Bali Medical Journal

Detail Cakupan

Diverting ileostomy (DI) is commonly constructed after low anterior resection (LAR) with primary anastomosis in an attempt to reduce anastomotic leakage and its clinical consequences. Its routine use, however, is increasingly debated, because stoma formation and subsequent closure carry their own morbidity and because advances in surgical technique and perioperative care may have reduced the need for routine faecal diversion. We report a 55-year-old man with rectal adenocarcinoma located approximately 5 cm from the anal verge who was offered LAR with or without a DI, and we appraise the evidence relevant to that decision. A structured search of PubMed, MEDLINE, the Cochrane Library, and Google Scholar was performed for clinical trials and observational studies published between 2014 and 2024 comparing LAR with and without DI in patients with rectal cancer. Records were screened in three stages and critically appraised using the Critical Appraisal Skills Programme checklists for randomised controlled trials and cohort studies. Eight studies were included: six observational cohorts and two randomised controlled trials. Most reported higher overall postoperative complication rates, longer hospitalisation, or more frequent bowel obstruction among diverted patients, although findings were not uniform and diverted patients frequently carried a less favourable baseline risk profile, raising the possibility of confounding by indication. Evidence on anastomotic leakage was inconsistent, with one randomised trial demonstrating a marked reduction in leakage with diversion. Routine diversion after every LAR does not appear justified. Diversion should instead be selective, guided by anastomotic height, neoadjuvant treatment, intraoperative findings, and validated prognostic scores. In the present case, the low anastomosis supported construction of a diverting ileostomy, which was subsequently closed without complication.