Discussion
stoma, anastomotic dehiscence
POSTOPERATIVE COMPLICATIONS, COMPLICATION, MEDICAL COMPLICATION, LEAKAGE, COMPLICATIONS
The present study showed no significant difference in postoperative complications after early or late reversal of a diverting loop ileostomy as assessed by CCI within 30 days after stoma reversal and within 90 days after the LAR. There were no differences in quality of life at the 6- or 12-month follow-up. Most importantly, a total of 5 patients developed clinical anastomotic leakage after stoma reversal, with four randomized to early reversal and one randomized to late reversal. The patient who developed AL in the late reversal group underwent early reversal due to stoma complications. In all 5 patients, postoperative CT scanning did not reveal any suspicion of AL, which may indicate that early stoma reversal may induce AL.The study also showed that early reversal was feasible in 69% of patients only and that more than 10% randomized to late reversal underwent an earlier reversal primary due to stoma-related complications.The major reason for not undergoing early reversal was anastomotic leakage demonstrated in 17 patients (22%) at routine postoperative CT scanning and/or endoscopy. Four of these patients developed overt clinical symptoms that needed intervention, and two of them died. In the remaining 13 patients, the leakage was subclinical.Seven of the nine previous RCTs showed that early closure was feasible, with similar complication profiles in patients randomized after index surgery and without clinical, radiological, or endoscopic signs of ALTheoretically, there may be several advantages to the early reversal of a diverting ileostomy, as it may relieve ostomy-related complications. This was also demonstrated in our study, as some of the patients in the late reversal group underwent early reversal due to stoma complications. Although stoma-related complications may seem less severe than other surgical and medical complications, they can be bothersome, distressing, and embarrassing for the patient. In the study by Danielsen et al.The development of AL after early reversal in a significant number of patients in our study is a concern, and it is problematic that neither CT scan nor endoscopy was able to demonstrate any leakage in the patient. This might be true, although it is hard to believe that an early reversal on postoperative Days 8–12 may cause anastomotic dehiscence. Another problem in early versus late reversal might be the logistical problems of planning the “subacute” stoma reversal 8 days after the initial surgery.