Colorectal surgery is an important component of the management of various gastrointestinal diseases, including colorectal cancer, diverticular disease, inflammatory bowel disease, traumatic injuries, and other benign and malignant conditions.1 Surgical resection followed by intestinal anastomosis is commonly performed to restore gastrointestinal continuity and maintain normal bowel function.2 However, anastomotic leakage remains one of the most serious complications following colorectal surgery, particularly in patients undergoing low colorectal or coloanal anastomosis.3 Anastomotic leakage may result in peritonitis, intra-abdominal sepsis, prolonged hospital stay, reoperation, increased healthcare costs, and significant morbidity and mortality.4 Therefore, various surgical techniques have been developed to reduce the risk and clinical consequences of anastomotic failure.

A protective ileostomy is a surgically created temporary opening of the ileum onto the abdominal wall, allowing intestinal contents to bypass a newly constructed distal colorectal or colonic anastomosis.5 The primary purpose of a diverting ileostomy is to reduce the passage of fecal material through the anastomotic site during the early postoperative healing period.6 Although protective ileostomy does not necessarily prevent anastomotic leakage, it may reduce the severity of leakage and minimize its clinical consequences by limiting fecal contamination of the pelvic cavity. This approach is particularly considered in patients undergoing low anterior resection, very low colorectal anastomosis, and procedures involving technically challenging or high-risk anastomoses.

The decision to create a protective ileostomy depends on several patient-related, disease-related, and surgical factors.7 The level of the anastomosis, adequacy of blood supply, tension at the anastomotic site, bowel preparation, nutritional status, comorbidities, immunosuppression, and the use of neoadjuvant chemoradiotherapy may influence the risk of anastomotic complications. Low anastomoses are generally associated with a greater risk of leakage because of their anatomical location and technical complexity.8 Surgeons may therefore use a diverting ileostomy in selected patients to provide additional protection during the healing process.9 However, the routine use of protective ileostomy in all colorectal anastomoses remains controversial, as its potential benefits must be balanced against the risks associated with stoma formation.

Despite its potential advantages, protective ileostomy is associated with several complications, including dehydration, electrolyte disturbances, acute kidney injury, high-output stoma, peristomal skin irritation, intestinal obstruction, and stoma-related infections.10 In addition, patients may require a second surgical procedure for ileostomy closure, which carries its own risks and may lead to further hospitalization and healthcare expenditure. Delayed stoma closure can also affect patients' quality of life and increase the duration of living with a stoma.11 Consequently, appropriate patient selection and careful postoperative monitoring are essential to maximize the benefits of diversion while minimizing its associated complications.

The role of protective ileostomy in colonic and lower colorectal anastomosis continues to be evaluated in clinical practice.12 While some studies have reported a reduction in the clinical impact of anastomotic leakage and the need for emergency reoperation, other studies have emphasized the morbidity associated with ileostomy formation and subsequent reversal. Differences in patient characteristics, anastomotic levels, surgical techniques, and institutional practices may contribute to variations in reported outcomes. Evaluating the indications, postoperative complications, anastomotic leakage rates, and outcomes of patients undergoing protective ileostomy may help improve surgical decision-making and patient counseling.

Therefore, this study aims to evaluate the role of protective ileostomy in patients undergoing lower colorectal and colonic anastomosis, with particular emphasis on its association with anastomotic leakage, postoperative complications, stoma-related morbidity, and overall surgical outcomes. The findings may provide clinically relevant information for assessing the benefits and limitations of protective ileostomy in colorectal surgical practice.

Study Design and Setting: A hospital-based observational study was conducted to evaluate the role of protective ileostomy in patients undergoing lower colorectal and colonic anastomosis. The study was conducted at Abbottabad International Medical College, Abbottabad, Pakistan, in collaboration with the affiliated clinical surgical unit. The study focused on evaluating the clinical outcomes, postoperative complications, and potential benefits associated with protective ileostomy in patients undergoing colorectal surgical procedures.

Study Duration: The study was conducted over a period of two years, from January 2024 to December 2025. During this period, eligible patients undergoing lower colorectal or colonic anastomosis were assessed according to the predefined study criteria, and relevant clinical and postoperative data were collected.

Sample Size: A total of 50 patients undergoing lower colorectal and colonic anastomosis were included in the study. The sample size was selected to assess the role of protective ileostomy and evaluate postoperative outcomes, including anastomotic leakage, surgical complications, and stoma-related morbidity.

Study Population: The study population comprised patients undergoing surgical resection followed by lower colorectal or colonic anastomosis at the study hospital during the study period. Patients were assessed based on their surgical procedure, demographic characteristics, clinical presentation, and postoperative course. The use of protective ileostomy was determined by the operating surgical team according to the patient's clinical condition, anastomotic level, and perceived risk of anastomotic complications.

Inclusion Criteria: Patients were included if they underwent lower colorectal or colonic anastomosis during the study period and were managed at the participating surgical unit. Patients of either sex and those who met the clinical and surgical criteria for inclusion were considered eligible. Patients who underwent an anastomosis with or without a protective ileostomy were included to facilitate assessment of postoperative outcomes between the relevant surgical groups.

Exclusion Criteria: Patients with incomplete medical records, those who underwent surgery outside the study hospital without adequate postoperative documentation, and patients whose clinical information was insufficient for outcome assessment were excluded. Patients who did not meet the predefined surgical inclusion criteria were also excluded from the study.

Data Collection: Data were collected from patients' medical records, operative notes, and postoperative follow-up documentation. Relevant information included demographic characteristics, clinical diagnosis, type of surgical procedure, location of the anastomosis, use of protective ileostomy, and postoperative outcomes. Additional variables included anastomotic leakage, wound infection, postoperative ileus, stoma-related complications, duration of hospital stay, and requirement for reoperation, where documented. Data were recorded using a structured data collection proforma to ensure systematic documentation of study variables.

Assessment of Postoperative Outcomes: Postoperative outcomes were evaluated by reviewing the clinical progress of patients following colorectal or colonic anastomosis. The occurrence of anastomotic leakage, surgical site infection, postoperative complications, and stoma-related morbidity was documented. In patients with protective ileostomy, complications such as high-output stoma, dehydration, electrolyte imbalance, and complications requiring medical or surgical intervention were assessed where information was available. The need for further surgical intervention and the clinical course during follow-up were also recorded.

Statistical Analysis: The collected data were entered into a statistical software package for analysis. Descriptive statistics were used to summarize demographic and clinical characteristics. Categorical variables, including the presence of protective ileostomy, anastomotic leakage, and postoperative complications, were presented as frequencies and percentages. Continuous variables, such as patient age and hospital stay, were summarized using mean and standard deviation or median and interquartile range, depending on data distribution. Where appropriate, comparative analysis was performed between patients who underwent protective ileostomy and those who did not. A p-value of less than 0.05 was considered statistically significant, where inferential statistical testing was performed.

Ethical Considerations: Ethical approval was obtained from the relevant institutional ethical review committee before commencement of the study, subject to institutional requirements. Patient confidentiality was maintained throughout data collection and analysis. Patient information was used exclusively for research purposes, and identifying details were excluded from the analytical dataset and research report.

A total of 50 patients undergoing lower colorectal and colonic anastomosis were included in the study. Patients were evaluated according to demographic characteristics, surgical procedure, use of protective ileostomy, and postoperative outcomes.

                                                       Table 1. Distribution of patients according to age and gender

Table 2. Indications for colorectal surgery

Table 3. Distribution according to use of protective ileostomy

Table 4. Type and level of anastomosis

Table 5. Postoperative complications

Table 6. Stoma-related complications among patients with protective ileostomy

Figure: 2 Postoperative clinical photograph of a protective ileostomy showing stoma prolapse with peristomal skin irritation.

Table 7. Comparison of anastomotic leakage according to protective ileostomy

Table 8. Hospital stay according to protective ileostomy

Table 9. Overall postoperative outcome

The present study evaluated the role of protective ileostomy among 50 patients undergoing lower colorectal and colonic anastomosis. In the present analysis, 22 patients (44.0%) underwent protective ileostomy, while 28 patients (56.0%) underwent anastomosis without diversion. The principal outcome of interest was postoperative anastomotic leakage, together with reoperation and other postoperative complications.

In the present study, anastomotic leakage occurred in 2 (9.1%) patients in the protective ileostomy group compared with 4 (14.3%) patients in the non-ileostomy group. Thus, the observed leakage rate was lower among patients who received a protective ileostomy. This finding is consistent with evidence from previous comparative studies. A meta-analysis of eight randomized controlled trials involving 892 patients undergoing low anterior resection reported an anastomotic leakage rate of 6.3% with diversion compared with 18.3% without diversion. The authors reported a significantly lower relative risk of leakage with a diverting stoma.13 Similarly, another meta-analysis restricted to randomized controlled trials included 768 patients and found that protective diversion significantly reduced anastomotic leakage, with a relative risk of 0.33 (95% CI 0.21–0.51). These findings support the concept that fecal diversion can reduce the clinical occurrence of leakage following low colorectal anastomosis14. The present findings, although based on a smaller observational sample, show a similar direction of effect and suggest that protective ileostomy may be particularly useful when the anastomosis is low or considered technically high risk.

Similarly, another meta-analysis restricted to randomized controlled trials included 768 patients and found that protective diversion significantly reduced anastomotic leakage, with a relative risk of 0.33 (95% CI 0.21–0.51). These findings support the concept that fecal diversion can reduce the clinical occurrence of leakage following low colorectal anastomosis14. The similarity between these published findings and the present results suggests that protective ileostomy may be particularly useful when the anastomosis is low or considered technically high risk.

An important observation in the present study was the difference in reoperation rates. Reoperation was recorded in 1 (4.5%) patient in the protective ileostomy group compared with 3 (10.7%) patients in the non-ileostomy group. Previous literature has demonstrated a similar pattern. The randomized-trial meta-analysis by Phan et al. reported reoperation rates of 5.9% in patients with diversion versus 16.7% without diversion, indicating that diversion may reduce the need for emergency surgical intervention when an anastomotic complication occurs15. Another meta-analysis of randomized trials also found a significant reduction in reoperation following protective diversion16.

The possible explanation for this observation is that a protective ileostomy diverts fecal stream away from the newly constructed anastomosis during the early healing period. Although diversion does not necessarily prevent every anastomotic defect, it can reduce fecal contamination and may therefore limit the severity of leakage and the subsequent need for emergency intervention. This distinction is important because the main potential benefit of protective ileostomy may be reduction in the clinical consequences of anastomotic failure rather than complete prevention of leakage.

The present study also demonstrated that protective ileostomy is associated with stoma-specific complications. Among patients with ileostomy, high-output stoma, dehydration, electrolyte disturbances, and peristomal skin irritation were observed. These complications represent important disadvantages of diversion. Therefore, the decision to construct a protective ileostomy should not be based solely on the potential reduction in anastomotic leakage. Patients should also be monitored for fluid and electrolyte abnormalities, particularly during the early postoperative period.

Previous evidence has similarly emphasized that diversion is not without disadvantages. The randomized-trial meta-analysis found no significant difference in several general postoperative complications between diverted and non-diverted groups, although diversion increased operative duration 15. In addition, patients with a temporary ileostomy require subsequent stoma closure, which exposes them to another surgical procedure and additional healthcare utilization.

The duration of hospital stay in the present study was also assessed. A relatively greater proportion of patients with protective ileostomy remained hospitalized for more than seven days. However, the interpretation of hospital stay requires caution because it can be influenced by several factors, including anastomotic complications, nutritional status, comorbidities, postoperative ileus, stoma function, and the overall complexity of surgery. Previous randomized evidence has not demonstrated a consistent significant difference in hospital stay between diverted and non-diverted patients.

The findings of the present study should therefore be interpreted in the context of patient selection. Protective ileostomy is frequently considered for patients perceived to have a higher risk of anastomotic failure, such as those with very low anastomoses, technically difficult procedures, compromised tissue perfusion, or other unfavorable clinical factors. Consequently, observational comparisons may be affected by selection bias because the patients receiving a stoma may initially have been at greater surgical risk. This is one reason why results from randomized trials and observational studies may differ.

Overall, the present findings are broadly consistent with published evidence showing lower rates of anastomotic leakage and reoperation with protective diversion, particularly following low anterior resection. However, the potential benefits must be balanced against stoma-related complications and the requirement for subsequent closure. The decision to perform a protective ileostomy should therefore be individualized according to the level and characteristics of the anastomosis, patient risk factors, intraoperative findings, and the surgeon's clinical judgment.

rotective ileostomy appears to be a useful surgical strategy in selected patients undergoing lower colorectal and colonic anastomosis. In the present study, patients with protective ileostomy showed a lower observed rate of anastomotic leakage and reoperation compared with patients without diversion. However, ileostomy was also associated with stoma-related complications, including dehydration, electrolyte imbalance, high-output stoma, and peristomal problems. Therefore, protective ileostomy should not be considered necessary for every colorectal anastomosis; rather, its use should be individualized according to the level of anastomosis, patient-related risk factors, intraoperative findings, and the surgeon's clinical judgment. Larger prospective studies with longer follow-up are recommended to further evaluate the benefits, complications, quality of life, and outcomes associated with protective ileostomy.

Limitations: This study had a relatively small sample size of 50 patients and was conducted at a single institution, which may limit the generalizability of the findings. The observational design may have introduced selection bias and confounding factors. The available follow-up may not have captured all long-term stoma-related complications and outcomes. Further multicenter prospective studies with larger sample sizes and longer follow-up are recommended.

1. Vogel JD, Felder SI, Bhama AR, Hawkins AT, Langenfeld SJ, Shaffer VO, Thorsen AJ, Weiser MR, Chang GJ, Lightner AL, Feingold DL. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of colon cancer. Diseases of the Colon &Rectum. 2022 Feb;65(2):148-77.
2. Carpinteyro‐Espín P, Santes O, Moctezuma‐Velazquez P, Navarro‐Iñiguez JA, Navarro‐Navarro A, Salgado‐Nesme N. Deloyers procedure compared to ileorectal anastomosis as restoration techniques of bowel continuity after extended left colon resection. ANZ journal of surgery. 2023 Apr;93(4):956-62.
3. Tsalikidis C, Mitsala A, Mentonis VI, Romanidis K, Pappas-Gogos G, Tsaroucha AK, Pitiakoudis M. Predictive factors for anastomotic leakage following colorectal cancer surgery: where are we and where are we going?. Current oncology. 2023 Mar 7;30(3):3111-37.
4. Rennie O, Sharma M, Helwa N. Colorectal anastomotic leakage: a narrative review of definitions, grading systems, and consequences of leaks. Frontiers in surgery. 2024 May 2;11:1371567.
5. Beck DE. Ostomy construction and management: personalizing the stoma for the patient. Shackelford's Surgery of the Alimentary Tract, 2 Volume Set. 2019 Jan 1:2147-62.
6. Yi X, Yang H, Li H, Feng X, Liao W, Lin J, Chen Z, Diao D, Ouyang M. Analysis of decision-making factors for defunctioning ileostomy after rectal cancer surgery and their impact on perioperative recovery: a retrospective study of 1082 patients. Surgical Endoscopy. 2024 Nov;38(11):6782-92.
7. Wang X, Shen B. Management of Crohn’s disease and complications in patients with ostomies. Inflammatory Bowel Diseases. 2018 May 18;24(6):1167-84.
8. Zhao Y, Li B, Sun Y, Liu Q, Cao Q, Li T, Li J. Risk factors and preventive measures for anastomotic leak in colorectal cancer. Technology in cancer research & treatment. 2022 Sep;21:15330338221118983.
9. Ahmad NZ, Abbas MH, Khan SU, Parvaiz A. A meta-analysis of the role of diverting ileostomy after rectal cancer surgery. International journal of colorectal disease. 2021 Mar;36(3):445-55.
10. Tsujinaka S, Suzuki H, Miura T, Sato Y, Murata H, Endo Y, Hoshi K, Sato Y, Shibata C. Diagnosis, treatment, and prevention of ileostomy complications: an updated review. Cureus. 2023 Jan 27;15(1).
11. Elnaim AL, Wong M, Sagap I. Intestinal stomas; basics, complications and controversy: systematic review. Academic Medicine & Surgery. 2024 Dec 7.
12. Davis BR, Valente MA, Goldberg JE, Lightner AL, Feingold DL, Paquette IM. The American Society of Colon and Rectal Surgeons clinical practice guidelines for ostomy surgery. Diseases of the Colon & Rectum. 2022 Oct;65(10):1173-90.
13. Phan K, Oh L, Ctercteko G, Pathma-Nathan N, El Khoury T, Azam H, Wright D, Toh JW. Does a stoma reduce the risk of anastomotic leak and need for re-operation following low anterior resection for rectal cancer: systematic review and meta-analysis of randomized controlled trials. Journal of gastrointestinal oncology. 2019 Apr;10(2):179.
14. Garg PK, Goel A, Sharma S, Chishi N, Gaur MK. Protective diversion stoma in low anterior resection for rectal cancer: a meta-analysis of randomized controlled trials. Visceral medicine. 2019 Jun 14;35(3):156-60.
15. Phan K, Oh L, Ctercteko G, Pathma-Nathan N, El Khoury T, Azam H, Wright D, Toh JW. Does a stoma reduce the risk of anastomotic leak and need for re-operation following low anterior resection for rectal cancer: systematic review and meta-analysis of randomized controlled trials. Journal of gastrointestinal oncology. 2019 Apr;10(2):179.
16. Garg PK, Goel A, Sharma S, Chishi N, Gaur MK. Protective diversion stoma in low anterior resection for rectal cancer: a meta-analysis of randomized controlled trials. Visceral medicine. 2019 Jun 14;35(3):156-60.