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

Andrea Balla; Federica Saraceno; Marika Rullo; Protective Ileostomy Creation after Anterior Resection of the Rectum (PICARR) Collaborative Group; Salvador Morales-Conde; Eduardo M. Targarona Soler; Salomone Di Saverio; Mario Guerrieri; Pasquale Lepiane; Nicola Di Lorenzo; Michel Adamina; Isaias Alarcon; Alberto Arezzo; Jesus Bollo Rodriguez; Luigi Boni; Sebastiano Biondo; Francesco Maria Carrano; Manish Chand; John T. Jenkins; Justin Davies; Salvadora Delgado Rivilla; Paolo Delrio; Ugo Elmore; Eloy Espin-Basany; Alessandro Fichera; Blas Flor Lorente; Nader Francis; Marcos Gomez Ruiz; Dieter Hahnloser; Eugenio Licardie; Carmen Martinez; Monica Ortenzi; Yves Panis; Carlos Pastor Idoate; Alessandro M. Paganini; Miguel Pera; Roberto Perinotti; Daniel A. Popowich; Timothy Rockall; Riccardo Rosati; Alberto Sartori; Daniele Scoglio; Mostafa Shalaby; Vicente Simo Fernandez; Neil J. Smart; Antonino Spinelli; Patricia Sylla; Pieter J. Tanis; Javier Valdes Hernandez; Steven D. Wexner; Pierpaolo Sileri

doi:10.1007/s13304-025-02111-6

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

Andrea Balla^*, Federica Saraceno, Marika Rullo, Protective Ileostomy Creation after Anterior Resection of the Rectum (PICARR) Collaborative Group, Salvador Morales-Conde, Eduardo M. Targarona Soler, Salomone Di Saverio, Mario Guerrieri, Pasquale Lepiane, Nicola Di Lorenzo, Michel Adamina, Isaias Alarcon, Alberto Arezzo, Jesus Bollo Rodriguez, Luigi Boni, Sebastiano Biondo, Francesco Maria Carrano, Manish Chand, John T. Jenkins, Justin DaviesSalvadora Delgado Rivilla, Paolo Delrio, Ugo Elmore, Eloy Espin-Basany, Alessandro Fichera, Blas Flor Lorente, Nader Francis, Marcos Gomez Ruiz, Dieter Hahnloser, Eugenio Licardie, Carmen Martinez, Monica Ortenzi, Yves Panis, Carlos Pastor Idoate, Alessandro M. Paganini, Miguel Pera, Roberto Perinotti, Daniel A. Popowich, Timothy Rockall, Riccardo Rosati, Alberto Sartori, Daniele Scoglio, Mostafa Shalaby, Vicente Simo Fernandez, Neil J. Smart, Antonino Spinelli, Patricia Sylla, Pieter J. Tanis, Javier Valdes Hernandez, Steven D. Wexner, Pierpaolo Sileri

^*Corresponding author for this work

Surgery

Research output: Contribution to journal › Article › Academic › peer-review

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.

Original language	English
Article number	e0003
Number of pages	19
Journal	Updates in Surgery
Early online date	23 Mar 2025
DOIs	https://doi.org/10.1007/s13304-025-02111-6
Publication status	E-pub ahead of print - 23 Mar 2025

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Publisher Copyright:
© Italian Society of Surgery (SIC) 2025.

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Balla, A., Saraceno, F., Rullo, M., Protective Ileostomy Creation after Anterior Resection of the Rectum (PICARR) Collaborative Group, Morales-Conde, S., Targarona Soler, E. M., Di Saverio, S., Guerrieri, M., Lepiane, P., Di Lorenzo, N., Adamina, M., Alarcon, I., Arezzo, A., Bollo Rodriguez, J., Boni, L., Biondo, S., Carrano, F. M., Chand, M., Jenkins, J. T., ... Sileri, P. (2025). Protective ileostomy creation after anterior resection of the rectum (PICARR): a decision-making exploring international survey. Updates in Surgery, Article e0003. Advance online publication. https://doi.org/10.1007/s13304-025-02111-6

@article{d9be328001da4230bd8b4bd89e8996c5,

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

abstract = "In our previous survey of experts, surgeon{\textquoteright}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{\textquoteright} 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{\textquoteright} 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{\textquoteright} practice.",

author = "Andrea Balla and Federica Saraceno and Marika Rullo and {Protective Ileostomy Creation after Anterior Resection of the Rectum (PICARR) Collaborative Group} and Salvador Morales-Conde and {Targarona Soler}, {Eduardo M.} and {Di Saverio}, Salomone and Mario Guerrieri and Pasquale Lepiane and {Di Lorenzo}, Nicola and Michel Adamina and Isaias Alarcon and Alberto Arezzo and {Bollo Rodriguez}, Jesus and Luigi Boni and Sebastiano Biondo and Carrano, {Francesco Maria} and Manish Chand and Jenkins, {John T.} and Justin Davies and {Delgado Rivilla}, Salvadora and Paolo Delrio and Ugo Elmore and Eloy Espin-Basany and Alessandro Fichera and Lorente, {Blas Flor} and Nader Francis and {Gomez Ruiz}, Marcos and Dieter Hahnloser and Eugenio Licardie and Carmen Martinez and Monica Ortenzi and Yves Panis and {Pastor Idoate}, Carlos and Paganini, {Alessandro M.} and Miguel Pera and Roberto Perinotti and Popowich, {Daniel A.} and Timothy Rockall and Riccardo Rosati and Alberto Sartori and Daniele Scoglio and Mostafa Shalaby and {Simo Fernandez}, Vicente and Smart, {Neil J.} and Antonino Spinelli and Patricia Sylla and Tanis, {Pieter J.} and Hernandez, {Javier Valdes} and Wexner, {Steven D.} and Pierpaolo Sileri",

note = "Publisher Copyright: {\textcopyright} Italian Society of Surgery (SIC) 2025.",

year = "2025",

month = mar,

day = "23",

doi = "10.1007/s13304-025-02111-6",

language = "English",

journal = "Updates in Surgery",

issn = "2038-131X",

publisher = "Springer Science+Business Media",

}

Balla, A, Saraceno, F, Rullo, M, Protective Ileostomy Creation after Anterior Resection of the Rectum (PICARR) Collaborative Group, Morales-Conde, S, Targarona Soler, EM, Di Saverio, S, Guerrieri, M, Lepiane, P, Di Lorenzo, N, Adamina, M, Alarcon, 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, Gomez 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, Simo Fernandez, V, Smart, NJ, Spinelli, A, Sylla, P, Tanis, PJ, Hernandez, JV, Wexner, SD & Sileri, P 2025, 'Protective ileostomy creation after anterior resection of the rectum (PICARR): a decision-making exploring international survey', Updates in Surgery. https://doi.org/10.1007/s13304-025-02111-6

TY - JOUR

T1 - Protective ileostomy creation after anterior resection of the rectum (PICARR)

T2 - a decision-making exploring international survey

AU - Balla, Andrea

AU - Saraceno, Federica

AU - Rullo, Marika

AU - Protective Ileostomy Creation after Anterior Resection of the Rectum (PICARR) Collaborative Group

AU - Morales-Conde, Salvador

AU - Targarona Soler, Eduardo M.

AU - Di Saverio, Salomone

AU - Guerrieri, Mario

AU - Lepiane, Pasquale

AU - Di Lorenzo, Nicola

AU - Adamina, Michel

AU - Alarcon, Isaias

AU - Arezzo, Alberto

AU - Bollo Rodriguez, Jesus

AU - Boni, Luigi

AU - Biondo, Sebastiano

AU - Carrano, Francesco Maria

AU - Chand, Manish

AU - Jenkins, John T.

AU - Davies, Justin

AU - Delgado Rivilla, Salvadora

AU - Delrio, Paolo

AU - Elmore, Ugo

AU - Espin-Basany, Eloy

AU - Fichera, Alessandro

AU - Lorente, Blas Flor

AU - Francis, Nader

AU - Gomez Ruiz, Marcos

AU - Hahnloser, Dieter

AU - Licardie, Eugenio

AU - Martinez, Carmen

AU - Ortenzi, Monica

AU - Panis, Yves

AU - Pastor Idoate, Carlos

AU - Paganini, Alessandro M.

AU - Pera, Miguel

AU - Perinotti, Roberto

AU - Popowich, Daniel A.

AU - Rockall, Timothy

AU - Rosati, Riccardo

AU - Sartori, Alberto

AU - Scoglio, Daniele

AU - Shalaby, Mostafa

AU - Simo Fernandez, Vicente

AU - Smart, Neil J.

AU - Spinelli, Antonino

AU - Sylla, Patricia

AU - Tanis, Pieter J.

AU - Hernandez, Javier Valdes

AU - Wexner, Steven D.

AU - Sileri, Pierpaolo

PY - 2025/3/23

Y1 - 2025/3/23

N2 - 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.

AB - 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.

UR - http://www.scopus.com/inward/record.url?scp=105000853586&partnerID=8YFLogxK

U2 - 10.1007/s13304-025-02111-6

DO - 10.1007/s13304-025-02111-6

M3 - Article

C2 - 40121358

SN - 2038-131X

JO - Updates in Surgery

JF - Updates in Surgery

M1 - e0003

ER -

Balla A, Saraceno F, Rullo M, Protective Ileostomy Creation after Anterior Resection of the Rectum (PICARR) Collaborative Group, Morales-Conde S, Targarona Soler EM et al. Protective ileostomy creation after anterior resection of the rectum (PICARR): a decision-making exploring international survey. Updates in Surgery. 2025 Mar 23;e0003. Epub 2025 Mar 23. doi: 10.1007/s13304-025-02111-6

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

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