Late anastomotic leakage is a significant issue in rectal cancer surgery, affecting morbidity and long-term outcomes.

• Overall anastomotic leakage occurred in 3.2% of patients, with late leakage at 48.3%.
• 24.1% of late leak cases were diagnosed over a year post-surgery, often following diverting stoma formation.

Surgeons should consider enhanced surveillance for patients at higher risk, particularly those undergoing neoadjuvant chemoradiotherapy or robotic surgery.

• Independent risk factors for late leakage include younger age, male sex, and high inferior mesenteric artery ligation.