in carefully selected patients only.