A Retrospective, Single-institution Review of Loop Ileostomy Reversal Outcomes

Although loop ileostomies are created to mitigate the risk of anastomotic leaks, their reversal is associated with significant morbidity. Complications such as ileostomy site hernia and wound infections are not uncommon. A retrospective study was conducted among 176 consecutive patients who had undergone ileostomy reversal between September 2009 and November 2012 at a tertiary care teaching hospital. The main purpose of the study was to compare differences in short-term outcomes associated with hand-sewn versus stapled anastomotic techniques and purse-string versus stapled/sutured skin closure versus wounds left to heal by secondary intention. Primary outcomes analyzed were length of stay (LOS), wound infection rates, and incisional hernia occurrence. All variables were abstracted from electronic medical records. Surgical techniques used were based on surgeon preference. Categorical variables were compared using Pearson chi-square test or Fisher's exact test. ANOVA and the Kruskal-Wallis test were used to compare closure technique, age, body mass index (BMI), and hemoglobin; ANOVA was used to compare the remaining continuous/ordinal variables. Anastomotic technique, age, BMI, and hemoglobin were compared using the t-test, and the Wilcoxon rank-sum test was used to compare the remaining continuous/ordinal variables. Age, BMI, and hemoglobin were compared using t-test, and Wilcoxon rank-sum test was used to compare the remaining continuous/ordinal variables. Univariate analysis for preoperative factors associated with postoperative hernia was performed as a secondary analysis due to hernia rates higher than reported in the literature. A P value <0.05 was considered statistically significant. Of the 176 patients (median age 53, median BMI 26), 53% were male. The number of hand-sewn and stapled anastomoses were similar (89 versus 87, respectively) and purse-string skin closures were more common (n = 108) than stapled (n = 45) closures or wounds left to heal by secondary intention (n = 23). The mean follow up time for all patients was 16.9 months (508 days, range 8-1406 days); the overall complication rate was 35.4%. LOS was shorter in the hand-sewn anastomoses than in the stapled anastomoses' group (3.36 days versus 3.82 days, P = 0.028) due to a greater proportion of patients with shorter stay (44 out of 89 [49%] 1 to 2 days versus 28 out of 87 [32%], hand-sewn versus stapled, respectively). No statistically significant differences were found in short-term outcomes among the 3 skin closure techniques, including wound infections (8 out of 108 [7%] in purse-string versus 2 out of 45 [4%] in stapled/sutured versus 0 out of 23 [0%] in open wounds, P = 0.84). Ileostomy site hernia (16.5%) was associated with a significantly higher BMI (32.2 with hernia versus 26.1 without, P <0.0001) and longer follow-up time (25.1 months with hernia versus 11.5 months without, P = 0.0003). In this study, anastomotic and skin closure technique did not result in clinically important differences in short-term outcomes. The results suggest that, depending on BMI, preoperative loop ileostomy closure counseling of patients should include the risk of developing an incisional hernia.