Rectal catheter versus diverting ileostomy after total mesorectal excision for rectal cancer: a propensity score-matched retrospective cohort study

Background Diverting ileostomy is frequently used to mitigate the clinical consequences of anastomotic leakage (AL) after low rectal anastomosis, but it entails stoma-related morbidity and usually requires a second operation for closure. A modified rectal catheter may provide decompression and fecal drainage without a stoma. We compared postoperative outcomes after rectal catheter placement versus diverting ileostomy in patients undergoing total mesorectal excision (TME) for rectal cancer. Methods This single-center retrospective cohort study included patients with rectal adenocarcinoma who underwent TME between July 2022 and July 2024 and received either a rectal catheter or diverting ileostomy. The primary outcome was AL; secondary outcomes were AL severity and postoperative length of stay. Propensity score matching (PSM) was performed in a 1:1 ratio using nearest-neighbor matching to reduce baseline imbalance. Results Among 1,029 patients, 248 received a rectal catheter and 781 underwent diverting ileostomy. After PSM, 248 matched pairs were analyzed. AL occurred in 40 patients (16.1%) in the rectal catheter group and 37 (14.9%) in the ileostomy group (RR 1.097, 95% CI 0.674–1.784; P = 0.804). Grade B/C AL rates did not differ significantly (P = 0.864). Postoperative length of stay was shorter after rectal catheter placement [median 7 (IQR 6–9) vs 8 (IQR 7–11) days; P < 0.001]. In multivariable logistic regression, rectal catheter placement was not significantly associated with AL (OR 0.754, 95% CI 0.437–1.302; P = 0.311). Conclusions In this propensity score-matched retrospective cohort, rectal catheter placement was associated with similar observed AL rates and severity and a shorter postoperative hospital stay compared with diverting ileostomy. Because the study was not designed to establish non-inferiority, prospective multicenter trials are required before rectal catheter placement can be considered a substitute for diverting ileostomy.