Stoma-Free Intersphincteric Resection in Low Rectal Cancer Without Radiotherapy: A Prospective Cohort Study on Safety and Recovery

BACKGROUND: Although defunctioning stoma creation is routine during intersphincteric resection for low rectal cancer, it carries significant complication risks and necessitates reoperation for closure. Defunctioning stoma omission in intersphincteric resection could avoid these complications; however, its feasibility remains unproven. OBJECTIVE: This study aims to compare Grade C anastomotic leakage and secondly evaluate postoperative complications and economic impact of stoma-free vs. defunctioning stoma-intersphincteric resection procedures. DESIGN: A prospective non-randomized cohort design. SETTING: This study was conducted at a single tertiary referral center. PATIENTS: Patients diagnosed with low rectal cancer, scheduled for intersphincteric resection from 2023 to 2025, were recruited, with those who received neoadjuvant radiotherapy excluded. The cohort was stratified by stoma free vs defunctioning stoma, which was dependent on patient decision. MAIN OUTCOME MEASURES: Grade C anastomotic leakage. RESULTS: A total of 101 patients were enrolled in this study, with 79 and 22 patients in the stoma-free and defunctioning stoma cohorts, respectively. Baseline demographic characteristics, tumor profiles, and preoperative comorbidities showed no statistically significant intergroup differences. Intraoperative parameters, including lymph node yield [13.00 (IQR 10.00–17.00) vs. 14.50 (IQR 10.75–17.00), p = 0.59] and intraoperative blood loss [20.00 (IQR 20.00–50.00) vs. 30.00 (IQR 20.00–50.00) mL, p = 0.10], were similar. Within 30 days, safety outcomes were comparable: Grade C anastomotic leakage (1.3% vs. 4.5%, p = 0.39) and overall complications (Clavien–Dindo I–IV, p = 0.46). Notably, the stoma-free group had shorter hospital stays (5 days [IQR 4–6] vs. 6 days [IQR 5–9], p = 0.004) and lower hospitalization costs (CNY 29,598 [IQR 26,803–33,863] vs CNY 49,734 [IQR 36,731–65,018], p < 0.001). LIMITATIONS: This study was conducted at a single tertiary referral center with a limited patient population. CONCLUSIONS: Under standardized perioperative protocols, stoma-free intersphincteric resection surgery exhibits comparable Grade C leak rates to defunctioning stoma procedures, along with lower medical costs in patients with low rectal cancer without neoadjuvant radiotherapy. See Video Abstract.