Protective Ileostomy After Low Anterior Resection for Rectal Cancer: Modifying the Clinical Course of Anastomotic Leakage at the Cost of Stoma-Related Morbidity

Background Protective ileostomy (PI) after low anterior resection may not prevent anastomotic leakage (AL) but may lessen its clinical consequences, while adding stoma-related morbidity. This study evaluated the association of PI with the clinical course of AL and stoma-related outcomes. Methods Patients who underwent total mesorectal excision with low anterior resection after neoadjuvant therapy were retrospectively reviewed and grouped as LAR alone (n = 10) or LAR + PI (n = 74). Main outcomes were AL severity, management, leak-related mortality, AL incidence, and PI-related morbidity, including closure outcomes. Results Among 84 patients, AL occurred in 5.9% (5/84), without a significant difference (LAR 10.0% vs LAR + PI 5.4%; P = 0.478). Reoperation was required in one LAR patient and two PI patients; two PI patients were managed with percutaneous drainage. Leak-related mortality occurred in one LAR patient and none in the PI group. Length of stay was longer with PI (median 10.0 days, interquartile range [IQR] 9.0-11.0) than without PI (7.5 days, IQR 6.0-8.0; P < 0.001). Protective ileostomy-related complications included outlet obstruction (9.5%), surgical site infection (4.1%), bleeding (4.1%), and parastomal hernia (2.7%). Closure was achieved in 90.5% after a median of 180 days (IQR 142.5-273); post-closure complications included obstruction (9.2%), infection (4.6%), small-bowel leak (4.6%), and bleeding (1.5%). Discussion Protective ileostomy was not associated with a statistically significant reduction in anastomotic leakage incidence but appeared to be associated with a more favorable clinical course when leakage occurred, including lower mortality and the feasibility of less invasive management.