Abstract
Aims
The decision to create an ileostomy following anterior resection is a clinical one based on the judgement of the surgical team. However, there are few data to support decision‐making. This study aimed to explore variation in, and factors associated with, ileostomy creation rates following surgery for rectal cancer in England.
Methods
This exploratory, retrospective analysis used observational data from England's Hospital Episode Statistics (HES) dataset. All patients aged ≥17 years undergoing an elective anterior resection with ileostomy creation from 1 April 2016 to 31 March 2024 were included. The primary outcome of interest was ileostomy creation at the time of index surgery.
Results
In total, 17,540 anterior resections for rectal cancer were included, and 5,954 patients (33.9%) had a diverting ileostomy. Rates of ileostomy creation declined over time, from 38.6% in 2016/17 to 29.7% in 2023/24, while the number of anterior resections remained relatively stable, other than during the COVID‐19 pandemic. There was substantial variation in ileostomy creation rates across hospital trusts from 5.8% to 62.5%. Greater odds of ileostomy creation were associated with younger age, male sex, mild/moderate frailty, living in a less deprived area, Asian ethnicity, higher surgeon and trust volume and earlier time periods.
Conclusions
Rates of ileostomy creation are falling, but there is huge variation in creation rates across providers and patient groups. Standardised guides on when to create an ileostomy may help reduce the extent of this variation.
Keywords: anterior resection, colorectal surgery, ileostomy, rectal cancer, stoma
What does this paper add to the literature?
Rates of ileostomy creation during anterior resection for rectal cancer declined from 38.6% to 29.7% from 2016/17 to 2023/24, with huge variation in creation rates across providers (5.8–62.5%) and patient groups. Standardised guidance on when to create an ileostomy may help reduce the extent of this variation.
INTRODUCTION
There are significant advances being made in the treatment of rectal cancer [1]. Total mesorectal excision (TME) is now the standard operation for rectal cancer in many countries. More recently, laparoscopic, trans‐anal and robot‐assisted procedures have started to replace some open TME procedures with positive outcomes [2, 3]. While surgery remains the main modality of treatment, pre‐operative radiotherapy, total neoadjuvant chemotherapy and watch‐and‐wait policies are gaining prominence leading to some patients not requiring surgery [1, 4].
Creation of a diverting ileostomy can mitigate the impact of an anastomotic leak following low anterior resection for rectal cancer [5]. However, an ileostomy can impact patients' quality of life and functional outcomes, and creation of an ileostomy comes with additional costs to the health service, attendant complication risks following ileostomy reversal and the risk of a permanent stoma [6, 7, 8, 9]. Some studies have reported a higher incidence of low anterior resection syndrome (LARS) in patients who had a temporary ileostomy or colostomy when compared with patients who had no stoma [6]. Deciding which patients would benefit from a diverting ileostomy is based on the judgement of the clinical team who must consider a complex interplay of factors, including tumour grade and location and demographic factors. However, there are few published data to guide decision‐making and the choice of whether to create an ileostomy is often subjective or driven by surgeon personality type [10, 11, 12]. The 2025 National Bowel Cancer Audit (NBOCA) ‘State of the Nation’ report states that ileostomy creation rates during or following anterior resection fell from 59.8% in 2019 to 54.9% in 2023 [13]. Likewise, a study using data from the Dutch Colorectal Registry reported a fall in the use of diverting ileostomy for rectal cancer over a 9‐year period accompanied by a rise in anastomotic leaks [14].
Our study aims to explore variation in ileostomy creation with anterior resection across National Health Service (NHS) hospital trusts in England, factors associated with ileostomy creation and trends in ileostomy creation rates over time.
METHODS
Study design
We conducted an exploratory analysis of routine administrative data from the Hospital Episode Statistics (HES) dataset for England. The HES dataset includes data for NHS hospital activity in England. Data for patients treated at non‐NHS (e.g. private or independent sector) hospitals who are funded by the NHS are included in the dataset. Patients paying for their own treatment are not included.
Ethics
The presentation of data follows current NHS England guidance for use of HES data for research purposes [15]. Patients were not directly involved in this study and so ethical approval and informed consent from individuals involved in this study were not required for analysis of this administrative dataset.
Data extraction
Setting
All NHS hospitals in England are run by hospital trusts. Each trust covers a catchment area defined by geography and of varying physical size and population. Some trusts only run one secondary or tertiary care facility; others run multiple hospitals.
Time period
The study covered the period from 1 April 2016 to 31 March 2024.
Inclusion and exclusion criteria for index procedure
The index procedure of interest was anterior resection with ileostomy creation during the same hospital admission. Anterior resections were identified using any of the Office of Populations Censuses and Surveys Classification of Interventions and Procedures version 4 (OPCS‐4) codes listed below if used in the first position in the procedural record: H332 (proctectomy and anastomosis of colon to anus), H333 (anterior resection of rectum and anastomosis of colon to rectum using staples) or H334 (anterior resection of rectum and anastomosis). Formation of an ileostomy was identified using any of the OPCS‐4 codes listed below used in any position in the procedural record: G742 (creation of temporary ileostomy), G743 (creation of defunctioning ileostomy), G748 (other specified creation of artificial opening into ileum) or G749 (unspecified creation of artificial opening into ileum). Patients were excluded where the patient was aged <17 years and where the procedure was non‐elective.
Outcomes
The primary outcome used in modelling was ileostomy creation. Data for several other outcomes of the index stay are reported but were not modelled.
Emergency hospital readmission within 30 days of discharge with an overnight stay. Early post‐surgery emergency admissions can reflect post‐procedural complications. Emergency readmissions without an overnight stay were not counted as these tend to be for more minor issues and recording practice varies across hospital trusts.
Length of hospital stay and stays longer than the median (6 days).
Anastomotic leak was identified using the International Statistical Classification of Diseases and Related Health Problems, tenth revision (ICD‐10) code K918 if present anywhere in the diagnostic record during index admission or emergency readmission within 30 days post‐discharge.
Other complications of surgery identified during index admission or emergency admission within 30 days post‐discharge were identified: post‐procedural haemorrhage (ICD‐10 code T810), post‐procedural infection (ICD‐10 code T814), abdominal or pelvic pain (ICD‐10 code R10), venous thromboembolism (ICD‐10 codes identifying venous thromboembolism are given in Table S1).
Death within 1 year of index discharge. Dates of death were as reported by the Office for National Statistics (ONS) and linked via patient identifier.
Covariates
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1
Years of age. Categorised as 17–49, 50–59, 60–69, 70–79, ≥80.
-
2
Biological sex (male/female).
-
3
Admission financial year.
-
4
Index of Multiple Deprivation (IMD) quintile for the Lower Super Output Area (LSOA) of the patient's home address [16]. The IMD score is compiled by the ONS and based on deprivation markers. The 2019 edition of the index was used.
-
5
Ethnicity. Defined as White, Black, Asian, Mixed and other according to NHS England definitions [17].
-
6
Hospital Frailty Risk Score (HFRS) [18]. The HFRS was categorised as none, mild, moderate and severe for analysis. The HFRS uses 109 weighted ICD‐10 codes recorded during admissions over the previous 2 years to establish a frailty score for each patient at the point of admission. It is calculated post hoc.
-
7
Trust volume. Calculated as the number of procedures in the dataset conducted by each trust in the financial year of the index procedure; categorised as 1–9, 10–19, 10–29, 30–39 and ≥40 procedures per year.
-
8
Surgeon volume. Calculated as the number of procedures in the dataset conducted by each surgeon in the financial year of the index procedure; categorised as 1–2, 3–4, 5–6, 7–8 and ≥9 procedures per year.
-
8
Open, laparoscopic or robot‐assisted index surgery. Robot‐assisted surgery was defined using the OPCS‐4 codes Y753 (robotic minimal access approach to abdominal cavity) or Y765 (robotic assisted minimal access approach to other body cavity) or Y452 (approach to organ under robotic control) if present anywhere in the procedural record. Laparoscopic surgery was defined using the OPCS‐4 codes Y751 (laparoscopically assisted approach to abdominal cavity) or Y752 (laparoscopic approach to abdominal cavity) if present anywhere in the procedural record. Procedures where none of these codes were present were recorded as open surgery.
-
9
Diagnosis during index admission of obesity was identified using the ICD‐10 code E66—(obesity). Body mass index is not captured in the HES dataset.
Data management and statistical analyses
Data were analysed using statistical and data management software: Microsoft Excel (Microsoft Corp, Redmond, WA, USA) and Stata (Stata Corp LLC, College Station, TX, USA). All data were categorised as described above and summarised as frequency and percentage in descriptive analysis. The variation in rates of ileostomy creation is presented for each NHS hospital trust in England as a funnel plot. The control limits for the funnel plot are based on the assumptions of a binomial distribution and are placed at three standard errors from the England average with 99.8% of values expected to fall within these limits if there were no over‐dispersion or unwarranted variation.
For the exploratory analysis of factors associated with ileostomy creation, multilevel, multivariable logistic regression was used to adjust for the covariates listed. The clustering variable was NHS hospital trust. All variables were modelled as categorical factors. Confidence intervals (CIs) were used to draw inference, with a 95% CI for an odds ratio (OR) not including the value 1 taken to indicate significance.
RESULTS
Of 17,540 anterior resections for rectal cancer performed during the 8‐year study period, 5,954 patients (33.9%) had a diverting ileostomy created. Table 1 summarises the demographic, co‐morbidity and outcome profile of patients. Ileostomy creation was more likely in males, those who had open or robot‐assisted operations and less likely in patients aged 80 years or more. Post‐procedural complications including anastomotic leak and emergency readmissions were higher in the ileostomy creation group. Low annual volume operating by hospital trusts and surgeons was common. In total, 1,308 (7.5%) patients were operated on at trusts with <10 procedures per annum volume and 4,031 (23.0%) patients were operated on by surgeons with an average <3 procedures per‐annum volume.
TABLE 1.
Profile of patient population categorised by ileostomy creation.
| Variable | No ileostomy created (n = 11,586) | Ileostomy created (n = 5,954) |
|---|---|---|
| Demographic factors | ||
| Age band | ||
| 17–49 years | 994 (8.6%) | 521 (8.8%) |
| 50–59 years | 2,111 (18.2%) | 1,241 (20.8%) |
| 60–69 years | 3,806 (32.8%) | 2,001 (33.6%) |
| 70–79 years | 3,511 (30.3%) | 1,808 (30.4%) |
| ≥80 years | 1,164 (10.0%) | 383 (6.4%) |
| Sex (13 missing values) | ||
| Female | 4,619 (39.9%) | 1,971 (33.1%) |
| Male | 6,962 (60.1%) | 3,975 (66.8%) |
| Hospital Frailty Risk Score band | ||
| None | 7,385 (63.7%) | 3,692 (62.0%) |
| Mild | 3,239 (28.0%) | 1,667 (28.0%) |
| Moderate | 920 (7.9%) | 574 (9.6%) |
| Severe | 42 (0.4%) | 21 (0.4%) |
| Obesity | 1687 (14.6%) | 847 (14.2%) |
| Deprivation (181 missing values) | ||
| 1 (most deprived) | 1674 (14.4%) | 770 (12.9%) |
| 2 | 1974 (17%) | 1100 (18.5%) |
| 3 | 2519 (21.7%) | 1254 (21.1%) |
| 4 | 2616 (22.6%) | 1360 (22.8%) |
| 5 (least deprived) | 2659 (23%) | 1433 (24.1%) |
| Ethnicity (2,602 missing values) | ||
| White | 9253 (79.9%) | 4709 (79.1%) |
| Asian | 288 (2.5%) | 197 (3.3%) |
| Black | 104 (0.9%) | 69 (1.2%) |
| Mixed | 44 (0.4%) | 27 (0.5%) |
| Other | 171 (1.5%) | 76 (1.3%) |
| Trust volume in the same financial year | ||
| 1–9 | 918 (7.9%) | 390 (6.6%) |
| 10–19 | 3858 (33.3%) | 1683 (28.3%) |
| 20–29 | 3735 (32.2%) | 1970 (33.1%) |
| 30–39 | 1676 (14.5%) | 953 (16.0%) |
| ≥40 | 1399 (12.1%) | 958 (16.1%) |
| Surgeon volume in the same financial year (151 missing values) | ||
| 1–2 | 2738 (23.8%) | 1293 (21.9%) |
| 3–4 | 3702 (32.2%) | 1798 (30.5%) |
| 5–6 | 2593 (22.6%) | 1228 (20.8%) |
| 7–8 | 1385 (12.1%) | 784 (13.3%) |
| ≥9 | 1070 (9.3%) | 798 (13.5%) |
| Type of index surgery | ||
| Open | 2,775 (24.0%) | 1,850 (31.1%) |
| Laparoscopic | 7,324 (63.2%) | 3,293 (55.3%) |
| Robot assisted | 1,487 (12.8%) | 811 (13.6%) |
| Outcomes of index stay | ||
| Post‐procedural complication during index stay | 597 (5.2%) | 491 (8.2%) |
| Anastomotic leak | 320 (2.8%) | 302 (5.1%) |
| Post‐discharge outcomes | ||
| Emergency hospital readmission within 30 days of discharge | 1,326 (11.4%) | 1,099 (18.5%) |
| Length of stay greater than the median (6 days) | 3779 (32.6%) | 3873 (65.0%) |
| Death within 1 year of discharge | 316 (2.7%) | 180 (3.0%) |
| Post‐procedural complication recorded on emergency readmission within 30 days of discharge | 433 (3.7%) | 278 (4.7%) |
| Anastomotic leak recorded on emergency readmission within 30 days of discharge | 178 (1.5%) | 117 (2.0%) |
Figure 1 shows the steady decline in ileostomy creation over the study period, from 38.6% to 29.7%, while the number of anterior resections remained stable before and following the COVID‐19 pandemic. Trends over time are summarised in Table 2. The proportion of patients with length of stay greater than 6 days reduced over the study period from 50.2% to 39.4%. However, there was no evidence that post‐operative outcomes worsened.
FIGURE 1.
Change in number of patients and the proportion of patients who had a diverting ileostomy with anterior resection for rectal cancer over the 8‐year study period.
TABLE 2.
Change in patient outcomes over time.
| Financial year | 2016/17 (n = 2265) | 2017/18 (n = 2188) | 2018/19 (n = 2197) | 2019/20 (n = 2262) | 2020/21 (n = 1730) | 2021/22 (n = 2379) | 2022/23 (n = 2232) | 2023/24 (n = 2287) |
|---|---|---|---|---|---|---|---|---|
| Ileostomy creation | 874 (38.6%) | 824 (37.7%) | 761 (34.6%) | 748 (33.0%) | 601 (34.7%) | 786 (33.0%) | 681 (30.5%) | 679 (29.7%) |
| Emergency hospital readmission within 30 days of discharge | 312 (13.8%) | 307 (14%) | 306 (13.9%) | 304 (13.4%) | 225 (13.0%) | 313 (13.2%) | 298 (13.4%) | 360 (15.7%) |
| Length of stay greater than the median (6 days) | 1136 (50.2%) | 1048 (47.9%) | 1018 (46.3%) | 1002 (44.3%) | 685 (39.6%) | 930 (39.1%) | 932 (41.8%) | 901 (39.4%) |
| Death within 1 year of discharge | 83 (3.7%) | 66 (3.0%) | 64 (2.9%) | 69 (3.1%) | 60 (3.5%) | 53 (2.2%) | 54 (2.4%) | ‐ |
| Post‐procedural complication recorded on emergency readmission within 30 days of discharge | 77 (3.4%) | 81 (3.7%) | 94 (4.3%) | 96 (4.2%) | 71 (4.1%) | 96 (4.0%) | 97 (4.3%) | 99 (4.3%) |
| Anastomotic leak recorded on emergency readmission within 30 days of discharge | 31 (1.4%) | 31 (1.4%) | 36 (1.6%) | 35 (1.5%) | 30 (1.7%) | 39 (1.6%) | 43 (1.9%) | 50 (2.2%) |
The results of the exploratory, multilevel, multivariable model investigating factors associated with ileostomy creation are summarised in Table 3. Greater odds of ileostomy creation were associated with younger age, male sex, mild or moderate frailty (relative to no frailty), living in a less deprived area, Asian ethnicity (relative to White ethnicity) and earlier time periods. Patients operated on by surgeons in the ≥9 procedures per annum surgeon volume category had 21% higher odds of ileostomy creation than surgeons in the 1–2 volume category. Patients operated on in trusts in the 30–39 and ≥40 procedures per annum surgeon volume categories had an approximately 25% higher odds of ileostomy creation than trusts in the 1–9 procedure volume category, although this was only statistically significant for the 30–39 category.
TABLE 3.
Summary of exploratory, multilevel, multivariable regression model with ileostomy creation as the outcome.
| Variable | Odds ratio (95% confidence interval), significance |
|---|---|
| Demographic factors | |
| Age band | |
| 17–49 years | 1 (reference) |
| 50–59 years | 1.05 (0.91 to 1.22), p = 0.496 |
| 60–69 years | 0.86 (0.75 to 1.00), p = 0.045 |
| 70–79 years | 0.76 (0.65 to 0.89), p = 0.001 |
| ≥80 years | 0.45 (0.37 to 0.55), p < 0.001 |
| Sex (13 missing values) | |
| Female | 1 (reference) |
| Male | 1.39 (1.29 to 1.50), p < 0.001 |
| Hospital Frailty Risk Score band | |
| None | 1 (reference) |
| Mild | 1.23 (1.12 to 1.36), p < 0.001 |
| Moderate | 1.51 (1.31 to 1.75), p < 0.001 |
| Severe | 1.20 (0.67 to 2.16), p = 0.531 |
| Obesity | 0.92 (0.83 to 1.02), p = 0.118 |
| Deprivation (181 missing values) | |
| 1 (most deprived) | 0.85 (0.74 to 0.96), p = 0.012 |
| 2 | 0.98 (0.87 to 1.10), p = 0.714 |
| 3 | 0.91 (0.81 to 1.02), p = 0.096 |
| 4 | 0.94 (0.84 to 1.05), p = 0.268 |
| 5 (least deprived) | 1 (reference) |
| Ethnicity (2,602 missing values) | |
| White | 1 (reference) |
| Asian | 1.29 (1.04 to 1.58), p = 0.018 |
| Black | 1.38 (0.98 to 1.94), p = 0.063 |
| Mixed | 1.31 (0.79 to 2.20), p = 0.297 |
| Other | 0.76 (0.56 to 1.04), p = 0.090 |
| Trust volume in the same financial year | |
| 1–9 | 1 (reference) |
| 10–19 | 1.02 (0.85 to 1.21), p = 0.838 |
| 20–29 | 1.21 (1.00 to 1.48), p = 0.051 |
| 30–39 | 1.25 (1.00 to 1.57), p = 0.046 |
| ≥40 | 1.26 (0.97 to 1.63), p = 0.082 |
| Surgeon volume in the same financial year (151 missing values) | |
| 1–2 | 1 (reference) |
| 3–4 | 1.02 (0.92 to 1.13), p = 0.676 |
| 5–6 | 0.99 (0.88 to 1.11), p = 0.852 |
| 7–8 | 1.09 (0.95 to 1.25), p = 0.211 |
| ≥9 | 1.21 (1.04 to 1.42), p = 0.013 |
| Type of index surgery | |
| Laparoscopic | 1 (reference) |
| Open | 1.46 (1.34 to 1.60), p < 0.001 |
| Robot assisted | 1.20 (1.05 to 1.37), p = 0.006 |
| Financial year | |
| 2016/17 | 1 (reference) |
| 2017/18 | 0.97 (0.85 to 1.12), p = 0.703 |
| 2018/19 | 0.85 (0.74 to 0.97), p = 0.018 |
| 2019/20 | 0.77 (0.67 to 0.89), p < 0.010 |
| 2020/21 | 0.89 (0.76 to 1.04), p = 0.149 |
| 2021/22 | 0.80 (0.69 to 0.92), p = 0.002 |
| 2022/23 | 0.75 (0.65 to 0.87), p < 0.001 |
| 2023/24 | 0.64 (0.55 to 0.74), p < 0.001 |
Patients who underwent open anterior resections had nearly one and a half times the odds of diversion as those who had laparoscopic procedures. The change in approach to anterior resections over the study period is summarised in Figure 2. Laparoscopic procedures were most frequently performed overall. Robot‐assisted operations saw a 10‐fold increase, overtaking open procedures to become the second most frequently used approach in 2023/24.
FIGURE 2.
Change in number of patients and type of surgery for rectal cancer over the 8‐year study period.
For the 123 hospital trusts operating on more than 10 patients during the study period, adjusted ileostomy creation rates for trusts in England are summarised as a funnel plot in Figure 3. There was substantial variation in ileostomy creation rates from 5.8% to 62.5%, with 22 (17.9%) trusts having creation rates above the control limit and 23 (18.7%) trusts having creation rates below the control limit.
FIGURE 3.
Funnel plot of adjusted rates of stoma creation with anterior resection across NHS hospital trusts in England.
DISCUSSION
Our study explores variations, trends and factors associated with creation of an ileostomy with an anterior resection for rectal cancer across the entire NHS in England. There was substantial variation in ileostomy creation rates across trusts, even after adjusting for demographic factors and frailty. Ileostomy creation rates declined over the study period.
Ileostomy creation was significantly associated with younger age, mild and moderate (but not severe) frailty, being male, Asian ethnicity and lower deprivation levels. The associations with age and frailty may be explained by the desire to avoid resection in older and very frail patients. An association with deprivation was only observed between the lowest and highest quintiles and may be related to an additional burden of comorbidity and frailty in the quintile of highest deprivation that was unmeasured in our study. Asian, Black and mixed ethnic groups all had a higher ileostomy creation rate than the White ethnic groups, although this was only significant for the Asian ethnicity group. As for deprivation, this may reflect higher unmeasured comorbidity in these patients. These associations and the association with male sex merit further study.
Accepting variation in patient numbers in the years during and following the COVID‐19 pandemic, the number of anterior resections performed was similar at the start and end of our study period. This is consistent with reports of stable rates of colorectal cancer in the United Kingdom over the period [19]. Our study is one of the largest globally to explore ileostomy creation rates following anterior resection and the largest UK‐based study we are aware of. Previous studies also suggest large variation in ileostomy creation rates, depending on the time period, setting and case definition. A registry study of 13,263 patients from the Netherlands by Ingwersen et al. identified a 40% fall in ileostomy creation rates from 69.8% in 2011 to 29.7% in 2020 [20]. This change was accompanied by a 5% increase in anastomotic leak rates. However, patients with a diverting ileostomy were also more likely to have minor complications, emergency readmissions within 90 days, admissions to intensive care and longer stay than patients without an ileostomy. Although none of these associations can be assumed to be causal, the authors note the complexity of the decision‐making process around this trade off in outcomes. A study from China using data for 382 patients from 2019 to 2021 reported a diverting ileostomy rate of 52.4% [21]. Xu et al. conducted a case control study to explore outcomes for anterior resection with and without an ileostomy [22]. The authors used data from the American College of Surgeons‐National Surgical Quality Improvement Program dataset from 2016 to 2022. The overall ileostomy creation rate was high, 69.3% across 4048 patients. There was no difference in anastomosis leak rates between those with and without an ileostomy.
The reason for the decline in ileostomy creation rates is likely to be complex and setting specific. However, improving surgical technique and confidence, and a greater recognition of the potential harms associated with a diverting ileostomy are likely to be important. Our study suggests that robotic surgery has not, so far, led to fewer ileostomies being created; this finding is supported by other authors. A Swedish database study comparing open, laparoscopic and robotic assisted rectal tumour operations from 2010 to 2020 in 3125 patients reported ileostomy creation rates of 38%, with little variability in creation rates across the surgical approaches [23]. A small, single‐site UK‐based study by Butnari et al. supports this finding [24] Greater use of neoadjuvant radiotherapy and chemotherapy in more recent years is also likely to impact ileostomy creation rates. A national survey of intensity‐modulated radiotherapy has identified significant uptake in use in the United Kingdom [25]. Depending on cancer stage, NBOCA also reports increases in use of local excision, chemotherapy and short‐ course radiotherapy from 2019 to 2023 [13]. However, they also report significant differences in rates of uptake of these modalities between units. As adoption increases, these and similar changes are likely to continue to impact ileostomy creation rates.
Waqas et al. report on interventions to avoid a diverting ileostomy by improving the integrity of the anastomosis during robotic TME through use of indocyanine green (ICG), reinforcement of the staple line with absorbable sutures, underwater air leak test and direct visualisation of the staple line with flexible sigmoidoscopy [26]. A recent systematic review found evidence that ICG fluorescence angiography significantly reduces anastomosis leak rates without increasing operating time or postoperative complications [27].
We present some evidence that hospital trusts and surgeons with higher case volumes were more likely to create an ileostomy, although the associations were generally weak and often non‐significant. The reasons for these associations are not clear. Greater case complexity (e.g. disease severity, tumour position and size, patient comorbidity), not fully adjusted for by the covariates included in our models, in the case load of higher volume units and surgeons is one possible explanation. However, as a counterpoint, anterior resection surgery is not centralised to any great extent in England, with few patients referred to tertiary centres for surgery. Thus, presentational factors may not be a key driver for trust‐level ileostomy creation rates, with most trusts having a similar complexity of case‐mix. Under these circumstances, the impact of more complex presentation on trust‐level creation rates would be expected to be weak, as observed. A Netherlands‐based registry study by Snijders et al. reported wide variation in use of defunctioning ileostomy (0–98%) across hospitals, but, in contrast to our findings, they reported lower rates of ileostomy creation in higher volume units [28]. Notably they were able to include many variables relating to clinical presentation not available to us. With regard to surgeon and trust volumes for rectal cancer anterior resection more generally, we found evidence of low volume surgery, particularly at a surgeon level. The UK National Institute for Health and Care Excellence (NICE) recommends five major rectal excisions per year as a surgeon level minimum case volume and 10 per year as institution level minimum case volume [29, 30]. These thresholds are supported by NHS England's Getting It Right First Time (GIRFT) programme. Given that anterior resection is only a proportion of that case load, we cannot draw any firm conclusions on how many surgeons and trusts are not meeting these thresholds, but we recommend ongoing monitoring.
There is evidence that the decision to create an ileostomy is often subjective or influenced by surgeon personality [10, 11, 12]. Our findings point to the fact that this need not be the case, and that it should be possible to develop validated screening tools for anastomotic leak that could be used to inform decision‐making. A 2023 systematic review of 31 anastomotic leak prediction scores by Venn et al. concluded that poor reporting practices, limited external validation and methodological flaws limited uptake of these tools [31]. Tools such as the anastomotic failure observed risk (AFOR) score are used to assess anastomotic leak risk but are not used routinely in clinical practice [32]. However, there are signs that more structured approaches are becoming more common. A French study published in 2024 externally validated the AFOR score as part of a tailored approach to anastomotic leak prediction and selective use of ileostomy, with encouraging results [33]. Likewise, highly selective use of diversion with proactive leak monitoring and management has been shown to be effective in managing the anastomosis and avoiding ileostomy in the Netherlands [34]. The ongoing GRECCAR‐17 trial may provide further insight as to whether a more tailored approach to ileostomy creation based on clinical presentation, rather than creating an ileostomy routinely, may be more productive and be better for patient quality of life [32].
Strengths and limitations
We accessed the most recent data available to us for all anterior resections for rectal cancer conducted in England over an 8‐year period, thus minimising the risk of collider effects [35]. This degree of coverage was a strength and allowed us to identify emergency readmissions and post‐operative complications even if they took place at a different hospital from the index procedure.
The study has a few limitations such as the lack of detailed data regarding some aspects of clinical presentation, intra‐operative events, decision‐making and reasoning around ileostomy creation and patient‐related quality of life outcomes. In particular, HES data does not capture the use, timing and dose of neoadjuvant radiotherapy or the tumour characteristics. Additionally, HES doesn't include data regarding the height or stage of the tumour; lower anterior resections are more complex and more likely to need an ileostomy. As noted previously, these factors may well help explain why higher volume centres and surgeons, conducting disproportionately more complex surgery, created ileostomies more often. With regard to the lack of data on tumour height, we recognise that our reported ileostomy creation rates are lower than those reported elsewhere [13]. This is likely due to our inclusion of anterior resections of all heights; reports focussing on lower anterior resection will have much higher reported rates of ileostomy formation.
As for most administrative datasets, there are likely to be some inconsistencies and errors in the coding of clinical data [36, 37, 38]. Despite national coding guidance and training, some variation in clinical coding practice will exist. Nevertheless, anterior resection, rectal cancer and ileostomy creation all have a relatively simple coding structure, which is likely to minimise the rate of such errors.
CONCLUSIONS
Rates of ileostomy creation are falling, but there is huge variation in creation rates across providers and patient groups. Standardised guides on when to create an ileostomy may help reduce the extent of this variation.
AUTHOR CONTRIBUTIONS
Katrein Savage: Writing – review and editing; supervision; resources; project administration. Tim W. R. Briggs: Conceptualization; project administration; funding acquisition; writing – review and editing; resources; supervision. William K. Gray: Conceptualization; methodology; data curation; supervision; formal analysis; validation; writing – original draft; funding acquisition; writing – review and editing. Mark Cheetham: Conceptualization; methodology; writing – review and editing; project administration; supervision; resources. Naomi Olagunju: Conceptualization; methodology; data curation; formal analysis; writing – review and editing; writing – original draft; investigation.
FUNDING INFORMATION
This research received no specific grant from any funding agency in the public, commercial, or not‐for‐profit sectors.
CONFLICT OF INTEREST STATEMENT
The authors declare that there is no conflict of interest.
ETHICAL APPROVAL
Ethics approval was not sought for the present study because it did not directly involve human participants. This study was completed in accordance with the Helsinki declaration as revised in 2013.
CONSENT
The authors have nothing to report.
Supporting information
Table S1. Descriptions of ICD‐10 codes for venous thromboembolism.
Data S1. STROBE Statement—checklist of items that should be included in reports of observational studies.
DATA AVAILABILITY STATEMENT
This study does not contain patient identifiable data. Data in this study are anonymised. The underlying HES data cannot be made available directly by the authors, as the data were obtained under licence/data sharing agreement from NHS England. HES data are available from NHS England upon application.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Table S1. Descriptions of ICD‐10 codes for venous thromboembolism.
Data S1. STROBE Statement—checklist of items that should be included in reports of observational studies.
Data Availability Statement
This study does not contain patient identifiable data. Data in this study are anonymised. The underlying HES data cannot be made available directly by the authors, as the data were obtained under licence/data sharing agreement from NHS England. HES data are available from NHS England upon application.