Selective ileostomy and proactive anastomotic leak management after low rectal resection: a prospective single-center cohort with historical comparison

Abstract Background Anastomotic leakage (AL) remains a major complication after low rectal resection. Protective ileostomy is widely used, although it may not reduce leak incidence and may mask subclinical events. This study evaluated the feasibility and clinical outcomes of a selective ileostomy strategy combined with proactive anastomotic monitoring and leak management. Methods This prospective single-center cohort study included 100 patients undergoing low rectal resection with primary anastomosis (≤ 10 cm from the anal verge). Outcomes were descriptively compared with a historical institutional cohort. Protective ileostomy was applied selectively. A proactive protocol with routine postoperative endoscopic assessment was used to detect and manage subclinical AL. Primary outcomes were AL rate and anastomotic preservation. Secondary outcomes included stoma-related outcomes and quality of life (SF-36). Results AL occurred in 23% of patients. Symptomatic leakage occurred in 6%, whereas 78% of leaks were detected only during routine endoscopic follow-up. Anastomotic preservation was achieved in 17 of 23 patients with AL. Primary ileostomy was performed in 34% of patients. Stoma closure was achieved in 84.2% of eligible cases. Compared with the historical cohort, postoperative stoma prevalence remained lower during the 1st postoperative year. Quality of life was comparable between groups, although patients with a primary stoma had higher emotional and social scores. Conclusions Selective ileostomy combined with proactive anastomotic monitoring and leak management appears to be a safe strategy after low rectal resection. Routine postoperative endoscopic assessment enables early detection of subclinical leaks and facilitates anastomotic preservation.