title: Optimal Treatment Strategy in Rectal Cancer Surgery: Should We Be Cowboys or Chickens?
abstract: OBJECTIVE
  Surgeons and hospitals are increasingly accountable for their postoperative complication rates, which may lead to risk adverse treatment strategies in rectal cancer surgery. It is not known whether a risk adverse strategy leads to providing better care. In this study, the association between the strategy of hospitals regarding defunctioning stoma construction and postoperative outcomes in rectal cancer treatment was evaluated.
  
  
  METHODS
  Population-based data of the Dutch Surgical Colorectal Audit, including 3,104 patients undergoing rectal cancer resection between January 2009 and July 2012 in 92 hospitals, were used. Hospital variation in (case-mix-adjusted) defunctioning stoma rates was calculated. Anastomotic leakage and 30-day mortality rates were compared in hospitals with a high and low tendency towards stoma construction.
  
  
  RESULTS
  Of all patients, 76 % received a defunctioning stoma; 9.6 % of all patients developed anastomotic leakage. Overall postoperative mortality rate was 1.8 %. The hospitals' adjusted proportion of defunctioning stomas varied from 0 to 100 %, and there was no significant correlation between the hospitals' adjusted stoma and anastomotic leakage rate. Severe anastomotic leakage was similar (7.0 vs. 7.1 %; p = 0.95) in hospitals with the lowest and highest stoma rates. Mild leakage and postoperative mortality rates were higher in hospitals with high stoma rates.
  
  
  CONCLUSIONS
  A high tendency towards stoma construction in rectal cancer surgery did not result in lower overall anastomotic leakage or mortality rates. It seems that the ability to select patients for stoma construction is the key towards preferable outcomes, not a risk adverse strategy.
authors.affiliation: Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands. h.s.snijders@lumc.nl.
authors.forename: Heleen S
authors.initials: HS
authors.lastname: Snijders
authors.affiliation: Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.
authors.forename: Nicoline J
authors.initials: NJ
authors.lastname: van Leersum
authors.affiliation: Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.
authors.forename: Daan
authors.initials: D
authors.lastname: Henneman
authors.affiliation: Department of Surgery, Medical Center Haaglanden, The Hague, The Netherlands.
authors.forename: Alexander C
authors.initials: AC
authors.lastname: de Vries
authors.affiliation: Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.
authors.forename: Rob A E M
authors.initials: RA
authors.lastname: Tollenaar
authors.affiliation: Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Anne M
authors.initials: AM
authors.lastname: Stiggelbout
authors.affiliation: Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
authors.forename: Michel W J M
authors.initials: MW
authors.lastname: Wouters
authors.affiliation: Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands.
authors.forename: Jan Willem T
authors.initials: JW
authors.lastname: Dekker
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D057868:Anastomotic Leak / Q000453:epidemiology* / Q000401:mortality; D005260:Female; D006739:Hospital Administration; D006761:Hospitals / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D016134:Organizational Policy; D010030:Ostomy / Q000706:statistics & numerical data*; D011787:Quality of Health Care; D012004:Rectal Neoplasms / Q000601:surgery*; D055815:Young Adult