Short-Term Outcomes and Stoma-Related Morbidity of Diverting Ileostomy After Laparoscopic Total Mesorectal Excision Following Neoadjuvant Chemoradiotherapy for Mid- and Distal Rectal Cancer: A Retrospective Single-Center Study

Background and Objectives: Diverting ileostomy (DI) is frequently used after low rectal cancer surgery to mitigate the clinical consequences of anastomotic leakage (AL). However, its potential benefits must be balanced against stoma-related morbidity. This study aimed to evaluate short-term postoperative outcomes and stoma-related morbidity associated with DI after laparoscopic total mesorectal excision (TME) following neoadjuvant chemoradiotherapy (nCRT) for mid- and distal rectal cancer. Methods: This retrospective single-center cohort study included 104 of 233 patients assessed for eligibility who had locally advanced mid- or distal rectal adenocarcinoma and underwent TME using an initial laparoscopic approach following nCRT between 2020 and 2025. Patients were stratified according to DI status. Preoperative, operative, pathological, and postoperative outcomes, including AL, 30-day postoperative complications, readmission, surgical reintervention, and stoma-related morbidity, were compared. Propensity score overlap weighting was used as the primary adjusted analysis to address confounding by indication. Results: A total of 50 patients (48.1%) underwent DI and 54 (51.9%) did not. Patients in the DI group had more distal tumors and more frequently underwent ultra-low anterior resection or intersphincteric resection. After propensity score overlap weighting, DI was not significantly associated with non-stoma-related complications within 30 days (adjusted RR, 0.935; 95% CI, 0.566–1.543; p = 0.792) or overall 30-day morbidity (adjusted RR, 1.301; 95% CI, 0.893–1.895; p = 0.158). However, DI was associated with major morbidity (adjusted RR, 4.658; 95% CI, 1.477–14.688; p = 0.004) and 30-day readmission (adjusted RR, 3.665; 95% CI, 1.397–9.621; p = 0.003). Nine patients in the DI group (18.0%) required reoperation within 30 days for stoma-related complications. Conclusions: After adjustment for baseline differences, DI was not significantly associated with overall or non-stoma-related 30-day morbidity, whereas associations with major morbidity and 30-day readmission persisted. Serious stoma-related complications may represent an important component of the early postoperative treatment burden associated with DI. These findings support careful patient selection when balancing the potential benefits of fecal diversion against stoma-related morbidity.