Diverting ileostomy in colorectal surgery: balancing benefits and complications through selective indications and risk stratification

Purpose. Diverting ileostomy is useful to prevent morbidity and mortality of an anastomotic leak after colorectal surgery. However it has its own complications such as acute kidney injury, bowel obstruction, anastomotic leak and incisional hernia. The aim of this study is to analyze the risks and benefits of a diverting ileostomy in colorectal surgery. Methods. Patients with a diagnosis of rectal cancer who underwent minimally invasive anterior rectal resection, between June 2018 and September 2025, were retrospectively analyzed. All patients were managed according to the institutional ERAS protocol. Comparison was made between patients with diverting loop ileostomy versus no diverting ileostomy. Primary outcome was the incidence of postoperative complications due to diverting loop ileostomy. Secondary outcomes were overall postoperative complications, such as after loop ileostomy closure. Variables with high accuracy were included in a preoperative predictive score aiming to avoid loop ileostomy during anterior rectal resection. Results. 170 patients were analysed: 108 underwent a diverting loop ileostomy, 3 had ileostomy after complications of primary surgery, 42 did not undergo ileostomy and 18 performed Hartmann’s procedure. 14 (9.2%) of all patients experienced anastomotic leak. Among patients who underwent ileostomy, overall postoperative complications rate was 36.4%. The major complication related to the loop ileostomy was acute kidney injury (17.3%). Anastomotic leak was correlated with male sex, ASA III score, and preoperative neoadjuvant treatment with bevacizumab. Conclusions. According to our data, more than one third of patients developed complications related to the ileostomy. Although diverting ileostomy confers clinical benefit in patients undergoing surgery for rectal cancer, the decision to create a diverting ileostomy should be individualized, balancing the potential benefits of anastomotic protection against the risks and burdens associated with stoma formation.