Indications for Colostomy Takedown
Colostomy reversal should be performed only after the underlying condition requiring its creation has been adequately treated, the patient demonstrates adequate anal sphincter function, the distal bowel is patent without stricture, and sufficient time has elapsed to allow complete resolution of inflammation or completion of oncologic therapy. 1
Primary Prerequisites for Reversal
Resolution of Underlying Pathology
For diverticulitis with perforation:
- All inflammation must be completely resolved with no evidence of ongoing sepsis before considering reversal 1
- The decision should be made on a case-by-case basis, considering risk factors, complications, age, and severity of episodes 2
For colorectal cancer:
- All oncologic treatment, including neoadjuvant chemoradiotherapy if indicated, must be completed before reversal 1
- Patients should be disease-free with no evidence of recurrence on imaging 3
- Unresectable or progressive malignancy is an absolute contraindication to reversal 1
For trauma cases:
- All injuries must be completely healed with no ongoing intra-abdominal complications 1
Technical Feasibility Requirements
Distal bowel assessment:
- The distal bowel segment must be patent and functional with no evidence of stricture or obstruction 1
- Colonoscopy should be performed preoperatively to confirm patency and rule out pathology 3
- A stricture in the distal rectum may require additional mobilization or alternative anastomotic techniques 3
Patient-Related Factors
Sphincter Function Assessment
Expected anal sphincter function must be adequate to justify reversal 1:
- Pre-existing fecal incontinence is a contraindication to reversal 1
- Permanent sphincter damage or dysfunction from disease, radiation, or surgical trauma precludes reversal 1
For radiation-treated patients:
- High-dose pelvic radiation often causes permanent fecal incontinence or anal stenosis, making reversal inadvisable 1
- Waiting 18 months may be necessary to allow complete resolution of radiation changes 1
Timing Considerations
The interval between colostomy creation and reversal varies significantly:
- In contemporary practice, the median interval ranges from 87 to 1,489 days 4
- For damage control surgery cases, bowel continuity was restored in 76-84% of patients at second-look operations performed 24-48 hours later 2
- No specific minimum interval is mandated by guidelines, but adequate healing and resolution of the underlying condition must be confirmed 1
Absolute Contraindications to Reversal
The following are absolute contraindications 1:
- Permanent sphincter damage or dysfunction from disease, radiation, or surgical trauma
- Unresectable or progressive malignancy
- Patient preference to maintain permanent colostomy
Special circumstances:
- In Fournier's gangrene cases, reversal should only be considered after complete wound healing and confirmation of intact sphincter function 1
Common Pitfalls and Caveats
Hartmann reversal carries substantial morbidity:
- In contemporary series, 29% of patients experienced postoperative complications, with an 11% rate of having two or more complications 4
- Anastomotic leak occurred in 4% of cases, and inadvertent enterotomy occurred in 7% 4
- Only ASA status predicted postoperative complications 4
Low reversal rates:
- In one series, only 31% of patients who underwent Hartmann procedures eventually had their colostomy reversed, suggesting that many patients who receive colostomies are poor candidates for takedown 4
- Stoma reversal after Hartmann procedure was performed in 76% of evaluable patients in emergency laparoscopic series 2
Stoma-related complications:
- Major stoma-related complications requiring reintervention occurred in 10.5% of patients with colostomies 5
- The overall morbidity rate for ostomy takedown is 36.5%, though mortality is low at 0.65% 6
- Colostomy location (large vs. small bowel) has a higher impact than stoma type on complication incidence and severity 6