Is a colonoscopy recommended before diversion ileostomy closure?

Colonoscopy Before Diversion Ileostomy Closure

Colonoscopy is recommended before diversion ileostomy closure to evaluate the excluded colon segment for potential pathology that could affect surgical outcomes. 1

Rationale for Pre-Closure Colonoscopy

• Endoscopic examination of the bowel distal to a colostomy/ileostomy reveals abnormal findings in up to 80% of patients, including mucous plugs, diversion colitis, polyps, or even carcinoma 1
• Diversion colitis (inflammation in the excluded colon segment) is common, occurring in 70-76% of patients with diverted bowel segments 2, 3
• These findings may be asymptomatic but could potentially affect surgical outcomes if not identified and addressed before stoma closure 1

Timing Considerations

• The optimal timing for ileostomy closure appears to be no earlier than 8.5 weeks after the primary operation to reduce postoperative complications 4
• Diversion colitis is more commonly observed in patients with longer intervals between stoma creation and closure (average 29.9 weeks) compared to those without colitis (average 16.6 weeks) 2
• Colonoscopic evaluation should be scheduled shortly before planned closure to ensure the most current assessment of the bowel condition 1

Clinical Implications of Pre-Closure Findings

• Mucous plugs and scybala (hardened fecal matter) should be treated by irrigation before closure 1
• Polyps or carcinomas discovered during examination should be treated as they would be in a non-diverted colon 1
• Diversion colitis can be treated medically with local steroids, but in most cases, even with severe colitis, closure of the stoma is recommended and typically resolves the condition 1
• Severe strictures at the anastomosis may require dilation before stoma closure 5

Specific Recommendations for Different Clinical Scenarios

• For patients with inflammatory bowel disease: Ileocolonoscopy is the gold standard for evaluating disease status and should be performed before stoma reversal to assess for recurrence 6
• For patients with previous colorectal cancer: Colonoscopy is recommended to rule out recurrence or metachronous lesions before stoma closure 6
• For patients with diverting stoma after low anterior resection: Examination of the rectum is recommended to identify local recurrence, typically performed at 3-6 month intervals for the first 2-3 years 6

Management Algorithm

1. Schedule colonoscopy 1-2 weeks before planned ileostomy closure 1
2. Evaluate for:
   • Anastomotic integrity and patency
   • Presence of diversion colitis
   • Presence of polyps or other lesions
   • Strictures requiring dilation
3. If abnormalities are found:
   • Treat mucous plugs with irrigation 1
   • Dilate strictures if present 5
   • Remove polyps if detected 1
   • Consider local steroids for severe diversion colitis 1
4. Proceed with ileostomy closure if no contraindications are found 1

Caveats and Pitfalls

• Failure to examine the diverted segment may result in missed pathology that could complicate stoma closure 1
• Diversion colitis in an otherwise healthy individual does not appear to increase the risk of infection following stoma closure 2
• In cases of complete luminal obliteration at the anastomosis, specialized techniques may be required, such as antegrade colonoscopy through the diverted limb of the stoma 5
• Mechanical bowel preparation may be necessary when a diverting ileostomy is planned, though this is not routinely recommended for all colorectal procedures 6