Routine versus postoperative CRP/CT guided selective diverting ileostomy after laparoscopic low anterior resection for rectal cancer: a comparative randomized controlled trial.

BACKGROUND

Diverting ileostomy is routinely used to protect the anastomosis after laparoscopic low anterior resection (LAR) for rectal cancer, but it exposes most patients to stoma-related morbidity even though only a minority develop a true anastomotic leak. This trial evaluated whether a postoperative C-reactive protein (CRP) and computed tomography (CT) guided selective ileostomy strategy could reduce the rate of ileostomy formation compared with routine diversion.

METHODS

In this RCT, 200 patients with stage II or III middle or lower third rectal cancer undergoing laparoscopic LAR were randomized 1:1 to a CRP/CT-guided selective ileostomy group (n = 100) or a routine diverting ileostomy group (n = 100). In the CRP/CT group, serum CRP was measured daily from postoperative day 1; a threshold of 114 mg/L on day 3 or a rise greater than 15 mg/L per day triggered confirmatory contrast-enhanced CT, with ileostomy formed only if findings were suspicious for leak. The primary outcome was the stoma-free status throughout the 12-month follow-up.

RESULTS

Baseline demographic and tumor characteristics were similar between groups (all p > 0.05). Ileostomy formation was markedly lower in the CRP/CT group than the routine group (22.0% vs. 100.0%, p < 0.001). Anastomotic leak rates did not differ (0% vs. 1.0%, p = 1.000), nor did overall complication rates (31.0% vs. 32.0%, p = 0.879). Operative time (148.4 ± 14.0 vs. 166.6 ± 13.1 min, p < 0.001) and intraoperative blood loss (168.9 ± 28.2 vs. 197.3 ± 39.7 mL, p < 0.001) were significantly lower in the CRP/CT group. Stoma-related complications were far less frequent with the selective strategy (3.0% vs. 30.0%, p < 0.001). The CRP/CT group reported significantly better global health status, physical functioning, and emotional functioning scores (all p < 0.001).

CONCLUSION

A postoperative CRP/CT-guided selective ileostomy strategy reduces the need for diverting ileostomy after laparoscopic low anterior resection for rectal cancer while improving operative outcomes and quality of life; however, confirmed leakage was infrequent in both groups. This approach may serve as an alternative to routine diversion in appropriately monitored surgical units.

TRIAL REGISTRATION: This trial was retrospectively registered at ClinicalTrials.gov (Identifier: NCT07722533) on July 17, 2026.