Early Closure of Diverting Ileostomy After Rectal Resection: Are We Ready to Make the Shift?

Diverting ileostomy is widely used to mitigate the consequences of anastomotic leakage after low anterior resection for rectal cancer. While its protective role is well established, the optimal timing of ileostomy closure remains controversial, with traditional delayed reversal exposing patients to stoma-related morbidity and potential permanent diversion.

The aim of this review is to synthesize randomized controlled trial (RCT) and meta-analysis evidence on early ileostomy closure, assess safety and outcomes, and evaluate whether a shift toward earlier reversal is justified in selected patients.

A narrative review of the published literature was conducted, including randomized trials, prospective studies, and systematic reviews identified through PubMed, Scopus, and Google Scholar. Outcomes of interest included perioperative morbidity, stoma-related complications, quality of life, and functional results.

Evidence from RCTs shows heterogeneity. Trials such as EASY, Kłęk, and Lasithiotakis support early closure, reporting comparable morbidity and reduced stoma-related complications, whereas Bausys, Elsner, and Fukudome caution against indiscriminate application due to increased septic and wound-related morbidity. Meta-analyses consistently indicate that early closure reduces stoma-related complications but increases wound infections, with overall morbidity largely comparable between groups. Patient selection, confirmation of anastomotic integrity, and oncologic treatment schedules are central to outcomes. Cost-effectiveness analyses and retrospective series further support potential system-level and quality-of-life benefits.

Current evidence suggests that early ileostomy closure is feasible and safe in carefully selected patients, reducing the burden of stoma-related morbidity without compromising oncologic treatment. However, it should not yet be routine practice, as risks of septic complications persist in unselected populations. Future multicenter RCTs with standardized definitions, uniform imaging protocols, and long-term functional and cost-effectiveness endpoints are needed to guide practice.