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

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.

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.