Preoperative bowel stimulation prior to ileostomy closure to restore bowel function more quickly and improve postoperative outcomes: a systematic review

Abstract

Aim Closure of a diverting ileostomy following restorative surgery is often associated with significant shortterm morbidity and variable long-term bowel function. The aim of this systematic review was to investigate if preoperative stimulation of the defunctioned bowel restores bowel function more quickly after ileostomy closure and improves postoperative outcomes when compared with standard preoperative care.Method MEDLINE, Embase, CENTRAL, Google Scholar and ClinicalTrials.gov were searched for studies evaluating preoperative bowel stimulation in patients with a temporary ileostomy after low anterior resection or ileal pouch-anal anastomosis, regardless of their design, publication type or language. Study selection, data extraction and study assessment were performed by one reviewer and verified by another. Study results were synthesized narratively. The GRADE approach was used to assess the quality of evidence.Results Eight studies involving a total of 267 participants were included. The studies had a moderate to high risk of bias and were of varying methodological quality. Preoperative stimulation of the defunctioned bowel reduced the time to postoperative restoration of bowel function and the length of hospital stay when compared with standard preoperative care. Other functional outcomes and postoperative complication rates were similar to those of standard preoperative care. The overall quality of evidence was very low.Conclusion Despite these promising early results, there is insufficient high-quality evidence to recommend routine implementation of preoperative bowel stimulation in clinical practice. Nevertheless, there is no evidence suggesting that the intervention worsens outcomes or is unsafe, paving the way for rigorous assessment of effectiveness, acceptability and cost-effectiveness within the context of well-designed clinical trials.

Postoperative Ileus after Stimulation with Probiotics before Ileostomy Closure

“…The difference in terms of duration of hospital stay was 1 day, with a median of 4 days in the SG and 5 days in the CG. This was associated with a 24-h difference in oral tolerance in the SG, in which 58% of patients tolerated a liquid diet in the first 24-48 h, compared to the CG, which took 48-72 h. These results are similar to those reported by other studies [9,14,15]. Moreover, it was observed that the incidence of postoperative ileus was exactly the same as that presented in colorectal surgery and that this was due to the fact that all the patients who presented ileus after reconstruction surgery also did in the previous colorectal surgery.…”

“…A notable reduction in surgical time was observed in the SG, which we associate with the thickening of the efferent loop, resulting from the stimulation, and which facilitates the performance of anastomosis. We also did not find differences between the incidence of paralytic ileus in the SG (n = 10; 29.4%) and the CG (n = 11; 31.4%), with a slight increase in it, compared to studies collected in systematic reviews published by Rombey and Garfinkle [4,9], that we associate to the standardization of the definition of postoperative gastrointestinal dysfunction. The difference in terms of duration of hospital stay was 1 day, with a median of 4 days in the SG and 5 days in the CG.…”

“…Distal bowel and colon, which are unready to re-establish transit, cause intestinal paralysis. In this regard, several articles have been published [13][14][15][16][17], but the first systematic review was published by Rombey et al [9] in 2019, including eight studies with 267 patients. Despite the excellent initial results, there is not sufficient evidence to recommend the routine implementation of preoperative bowel stimulation in clinical practice.…”

“…The hypothesis of the present study was motivated by the absence of clear scientific evidence on the benefit of stimulation of the efferent loop. We used a double-blind design, maintained until the end of the study, a standardized definition of postoperative gastrointestinal dysfunction, which had not been used up to now, and based our trial on comparative studies and published meta-analyzes on intestinal pathophysiological changes caused by the loss of intestinal flora in the excluded colon segment [6][7][8][9]14]. We decided to carry out our study to compare results after stimulation of the efferent loop with probiotics in patients previously operated on for colorectal carcinoma.…”

“…There are many publications on stimulation of the efferent loop prior to stoma closure. Different protocols exist, with different substances administered, from autologous fecal fluid to physiological serum with thickeners, passing through short-chain fatty acids, liquid diet, and sucrose [9].…”