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. 2023 Apr;25(4):647-659.
doi: 10.1111/codi.16454. Epub 2022 Dec 28.

Protective ileostomy creation after anterior resection of the rectum: Shared decision-making or still subjective?

Andrea Balla  1 , Federica Saraceno  1   2 , Marika Rullo  3 , Salvador Morales-Conde  4 , Eduardo M Targarona Soler  5 , Salomone Di Saverio  6 , Mario Guerrieri  7 , Pasquale Lepiane  1 , Nicola Di Lorenzo  2 , Michel Adamina  8 , Isaias Alarcón  4 , Alberto Arezzo  9 , Jesus Bollo Rodriguez  5 , Luigi Boni  10 , Sebastiano Biondo  11 , Francesco Maria Carrano  2 , Manish Chand  12 , John T Jenkins  13 , Justin Davies  14   15 , Salvadora Delgado Rivilla  16 , Paolo Delrio  17 , Ugo Elmore  18 , Eloy Espin-Basany  19 , Alessandro Fichera  20 , Blas Flor Lorente  21 , Nader Francis  22 , Marcos Gómez Ruiz  23   24 , Dieter Hahnloser  25 , Eugenio Licardie  26 , Carmen Martinez  5 , Monica Ortenzi  7 , Yves Panis  27 , Carlos Pastor Idoate  28 , Alessandro M Paganini  29 , Miguel Pera  30 , Roberto Perinotti  31 , Daniel A Popowich  32 , Timothy Rockall  33 , Riccardo Rosati  18 , Alberto Sartori  34 , Daniele Scoglio  35 , Mostafa Shalaby  36 , Vicente Simó Fernández  37 , Neil J Smart  38 , Antonino Spinelli  39   40 , Patricia Sylla  41 , Pieter J Tanis  42   43 , Javier Valdes-Hernandez  44 , Steven D Wexner  45 , Pierpaolo Sileri  18
Affiliations

Protective ileostomy creation after anterior resection of the rectum: Shared decision-making or still subjective?

Andrea Balla et al. Colorectal Dis. 2023 Apr.

Abstract

Aim: The choice of whether to perform protective ileostomy (PI) after anterior resection (AR) is mainly guided by risk factors (RFs) responsible for the development of anastomotic leakage (AL). However, clear guidelines about PI creation are still lacking in the literature and this is often decided according to the surgeon's preferences, experiences or feelings. This qualitative study aims to investigate, by an open-ended question survey, the individual surgeon's decision-making process regarding PI creation after elective AR.

Method: Fifty four colorectal surgeons took part in an electronic survey to answer the questions and describe what usually led their decision to perform PI. A content analysis was used to code the answers. To classify answers, five dichotomous categories (In favour/Against PI, Listed/Unlisted RFs, Typical/Atypical, Emotions/Non-emotions, Personal experience/No personal experience) have been developed.

Results: Overall, 76% of surgeons were in favour of PI creation and 88% considered listed RFs in the question of whether to perform PI. Atypical answers were reported in 10% of cases. Emotions and personal experience influenced surgeons' decision-making process in 22% and 49% of cases, respectively. The most frequently considered RFs were the distance of the anastomosis from the anal verge (96%), neoadjuvant chemoradiotherapy (88%), a positive intraoperative leak test (65%), blood loss (37%) and immunosuppression therapy (35%).

Conclusion: The indications to perform PI following rectal cancer surgery lack standardization and evidence-based guidelines are required to inform practice. Until then, expert opinion can be helpful to assist the decision-making process in patients who have undergone AR for adenocarcinoma.

Keywords: Adenocarcinoma; Anterior resection of the rectum; Decision-making process; Defunctioning stoma; Protective ileostomy.

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References

REFERENCES

    1. Jutesten H, Draus J, Frey J, Neovius G, Lindmark G, Buchwald P, et al. High risk of permanent stoma after anastomotic leakage in anterior resection for rectal cancer. Colorectal Dis. 2019;21(2):174-82. https://doi.org/10.1111/codi.14469
    1. Morales-Conde S, Alarcón I, Yang T, Licardie E, Balla A. A decalogue to avoid routine ileostomy in selected patients with border line risk to develop anastomotic leakage after minimally invasive low-anterior resection: a pilot study. Surg Innov. 2020;27(1):44-53. https://doi.org/10.1177/1553350619890720
    1. Matsuda K, Hotta T, Takifuji K, Yokoyama S, Watanabe T, Mitani Y, et al. Clinical characteristics of anastomotic leakage after an anterior resection for rectal cancer by assessing of the international classification on anastomotic leakage. Langenbecks Arch Surg. 2015;400(2):207-12. https://doi.org/10.1007/s00423-015-1272-4
    1. Allaix ME, Rebecchi F, Famiglietti F, Arolfo S, Arezzo A, Morino M. Long-term oncologic outcomes following anastomotic leak after anterior resection for rectal cancer: does the leak severity matter? Surg Endosc. 2020;34(9):4166-76. https://doi.org/10.1007/s00464-019-07189-9
    1. Wang S, Liu J, Wang S, Zhao H, Ge S, Wang W. Adverse effects of anastomotic leakage on local recurrence and survival after curative anterior resection for rectal cancer: a systematic review and meta-analysis. World J Surg. 2017;41(1):277-84. https://doi.org/10.1007/s00268-016-3761-1

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