Objective: Defunctioning stoma (DS) and transanal tube (TT) placement have all been reported to be effective procedures to prevent anastomotic leakage after anterior resection. However, there are few studies that directly compare the 2 procedures, and those that do are unclear. Methods: We performed a systematic literature search from the databases of Pubmed, Embase and Cochrane library. We limited the publication date from 2008/01/01 to 2018/07/29. The bias risk of eligible randomized controlled trials and cohort studies were assessed by Cochrane Collaboration's tool and Newcastle-Ottawa Scale, respectively. The direct meta-analysis was performed by RevMan 5.3 software. The network graph, inconsistency test and comparison-adjusted funnel plot were performed by the Stata 14.0 software. The indirect meta-analysis and rank probabilities were performed by GeMTC R package. Results: 6 randomized controlled trials and 26 cohort studies were included in our meta-analysis. All eligible studies were assessed as low risk of bias. The anastomotic leakage rate and reoperation rate was lower in the patients receiving DS or TT placement than patients with non-protection. DS shared similar anastomotic leakage rate with TT. However, the reoperation rate was significantly lower in patients receiving DS than patients receiving TT. Conclusion: Both TT and DS were protective factors for anastomotic leakage after anterior resection for rectal cancer. DS reduced severity of anastomotic leakage in a more effective way than TT placement. However, we still suggested the routing use of TT for decreasing the risk of anastomotic leakage in anterior resection because it was cheaper and technically simpler. (C) 2019 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.