Peer-reviewedCC BY-NC-ND 4.0Langenbeck's Archives of Surgery10 Aug 2026

Ghost (virtual) ileostomy compared with protective ileostomy after low anterior resection for rectal cancer: A GRADE-assessed systematic review and meta-analysis

Wajahat Mirza¹
Saadia Anwar²
Muslim Hassnain³
Maroof Subhani⁴
Zain Nawaz³
Hadi Mohammad Khan⁵
Ahmed Al-Emam⁶

6 affiliations

¹Shifa College of Medicine, Shifa Tameer-e-Millat University, Sector H-8/4, Islamabad, Pakistan
²Department of General Surgery, Shifa International Hospital, Islamabad, Pakistan
³Pak Red Crescent Teaching Hospital, Lahore, Pakistan
⁴Pak Red Crescent Medical & Dental College, Lahore, Pakistan
⁵Department of General Surgery & Surgical Oncology, Kulsum International Hospital, Islamabad, Pakistan
⁶Department of Pathology, College of Medicine, King Khalid University, Abha, Saudi Arabia

Abstract

Background: Protective ileostomy is commonly performed after low anterior resection for rectal cancer to mitigate the clinical consequences of anastomotic leakage; however, it is associated with stoma-related and reversal-related morbidity. Ghost ileostomy has emerged as a selective alternative to avoid unnecessary stoma maturation.

Methods: This systematic review and meta-analysis of comparative studies was conducted in accordance with the PRISMA 2020 statement. PubMed/MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials were searched from inception to March 31, 2026. Six comparative studies involving 395 patients were included. The primary outcome was anastomotic leakage. Secondary outcomes were length of hospital stay, readmission/rehospitalization, and postoperative ileus. Random-effects models were used. The risk of bias was assessed using RoB 2 and ROBINS-I, and the certainty of evidence was evaluated using GRADE.

Results: The available evidence did not demonstrate a statistically significant difference in anastomotic leakage between ghost and protective ileostomy (RR 1.27, 95% CI 0.64–2.49; I² = 0%). Length of hospital stay was also not significantly different (MD 0.55 days, 95% CI -1.35 to 2.45; I² = 92%). Ghost ileostomy was associated with lower readmission/rehospitalization (RR 0.24, 95% CI 0.06–0.89; I² = 0%) and postoperative ileus (RR 0.33, 95% CI 0.13–0.82; I² = 0%). Leave-one-out sensitivity analysis did not materially alter the interpretation of the heterogeneous hospital-stay outcome. The certainty of evidence was low for anastomotic leakage, readmission, and postoperative ileus and very low for hospital stay.

Conclusions: The available evidence did not identify a statistically significant difference in anastomotic leakage between ghost and protective ileostomy, although imprecision and limited sample size preclude a definitive conclusion of equivalence. Ghost ileostomy may reduce postoperative ileus and readmission in carefully selected patients; however, larger, adequately powered randomized trials are required before routine adoption.

Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1007/s00423-026-04189-x.

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BibTeX RIS

BibTeX

@article{mirza2026ghost,
  title = {{Ghost (virtual) ileostomy compared with protective ileostomy after low anterior resection for rectal cancer: A GRADE-assessed systematic review and meta-analysis}},
  author = {Wajahat Mirza and Saadia Anwar and Muslim Hassnain and Maroof Subhani and Zain Nawaz and Hadi Mohammad Khan and Ahmed Al-Emam},
  journal = {Langenbeck's Archives of Surgery},
  year = {2026},
  month = aug,
  doi = {10.1007/s00423-026-04189-x},
  url = {https://doi.org/10.1007/s00423-026-04189-x},
  note = {CC BY-NC-ND 4.0},
}

RIS

TY  - JOUR
TI  - Ghost (virtual) ileostomy compared with protective ileostomy after low anterior resection for rectal cancer: A GRADE-assessed systematic review and meta-analysis
AU  - Wajahat Mirza
AU  - Saadia Anwar
AU  - Muslim Hassnain
AU  - Maroof Subhani
AU  - Zain Nawaz
AU  - Hadi Mohammad Khan
AU  - Ahmed Al-Emam
PY  - 2026
DA  - 2026/08/10
JO  - Langenbeck's Archives of Surgery
DO  - 10.1007/s00423-026-04189-x
UR  - https://doi.org/10.1007/s00423-026-04189-x
AB  - Background: Protective ileostomy is commonly performed after low anterior resection for rectal cancer to mitigate the clinical consequences of anastomotic leakage; however, it is associated with stoma-related and reversal-related morbidity. Ghost ileostomy has emerged as a selective alternative to avoid unnecessary stoma maturation.  Methods: This systematic review and meta-analysis of comparative studies was conducted in accordance with the PRISMA 2020 statement. PubMed/MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials were searched from inception to March 31, 2026. Six comparative studies involving 395 patients were included. The primary outcome was anastomotic leakage. Secondary outcomes were length of hospital stay, readmission/rehospitalization, and postoperative ileus. Random-effects models were used. The risk of bias was assessed using RoB 2 and ROBINS-I, and the certainty of evidence was evaluated using GRADE.  Results: The available evidence did not demonstrate a statistically significant difference in anastomotic leakage between ghost and protective ileostomy (RR 1.27, 95% CI 0.64–2.49; I² = 0%). Length of hospital stay was also not significantly different (MD 0.55 days, 95% CI -1.35 to 2.45; I² = 92%). Ghost ileostomy was associated with lower readmission/rehospitalization (RR 0.24, 95% CI 0.06–0.89; I² = 0%) and postoperative ileus (RR 0.33, 95% CI 0.13–0.82; I² = 0%). Leave-one-out sensitivity analysis did not materially alter the interpretation of the heterogeneous hospital-stay outcome. The certainty of evidence was low for anastomotic leakage, readmission, and postoperative ileus and very low for hospital stay.  Conclusions: The available evidence did not identify a statistically significant difference in anastomotic leakage between ghost and protective ileostomy, although imprecision and limited sample size preclude a definitive conclusion of equivalence. Ghost ileostomy may reduce postoperative ileus and readmission in carefully selected patients; however, larger, adequately powered randomized trials are required before routine adoption.  Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1007/s00423-026-04189-x.
SN  - 1435-2443
SN  - 1435-2451
ER  -

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