Comparing the safety and efficacy of virtual ileostomy versus diverting ileostomy in patients undergoing total mesorectal excision for rectal cancer: a propensity-matched study.

BACKGROUND: Diverting ileostomy (DI) reduces the clinical impact of anastomotic leakage but is associated with stoma-related complications, mandatory reversal, and substantial costs. We aim to compare the clinical outcomes of virtual ileostomy (VI) and DI. METHODS: A single-center retrospective case-control propensity score-matched analysis was performed on patients who underwent laparoscopic or robot-assisted anterior resection for rectal cancer between September 2014 and January 2024. RESULTS: We included 112 cases of VI and 500 cases of DI for propensity-matched analysis. After PSM, 111 well-balanced pairs were analyzed. The incidence of anastomotic leakage (AL) was 15.3% (17/111) in the VI group and 9.9% (11/111) in the DI group, with no statistically significant difference observed (OR = 0.608, 95% CI [0.271, 1.366], P = 0.448). The overall complication burden, evaluated by the Comprehensive Complication Index (CCI) at 6 months postoperatively, was comparable between the VI and DI groups (median [IQR], 0 [0, 20.9] vs. 0 [0, 22.6]; P = 0.087). However, the VI approach avoided formal stoma creation in 84.7% of selected patients and associated with lower total costs (median [IQR], 54,579 [49,264-74,552] vs. 96,925 [76,530-113,207] CNY; P < 0.001) and postoperative length of stay (median [IQR], 9.0 [8.0, 11.0] vs. 18.0 [14.0, 24.0]; P < 0.001). CONCLUSIONS: In carefully selected patients, VI avoided the need for DI in 84.7% of patients who underwent laparoscopic or robot-assisted anterior resection. Additionally, there was no significant difference in anastomotic leakage or 6-month complication burden. Moreover, VI was associated with advantages in terms of lower costs, lower rate of scheduled secondary operations and shorter hospital stay.