eP225 - Early vs Late Ileostomy Reversal in Patients with Rectal Cancer: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

Purpose/Background: Patients undergoing low anterior resection (LAR) for rectal cancer tend to receive a temporary ileostomy due to its benefits in preventing anastomotic leak. However, the optimal time for stoma reversal is still controversial. We aim to perform an updated systematic review and meta-analysis to evaluate the effects of early ileostomy reversal (ER), defined as reversal done ≤3 months after rectal resection, compared with late ileostomy reversal (LR) in patients with rectal cancer.Methods/Interventions: A comprehensive search of PubMed, Embase, and Cochrane databases was conducted for randomized controlled trials (RCTs) comparing ER with LR in patients with rectal cancer. Non-randomized cohorts, studies with no control group or with incomplete reporting were excluded. The primary outcomes were morbidity and mortality. Secondary outcomes were related to intraoperative and postoperative endpoints. Heterogeneity was examined using I² statistics. Odds ratio (OR) and mean difference (MD) with 95% confidence interval (CI) were computed with the use of a random-effects model.Results/Outcomes: From a total of 2,047 studies we included 8 RCTs with 697 patients. ER was performed in 352 (50.5%) patients. Morbidity (OR 1.11; 95% CI 0.65-1.88; p=0.71; I²=34%; Figure 1A) and mortality (OR 0.65; 95% CI 0.08-5.40; p=0.69; I²=0%; Figure 1B) showed no statistically significant difference. Postoperative length of stay (LOS) was longer in ER compared with LR (MD 0.85; 95% CI 0.16-1.53; p=0.02; I²=0%; Figure 1C).There was no statistically significant difference in stoma-related complications, anastomotic leak, wound complications, intraabdominal abscess, intraoperative bleeding, operative time, postoperative small bowel obstruction (SBO), time to passing of gas or time to oral nutrition. For lower anterior resection syndrome (LARS) ER showed no significant difference compared with LR in minor LARS (OR 0.99; 95% CI 0.54-1.81; p=0.97; I²=0%) and major LARS showed a marginally statistically significant difference (OR 0.57; 95% CI 0.32-1.01; p=0.05; I²=0%). On Trial Sequential Analysis (TSA) for postoperative LOS (figure 1D) the cumulative Z-curve surpassed both traditional monitoring and trial sequential monitoring boundaries. For all other analyzed outcomes, the cumulative Z-curve did not breach either the traditional or trial sequential monitoring boundaries. Subgroup analysis for early ileostomy reversal done in less than 30 days from its creation showed stoma-related complications were significantly lower compared with LR (OR 0.10; 95% CI 0.04-0.22; p= < 0.00001; I²=0%; figure 1E) but no statistically significant difference was found for morbidity, anastomotic leak, wound complications or postoperative SBO.Conclusion/

Discussion: This systematic review and meta-analysis provides evidence that ER may be associated with longer postoperative LOS compared with LR. TSA results support the significance of this finding. However, ER does not provide a statistically significant difference regarding other outcomes. Larger trials are required to improve the current evidence on this topic."Figure 1A - Morbidity and Figure 1B - Mortality

Primary outcomes of morbidity and mortality showed no statistical significant difference between ER and LR.
Figure 1C - Postoperative length of stay (LOS)

Postoperative LOS was longer in ER compared with LR.
Figure 1D - Trial Sequential Analysis (TSA) of postoperative LOS

On Trial Sequential Analysis (TSA) for postoperative LOS the cumulative Z-curve surpassed both traditional monitoring and trial sequential monitoring boundaries
Figure 1E - Stoma-related complications in Very Early Ileostomy Reversal ( < 30 days)

Subgroup analysis for Early Ileostomy Reversal done in less than 30 days from its creation showed stoma-related complications were significantly lower compared with LR."