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. 2025 Jun;77(3):805-823.
doi: 10.1007/s13304-025-02111-6. Epub 2025 Mar 23.

Protective ileostomy creation after anterior resection of the rectum (PICARR): a decision-making exploring international survey

Andrea Balla  1   2 , Federica Saraceno  3 , Marika Rullo  4 , Salvador Morales-Conde  5   6 , Eduardo M Targarona Soler  7 , Salomone Di Saverio  8 , Mario Guerrieri  9 , Pasquale Lepiane  10 , Nicola Di Lorenzo  11 , Michel Adamina  12 , Isaias Alarcón  13 , Alberto Arezzo  14 , Jesus Bollo Rodriguez  7 , Luigi Boni  15 , Sebastiano Biondo  16 , Francesco Maria Carrano  17 , Manish Chand  18 , John T Jenkins  19 , Justin Davies  20   21 , Salvadora Delgado Rivilla  22 , Paolo Delrio  23 , Ugo Elmore  24 , Eloy Espin-Basany  25 , Alessandro Fichera  26 , Blas Flor Lorente  27 , Nader Francis  28 , Marcos Gómez Ruiz  29   30 , Dieter Hahnloser  31 , Eugenio Licardie  5   6 , Carmen Martinez  7 , Monica Ortenzi  9 , Yves Panis  32 , Carlos Pastor Idoate  33 , Alessandro M Paganini  34 , Miguel Pera  35 , Roberto Perinotti  36 , Daniel A Popowich  37 , Timothy Rockall  38 , Riccardo Rosati  24 , Alberto Sartori  39 , Daniele Scoglio  40 , Mostafa Shalaby  41 , Vicente Simó Fernández  42 , Neil J Smart  43 , Antonino Spinelli  44   45 , Patricia Sylla  46 , Pieter J Tanis  47   48 , Javier Valdes Hernandez  49 , Steven D Wexner  50 , Pierpaolo Sileri  51 ; Protective Ileostomy Creation after Anterior Resection of the Rectum (PICARR) Collaborative Group
Collaborators, Affiliations

Protective ileostomy creation after anterior resection of the rectum (PICARR): a decision-making exploring international survey

Andrea Balla et al. Updates Surg. 2025 Jun.

Erratum in

  • Correction: Protective ileostomy creation after anterior resection of the rectum (PICARR): a decision-making exploring international survey.
    Balla A, Saraceno F, Rullo M, Morales-Conde S, Targarona Soler EM, Di Saverio S, Guerrieri M, Lepiane P, Di Lorenzo N, Adamina M, Alarcón I, Arezzo A, Bollo Rodriguez J, Boni L, Biondo S, Carrano FM, Chand M, Jenkins JT, Davies J, Delgado Rivilla S, Delrio P, Elmore U, Espin-Basany E, Fichera A, Lorente BF, Francis N, Gómez Ruiz M, Hahnloser D, Licardie E, Martinez C, Ortenzi M, Panis Y, Pastor Idoate C, Paganini AM, Pera M, Perinotti R, Popowich DA, Rockall T, Rosati R, Sartori A, Scoglio D, Shalaby M, Simó Fernández V, Smart NJ, Spinelli A, Sylla P, Tanis PJ, Valdes Hernandez J, Wexner SD, Sileri P; Protective Ileostomy Creation after Anterior Resection of the Rectum (PICARR) Collaborative Group. Balla A, et al. Updates Surg. 2025 Jun 10. doi: 10.1007/s13304-025-02277-z. Online ahead of print. Updates Surg. 2025. PMID: 40495057 No abstract available.

Abstract

In our previous survey of experts, surgeon's decision-making process (DMP) about protective ileostomy (PI) creation after anterior resection was investigated. Based on our previous data, a multiple choice questionnaire has been developed. The aim is to perform a quantitative analysis of the results obtained from an international survey and to describe the clinical practice worldwide. Ten questions were related to participants' demographics and, 20 questions (of which 17 Likert scale questions) investigated the DMP regarding PI creation. To evaluate the tendency of the answers in the Likert-type questions, the mean of the answers obtained was compared with the mean point of the Likert scale. The survey was completed by 1019 physicians. Neoadjuvant chemoradiotherapy and distance of the anastomosis from the anal verge ≤ 10 cm were each considered alone sufficient to justify creation of a PI, with statistically significant differences in comparison to the mean point of the scales in (p = < 0.0001 in both cases). Total Mesorectal Excision alone was not considered a factor sufficient to create a PI (p = 0.416). Most of the participants agree to define their approach to create a PI "tailored" to patients' risk factors (p = < 0.0001) and "influenced by my experience" in case of patients with low/moderate risk of anastomotic leakage (p = < 0.0001). This study provides useful insights on the worldwide clinical practice regarding creation of PI following anterior resection. Given the lack of standardization and evidence-based guidelines, this analysis may be helpful to assist surgeons' practice.

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

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Conflict of interest statement

Declarations. Conflict of interest: Dr. S.D.W. is a Consultant for ActivSurgical, Baxter, Becton, Dickinson and Co., Glaxo Smith Kline, Intuitive Surgical, Medtronic, OstomyCure, Stryker, Takeda, Virtual Ports, is a member of the Data Safety Monitoring Board of JSR/WCG/ACI (chair), Polypoid (chair), and Boomerang and receives royalties from Intuitive Surgical, Karl Storz Endoscopy America Inc., and Unique Surgical Solutions, LLC. Ethical approval: All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Consent to participate: Informed consent from all participants was obtained. Consent for publication: All authors approved the publication of the manuscript in the Journal. Informed consent: Informed consents from participants have been obtained. Research involving human participants and/or animals: All procedures performed in studies involving humans participants were in accordance with the ethical standards of the institutional and/or national research committee and with 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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