C-reactive protein guided transanal drainage tube removal reduces anastomotic leak after laparoscopic rectal surgery without stoma: a prospective cohort study

Background: Anastomotic leak (AL) remains a critical complication following laparoscopic rectal cancer surgery, significantly impacting patient outcomes and recovery. Although transanal drainage tubes (TDT) theoretically protect anastomoses by decreasing intraluminal pressure, clinical studies have reported inconsistent benefits. Recent evidence indicates that the duration of postoperative TDT placement may influence its protective efficacy. C-reactive protein (CRP), a reliable acute-phase reactant indicating systemic inflammation and local infection severity, may serve as a useful biomarker for guiding individualized decisions regarding the optimal duration of TDT use. Materials and methods: This prospective, single-center cohort study included 516 patients undergoing laparoscopic anterior resection for rectal cancer without protective stomas. Patients were assigned to two groups: a historical control group ( n = 258, April 2021–April 2023) managed without TDT, and a prospective cohort ( n = 258, April 2023–April 2025) managed using individualized TDT placement guided by postoperative CRP trajectory. Daily CRP monitoring determined TDT removal timing: patients with declining CRP levels underwent early removal (postoperative day 5), while those with persistent or rising CRP levels continued TDT decompression until clinical improvement. The primary outcome was the 30-day incidence of AL. Inverse probability of treatment weighting (IPTW) based on propensity scores was adjusted for baseline covariate differences between groups. Results: The CRP-guided TDT group demonstrated a significantly lower incidence of AL at 30 days (3.5%, 9/258) compared to the historical control group (8.5%, 22/258; weighted odds ratio: 0.37; 95% CI: 0.16–0.83; P = 0.017). Distinct CRP trajectory patterns were observed among patients without AL, those with AL, and those exhibiting risk trajectories without overt AL. No severe complications directly attributable to TDT placement occurred. Conclusion: Individualized, CRP trajectory–guided TDT management significantly reduces AL incidence following laparoscopic rectal cancer surgery without a protective stoma. This biomarker-driven approach represents a feasible and effective clinical strategy to enhance anastomotic safety and optimize postoperative patient care.