Surgical fecal diversion vs non-diversion in perineal necrotizing soft tissue infections: A systematic review and meta-analysis.

BACKGROUND

Perineal necrotizing soft tissue infections (P-NSTI) are aggressive and potentially fatal conditions. Surgical fecal diversion (SFD) is often used to reduce contamination, but whether non-diversion provides comparable outcomes remains uncertain. We hypothesized that non-diversion does not confer worse outcomes than SFD.

AIM: To evaluate clinical outcomes of non-diversion compared with SFD in adults with P-NSTI.

METHODS

Systematic review and meta-analysis following PRISMA and Cochrane standards. PubMed, EMBASE, Scopus, Web of Science and Cochrane Library were searched without date restrictions. Adults with P-NSTI comparing non-diversion vs SFD were included when outcomes were numerically extractable. Outcomes were mortality, hospital length of stay (LOS), number of surgical procedures and intensive care unit (ICU) admission. Random-effects models were used. Risk of bias was assessed with ROBINS-I and certainty of evidence with GRADE (PROSPERO CRD420251241839).

RESULTS

Thirty-six studies including 1751 patients were analyzed. In studies with reconstructed groups, mortality favored non-diversion, whereas no difference was observed in studies with predefined groups. Overall pooled analysis showed lower mortality with non-diversion (odds ratio 0.65; 95% confidence interval: 0.46-0.91; P = 0.01; I 2 = 24%), limited by serious confounding by indication. Hospital LOS showed substantial heterogeneity; excluding one outlier study favored non-diversion. ICU admission and number of surgical procedures did not differ. Certainty of evidence was very low for all outcomes.

CONCLUSION

No consistent outcome differences are demonstrated between non-diversion and SFD, and apparent mortality differences likely reflect baseline severity rather than treatment effect, with insufficient evidence to define superiority.