Ghost ileostomy as a selective diversion strategy after colorectal cancer surgery: A comparative cohort study

Abstract

Background: Conventional diverting loop ileostomy can mitigate the clinical consequences of anastomotic leakage after low rectal anastomosis, but it exposes many patients to stoma-related morbidity and a subsequent reversal procedure. Ghost ileostomy is a selective-diversion strategy in which an ileal loop is prepared for rapid exteriorization only if postoperative diversion becomes necessary. Methods: We conducted a retrospective comparative cohort study of 56 patients undergoing elective colorectal cancer surgery with a stapled colorectal anastomosis between January 2023 and December 2024. Thirty-three patients underwent ghost ileostomy (GI) and 23 underwent conventional loop ileostomy (LI). Baseline clinical, oncological, operative, and postoperative outcomes were compared. Between-group comparisons were performed using appropriate parametric and exact tests; exploratory multivariable analyses were undertaken where appropriate. Results: The GI and LI groups differed in age (67.00±0.83 vs 67.52±0.51 years; P=0.010), body mass index (27.95±0.34 vs 28.63±0.45 kg/m²; P<0.001), and tumor distance from the anal verge (7.05±0.15 vs 6.69±0.16 cm; P<0.001). An initially positive intraoperative leak test was identified in 8/56 patients (14.3%); all occurred in the LI group (8/23, 34.8%), whereas all GI patients had a negative initial leak test (P<0.001), reflecting the treatment-selection algorithm. Mean blood loss was lower with GI (200.0±13.9 vs 340.0±13.8 mL; P<0.001). Postoperative anastomotic leakage occurred in 3/33 GI patients (9.1%) and 1/23 LI patients (4.3%; P=0.636). Two GI leaks underwent conversion to a functioning ileostomy; consequently, 31/33 GI patients (93.9%) avoided conventional diversion. Overall postoperative complications (15.2% vs 69.6%), stoma-related complications (9.1% vs 56.5%), and Clavien-Dindo grade ≥III morbidity (15.2% vs 69.6%) were lower in GI (all P<0.001). Hospital-stay distribution also favored GI (P=0.004). Conclusions: Ghost ileostomy appears to be a feasible selective-diversion strategy that may reduce unnecessary conventional stoma formation while preserving a rescue option when postoperative anastomotic leakage occurs. Although postoperative leakage did not differ significantly between groups, GI was associated with lower reported morbidity, fewer stoma-related events, less blood loss, and a hospital-stay distribution favoring shorter admissions. These findings should be interpreted cautiously because of the retrospective, non-randomized design, baseline imbalance, treatment-selection bias, and a small number of leakage events. Larger prospective studies are required before GI can be recommended as a routine alternative to conventional loop ileostomy.