Early versus late closure of protective ileostomy after rectal cancer surgery

Abstract Purpose The optimal timing of protective ileostomy closure after rectal cancer surgery remains uncertain. This systematic review and meta-analysis compares early (EC) versus late closure (LC) and evaluates the associated risks and benefits. Methods Medline, Web of Science, and CENTRAL were searched for RCTs published up to May 2025 that compared EC (≤ 30 days after creation) with LC (≥ 12 weeks after creation) following rectal cancer surgery. Results Nine RCTs including 387 patients (EC: 195, LC: 192) were analyzed. We found no significant difference between the two groups regarding intraoperative blood loss, operation time, length of hospital stay, overall postoperative morbidity, major complications, anastomotic leakage, readmission, perioperative mortality, administration of adjuvant chemotherapy, occurrence of LARS, and quality of life. However, the EC group showed a tendency toward better functional outcomes in terms of shorter time to first passage of flatus ( p < 0.001). Additionally, one RCTs reported a significant, yet clinically irrelevant delay in initiation of adjuvant chemotherapy in the EC group ( p < 0.001). Two RCTs demonstrated a significant cost reduction in the EC group – lower costs of stoma bags over the treatment period ( p < 0.001) and lower total cost at 12 months following the initial rectal resection ( p < 0.001). Conclusion EC can be considered a safe and feasible alternative to LC in carefully selected patients. However, caution is required in treating high-risk patients, and further research is necessary in order to identify potential risk factors that may predict unfavorable outcomes.