In rectal cancer surgery, creation of diverting stomas can potentially minimize the fatal outcomes of anastomotic leakage, although it may not substantially decrease its incidence [1,2]. Several studies showing that a defunctioning stoma seems to be useful in preventing clinical anastomotic leakage and urgent reoperations in patients receiving a low anterior resection have been reported [1,3]; however, whether a diverting stoma itself can prevent anastomotic leakage independently is still a controversial issue. Rather, stoma creation in patients undergoing a low anterior resection after neoadjuvant chemoradiotherapy may be helpful for a patient's well-being because the predictable poor bowel function in the immediate postoperative period may be avoided.

Up to a quarter of patients who undergo sphincter-saving surgery with a temporary stoma may consequently remain in the permanent stoma status, including nonreversal conditions or re-creation of another stoma after stoma-closure surgery [4,5,6,7]. A review of the factors associated with a permanent stoma after a low anterior resection showed old age, anastomotic complications including leakage, radiation therapy, incurable local pelvic recurrence, systemic disease, and irreversible poor anal sphincter function after surgery to be significant [4,5,6,7].

The benefits of a stoma in mitigating the potential complications due to anastomotic problems/pelvic sepsis in low rectal cancer must be balanced against the potential disadvantages of ostomy-related complications and of its subsequent closure procedure. Although making a decision on whether or not to create a stoma based on these factors only is hardly possible, this issue should be discussed preoperatively so that permanent-stoma-creating surgery may be selected according to patient's condition, especially in more elderly patients who are receiving radiotherapy and who have a poor anal sphincter function preoperatively.