Geographical Variation in the Use of Diverting Loop Ileostomy in Australia and New Zealand Colorectal Surgeons

Abstract

Purpose: Anastomotic leak (AL) after a low pelvic anastomosis is a devastating complication, with short- and long-term morbidity and increased mortality. Surgeons may employ various adjuncts in an attempt to reduce AL rates or mitigate their impact. These include the use of temporary diverting ileostomy (TDI), transanal or rectal tubes and pelvic drains. This questionnaire evaluates the preferences and routine use of these adjuncts in Australasian colorectal surgeons.

Methods: A cross-sectional survey was administered to Australian and New Zealand colorectal surgeons on September 20, 2018. The study survey consisted of 15 questions exploring basic demographics and the number of rectal resections and ileal pouches performed in 12 months, along with the surgeon's preference for the use of diverting stomas, rectal tubes, and pelvic drains.

Results: There were 90 respondents to the survey (31.6%). Surgeons in Western Australia (71.4%) were more likely to use a mandatory TDI in colorectal extraperitoneal anastomoses than surgeons in Queensland (14.3%). South Australian surgeons are more likely to employ a mandatory TDI (100%) for ileal pouches than Queensland surgeons (42.9%). Rectal tubes are not commonly utilized (40.0% never use them), and pelvic drains are (45.6% in all cases). Surgeons consider a median AL rate of 15% was felt to justify the use of a TDI in low pelvic anastomoses and a median AL rate of 10% for ileal pouches.

Conclusion: There is considerable geographical variation in colorectal surgical practice throughout Australia and New Zealand. While surgeons interrogate the same literature, there are presumably other factors that see translation into variations in clinical practice.

Keywords: Anastomotic leak; Ileostomy; Pelvic drain; Restorative proctocolectomy; Trans anal tube.

Fig. 1.

Geographical distribution of participating surgeons. NZ, New Zealand; NSW, New South Wales; QLD, Queensland; SA, South Australia; VIC, Victoria; WA, Western Australia; NT/TAS, Northern Territory/Tasmania.

Fig. 2.

Percentage of surgeons using mandatory temporary diverting ileostomy (TDI) for low or ultra-low pelvic anastomoses. LPA, low pelvic anastomoses; NZ, New Zealand; NSW, New South Wales; QLD, Queensland; SA, South Australia; VIC, Victoria; WA, Western Australia; NT/TAS, Northern Territory/Tasmania.

Fig. 3.

Percentage of high-volume surgeons using mandatory temporary diverting ileostomy (TDI) for low or ultra-low anterior resections (with a high caseload >25/year). LPA, low pelvic anastomoses; NZ, New Zealand; NSW, New South Wales; QLD, Queensland; VIC, Victoria; WA, Western Australia; NT/TAS, Northern Territory/Tasmania.

Fig. 4.

Percentage of surgeons using a mandatory temporary diverting ileostomy (TDI) for ileal pouch surgery (IPS). NZ, New Zealand; NSW, New South Wales; QLD, Queensland; SA, South Australia; VIC, Victoria; WA, Western Australia.

Fig. 5.

Regular use of pelvic drains by colorectal surgeons. NZ, New Zealand; NSW, New South Wales; QLD, Queensland; SA, South Australia; VIC, Victoria; WA, Western Australia; NT/TAS, Northern Territory/Tasmania.

Fig. 6.

Distribution of respondents. Surgeons were asked at what percentage risk, on a visual analogue scale, of anastomotic leak (AL) they would consider a diverting ileostomy to be in their patient’s best interest. (A) Low pelvic colorectal anastomosis. (B) Ileal pouch surgery. Blue dotted line marks median risk.