title: Large variation in the use of defunctioning stomas after rectal cancer surgery. A lack of consensus.
abstract: OBJECTIVE
  When deciding about the use of a defunctioning stoma in rectal cancer surgery, benefits and risks need to be weighed. This study investigated: (1a) factors associated with the use of defunctioning stomas; (1b) hospital variation; and (2) surgeons' perceptions regarding factors that determine this decision.
  
  
  METHODS
  Population-based data from the Dutch Surgical Colorectal Audit were used. Factors for receiving a defunctioning stoma were analyzed with multivariate logistic regression analysis. Hospital variation was assessed before and after case-mix adjustment. A survey was performed among gastroenterological surgeons on the importance of factors for the decision to construct a defunctioning stoma.
  
  
  RESULTS
  In total 4368 patients were analyzed and 103 (34%) surgeons participated. Male gender, higher body mass index, lower tumors, preoperative radiotherapy, and treatment in a teaching/university hospital increased the odds for a defunctioning stoma. Unadjusted hospital variation ranged from 0% to 98%. Variation remained after case-mix adjustment (0-100%). There was large variation in factors considered important for the decision; almost all factors were ranked as 'most important' at least once.
  
  
  CONCLUSIONS
  There is large variation in the use of defunctioning stomas for patients with rectal cancer, and a lack in uniformity of the selection criteria. These results underline the need to improve current decision making and identification of high-risk patients.
authors.affiliation: a Department of Surgery Leiden , University Medical Center , Leiden , The Netherlands .
authors.forename: Heleen S
authors.initials: HS
authors.lastname: Snijders
authors.affiliation: b Department of Medical Decision Making Leiden , University Medical Center , Leiden , The Netherlands .
authors.forename: Marleen
authors.initials: M
authors.lastname: Kunneman
authors.affiliation: a Department of Surgery Leiden , University Medical Center , Leiden , The Netherlands .
authors.forename: Rob A E M
authors.initials: RA
authors.lastname: Tollenaar
authors.affiliation: c Department of Surgery St Antonius Hospital , Nieuwegein , The Netherlands , and.
authors.forename: Djamila
authors.initials: D
authors.lastname: Boerma
authors.affiliation: b Department of Medical Decision Making Leiden , University Medical Center , Leiden , The Netherlands .
authors.forename: Arwen H
authors.initials: AH
authors.lastname: Pieterse
authors.affiliation: a Department of Surgery Leiden , University Medical Center , Leiden , The Netherlands .|d Department of Surgery , Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital , Amsterdam , The Netherlands.
authors.forename: Michel J W M
authors.initials: MJ
authors.lastname: Wouters
authors.affiliation: b Department of Medical Decision Making Leiden , University Medical Center , Leiden , The Netherlands .
authors.forename: Anne M
authors.initials: AM
authors.lastname: Stiggelbout
mesh_terms: D000328:Adult; D000368:Aged; D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006761:Hospitals / Q000706:statistics & numerical data; D006785:Hospitals, University; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery*; D012307:Risk Factors; D066231:Surgeons; D054047:Surgical Stomas / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires