Stoma use in rectal cancer surgery remains highly surgeon-dependent: an international case-based interrater agreement study

Background The use of stomas related to rectal cancer resections varies considerably. This study aimed to assess interrater agreement among rectal cancer surgeons regarding the use of stomas in different clinical scenarios. Methods Twelve case-based scenarios of rectal cancer were developed and distributed digitally to colorectal surgeons in Europe, Asia, and the United States. For each case, respondents selected one of three management options: (1) anastomosis without diverting stoma, (2) anastomosis with diverting stoma, or (3) resection with permanent colostomy. Participants were additionally asked to report the degree of confidence associated with their response for each case. Interrater agreement was evaluated using Fleiss’ kappa. Results Of 106 invited surgeons, 53 completed the survey. Agreement on recommended management was fair (κ = 0.359). Higher agreement correlated strongly with higher confidence levels (r = 0.759, p = 0.004). Patient age > 70 years and tumor height > 12 cm from the anal verge were associated with greater consistency in decision-making. Conclusion Interrater agreement regarding stoma use in rectal cancer surgery was only fair across this international cohort. Despite a modest response rate, these findings highlight substantial variability in clinical decision-making and may inform future efforts to standardize practice