Restorative proctocolectomy (RPC) without defunctioning loop ileostomy (DLI) for the treatment of ulcerative colitis (UC) is associated with increased risk for pelvic sepsis and emergency reoperation, according to study results published in the Journal of Crohn’s and Colitis.
Researchers searched publication databases through January 2022 for studies on the safety of RPC with or without DLI in the setting of UC. A total of 20 studies were included in the analysis.
The studies were conducted in Europe, North America, and Japan and published between 1985 and 2021. The patient populations were adults in 15 studies and pediatric patients in 5 studies.
The studies comprised of 4,550 patients with UC, among whom 52.09% underwent RPC without and 47.91% with DLI. Stratified by without and with DLI, the patients had a mean [SD] age of 34.88[12.13] and 36.59[11.85] years; 51.8% and 53.9% were men or boys; 50.99% and 50.55% received previous steroid treatment; and 24.8% and 22.9% previous biologic therapy, respectively.
The RPC without DLI approach was associated with a higher rate of pelvic sepsis (56%) compared with RPC with DLI (44%), indicating a significant increase for pelvic sepsis risk by omitting DLI (odds ratio [OR], 1.68; 95% CI, 1.03-2.75; I2=0%; P =.04). Similarly, RPC without DLI associated with higher risk for emergency reoperation (OR, 1.74; 95% CI, 1.22-2.50; I2=26%; P =.002) than RPC with DLI.
Conversely, RPC without DLI was favored for reducing risk for small bowel obstruction (OR, 0.73; 95% CI, 0.57-0.93; I2=39%; P =.01) and strictures (OR, 0.45; 95% CI, 0.29-0.68; I2=6%; P =.0002) compared with RPC with DLI.
No group differences were observed in overall major morbidity (OR, 1.44; 95% CI, 0.91-2.29; I2=73%; P =.12), anatomic leak (OR, 1.13; 95% CI, 0.92-1.39; I2=72%; P =.25), pouch excision rate (OR, 1.01; 95% CI, 0.68-1.50; I2=46%; P =.97), and pouchitis (OR, 0.74; 95% CI, 0.53-1.03; I2=0%; P =.07).
Similarly, no group differences were observed for functional outcomes of incontinence (P =.45) or nocturnal (P =.61) or diurnal (P =.86) bowel motions. Nor were there any group differences for length of operation (P =.07) or hospital stay (P =.34).
In a sensitivity analysis which was stratified by adult and pediatric populations, the results were consistent with the main analysis.
This study was limited by the fact that all included studies were of retrospective observational designs and spanned a long period of time, during which clinical practice has evolved.
“This analysis suggests that while omission of DLI is potentially safe and may have certain advantages when performing RPC for UC including reduced rates of stricture formation, bowel obstruction, decreasing operation time and length of hospital stay,” the study authors noted. “This procedure should only be performed in select cohorts that may tolerate the increased need for emergency re-intervention, namely patients in whom creation of [ileal pouch–anal anastomosis] may be less technically challenging, and have better preoperative and intraoperative characteristics.”
Donnelly M, Ryan OK, Ryan ÉJ, et al. Comparison of restorative proctocolectomy with and without defunctioning loop ileostomy in patients with ulcerative colitis – a systematic review and meta-analysis. J Crohns Colitis. Published online February 13, 2023. doi:10.1093/ecco-jcc/jjad021