Timing of diverting ileostomy closure after low anterior resection for rectal cancer: a GRADE-assessed systematic review and meta-analysis of early and delayed closure

To compare early and delayed diverting ileostomy closure after low anterior resection for rectal cancer, focusing on postoperative morbidity and recovery outcomes, and to assess the certainty of available evidence. PubMed/MEDLINE, Embase, Scopus, and Web of Science were searched from inception to 26th April, 2026. Five comparative studies (four randomized trials and one prospective cohort; 512 participants) were included. Random-effects meta-analyses evaluated overall post-closure morbidity as the primary outcome and severe complications, index-to-closure interval, postoperative hospital stay, operative time, and reoperation as secondary outcomes. Certainty was assessed using GRADE. Overall morbidity occurred in 52/257 patients after early closure and 50/255 after delayed closure (RR 1.06, 95% CI 0.66–1.71; τ²=0.12; I²=40%). Severe complications and reoperation did not differ statistically, with confidence intervals compatible with benefit or harm. The index-to-closure interval was 107.09 days shorter with early closure (95% CI − 153.01 to − 61.17; τ²=2023.39; I²=96%); this process measure was largely inherent to the group definitions. Hospital stay and operative time did not differ statistically. The available evidence does not demonstrate a statistically significant difference in postoperative morbidity but does not establish equivalence. Early closure may be considered in selected patients after postoperative recovery and assessment of anastomotic integrity; however, these findings do not support routine early closure in all patients.