CRP/CT-Guided Selective Ileostomy After LAR

Eligible adult patients undergoing elective laparoscopic low anterior resection with primary colorectal or coloanal anastomosis will be prospectively enrolled.

Suitability for omission of a protective defunctioning ileostomy will be determined using predefined preoperative and intraoperative criteria, including the condition of the patient, anastomotic integrity, tissue perfusion, technical quality of the anastomosis and the absence of major intraoperative complications.

Serum C-reactive protein concentrations will be measured preoperatively and on postoperative days [insert exact days]. Computed tomography of the abdomen and pelvis will be requested when one or more of the following occur:

C-reactive protein exceeds [insert threshold] mg/L on postoperative day [insert day].

C-reactive protein fails to decrease by [insert percentage] between postoperative days [insert days].

There is a persistent or secondary increase in C-reactive protein. The patient develops clinical features suggestive of anastomotic leakage, intra-abdominal infection or postoperative deterioration.

Computed tomography will be performed using intravenous contrast and [oral/rectal contrast when indicated], unless contraindicated. Subsequent treatment will be based on clinical findings, laboratory results, CT findings and the predefined management protocol.

Anastomotic leakage will be classified according to the International Study Group of Rectal Cancer classification, with grade A requiring no active therapeutic intervention, grade B requiring active treatment without relaparotomy, and grade C requiring relaparotomy or major operative intervention.

Inclusion criteria

• Adults with primary resectable stage II or III middle- or lower-third rectal adenocarcinoma planned for laparoscopic low anterior resection with total mesorectal excision
• completion of long-course neoadjuvant chemoradiotherapy
• negative intraoperative air-leak test after anastomosis.

Exclusion criteria

• Stage I disease
• obstructed or perforated tumor
• metastatic or recurrent disease;
• synchronous colonic resection
• total neoadjuvant therapy
• positive intraoperative air-leak test.