Ghost (virtual) ileostomy compared with protective ileostomy after low anterior resection for rectal cancer: A GRADE-assessed systematic review and meta-analysis

Protective ileostomy is commonly performed after low anterior resection for rectal cancer to mitigate the clinical consequences of anastomotic leakage; however, it is associated with stoma-related and reversal-related morbidity. Ghost ileostomy has emerged as a selective alternative to avoid unnecessary stoma maturation. This systematic review and meta-analysis of comparative studies was conducted in accordance with the PRISMA 2020 statement. PubMed/MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials were searched from inception to March 31, 2026. Six comparative studies involving 395 patients were included. The primary outcome was anastomotic leakage. Secondary outcomes were length of hospital stay, readmission/rehospitalization, and postoperative ileus. Random-effects models were used. The risk of bias was assessed using RoB 2 and ROBINS-I, and the certainty of evidence was evaluated using GRADE. The available evidence did not demonstrate a statistically significant difference in anastomotic leakage between ghost and protective ileostomy (RR 1.27, 95% CI 0.64–2.49; I² = 0%). Length of hospital stay was also not significantly different (MD 0.55 days, 95% CI -1.35 to 2.45; I² = 92%). Ghost ileostomy was associated with lower readmission/rehospitalization (RR 0.24, 95% CI 0.06–0.89; I² = 0%) and postoperative ileus (RR 0.33, 95% CI 0.13–0.82; I² = 0%). Leave-one-out sensitivity analysis did not materially alter the interpretation of the heterogeneous hospital-stay outcome. The certainty of evidence was low for anastomotic leakage, readmission, and postoperative ileus and very low for hospital stay. The available evidence did not identify a statistically significant difference in anastomotic leakage between ghost and protective ileostomy, although imprecision and limited sample size preclude a definitive conclusion of equivalence. Ghost ileostomy may reduce postoperative ileus and readmission in carefully selected patients; however, larger, adequately powered randomized trials are required before routine adoption.