Introduction Colorectal cancer is the third most commonly diagnosed malignancy worldwide, with rectal cancer accounting for approximately one-third of all cases1. The incidence varies geographically, with higher rates observed in developed regions, whereas emerging economies are witnessing a rising trend. Rectal cancer poses a significant oncologic challenge in China according to the recent statics2. Over the past two decades, significant advances have transformed the management of rectal cancer. The introduction of total mesorectal excision has become the surgical gold standard, markedly reducing local recurrence rates. Concurrently, neoadjuvant chemoradiotherapy has been established as the standard of care for locally advanced disease, improving tumor downstaging and sphincter preservation. More recently, the emergence of total neoadjuvant therapy has further enhanced pathologic complete response rates and enabled organ preservation strategies in selected patients3. Despite these advances, challenges such as optimal patient selection, postoperative complications, and balancing oncologic efficacy with quality of life remain central to ongoing research effort .Advances in surgical techniques4 and neoadjuvant therapy have increased the feasibility of sphincter-preserving low anterior resection (LAR). However, anastomotic leakage (AL) remains a major postoperative complication. The use of a prophylactic ileostomy (PI) to divert fecal stream is a widely adopted strategy aimed at mitigating the consequences of AL5. Despite its common use, PI is associated with stoma-related morbidity and additional psychological and economic burdens. The evidence regarding its definitive benefit has been inconsistent, largely derived from single-center or small-sample studies6. The prospective, multicenter cohort study by Cao et al provides valuable, higher-level evidence to inform this critical clinical decision7. This large-scale study involving 728 patients from 17 centers compared outcomes between patients receiving PI and those without PI (NPI) undergoing laparoscopic LAR. After propensity score matching to balance baseline characteristics, several key findings were observed. First, there was no reduction in the anastomotic leak rate. The primary endpoint (AL rate) was not significantly different between the PI group (3.6%) and the NPI group (4.7%). Second, the study indicated that it was associated with increased overall morbidity with PI. The PI group experienced a significantly higher overall complication rate (17.2% vs 10.3%), primarily driven by Clavien–Dindo grade II complications, including stoma-related issues like dermatitis and obstruction. Third, it should pay attention to the higher resource utilization. PI was associated with longer operative time, heightened early postoperative inflammatory markers C-reactive protein (CRP) and procalcitonin (PCT), and increased hospitalization costs. Fourth, PI has an effect on modification of leak severity. In patients who developed AL, those with a PI exhibited a lower peak and a more rapid decline in systemic inflammatory markers (CRP and PCT), suggesting a potential ameliorating effect on the septic response. Finally, the study also identified some independent risk factors for AL, including male gender and an elevated postoperative day 5 CRP level. This study challenges the routine use of PI as a universal protective measure against AL in laparoscopic LAR. The central paradox revealed that, while PI did not prevent the occurrence of AL, it appeared to alter its clinical expression, potentially reducing the severity of systemic inflammation associated with leakage. This supports the prevailing theory that PI functions more as a “damage control” tactic, containing the sequelae of a leak, rather than preventing the leak itself. The significantly higher complication rate in the PI group underscores the “trade-off” inherent in this procedure. Stoma-related complications are frequent and substantiate the known downsides of diverting ileostomies. Furthermore, the increased operative time, inflammatory response, and cost highlight the tangible burdens imposed by PI. These findings compel a re-evaluation of the risk-benefit ratio, advocating for a more selective application of PI rather than its routine use. The identification of male gender and high postoperative CRP as independent risk factors is clinically useful. It aligns with the existing literature and provides tangible parameters for risk stratification. The subgroup analysis suggesting threshold values for CRP and PCT to predict AL within the PI group is intriguing and points toward potential biomarkers for closer monitoring. The major strengths of this study lie in its prospective, multi-center design and large sample size, enhancing the generalizability of its findings. The use of propensity score matching and weighted analysis strengthens the validity of the comparisons between the non-randomized groups. A primary limitation is the non-randomized allocation of PI based on surgeon judgment, which introduces selection bias. Although statistical adjustments were made, unmeasured confounding factors (e.g., exact tumor height, quality of the anastomosis under tension, individual surgeon’s risk aversion) may persist. The study also does not provide long-term functional outcomes or oncologic results, which are crucial for comprehensive assessment. This study provides robust evidence that a blanket policy of PI for all patients undergoing laparoscopic LAR is not justified. The decision to perform a PI should shift from routine to highly selective, targeting patients perceived to be at the highest risk for severe AL. The identified risk factors (male gender, high post-op CRP) can aid in this decision-making. Conclusion This study underscores a critical nuance in the surgical management of rectal cancer: although PI does not significantly reduce the incidence of AL following LAR, it may attenuate the systemic inflammatory response associated with AL. However, this potential benefit is counterbalanced by an increased overall complication rate and greater resource utilization. These findings advocate for a paradigm shift from routine diversion toward a more selective, risk-adapted strategy. Future research should prioritize the development and validation of refined risk prediction models integrating clinical, surgical, and biomarker data to better identify patients who stand to truly benefit from diversion. Additionally, cost-effectiveness analyses and investigations into enhanced recovery protocols and novel technologies aimed at reducing AL risk without diversion are warranted to optimize patient outcomes and resource allocation.
Fu et al. (Wed,) studied this question.