Stoma Formation in Rectal Cancer Surgery: Findings from an International Case-Based Survey

Stoma Formation in Rectal Cancer Surgery: Findings from an International Case-Based Survey | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Stoma Formation in Rectal Cancer Surgery: Findings from an International Case-Based Survey Lars A. B. Grønvold, Y. Nancy You, Stig Norderval, Håvard Mjørud Forsmo, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8787310/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 9 You are reading this latest preprint version Abstract 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 rectal cancer stoma anastomosis clinical decision making surgeon variability Figures Figure 1 Figure 2 Introduction Colorectal cancer is the third most common cancer worldwide with rectal cancer constituting about 25% of this volume[ 1 ]. The standardization of surgical and oncologic treatment over the last decades has resulted in greatly improved survival and decreased rates of local recurrence[ 2 , 3 ]. However significant variability remains in the utilization of stomas in the surgical management of rectal cancer. Controversy persists regarding the necessity of a temporary diverting stoma following the creation of an anastomosis. Proponents argue that such stomas decrease the risk of anastomotic leakage and reoperations, supported by multiple studies[ 4 – 7 ]. Conversely, opponents contend that diverting stomas merely postpone the detection of a leak, and entail a spectrum of stoma-specific complications, also supported by literature[ 8 – 11 ]. Consequently, clinicians face challenges in integrating evidence into practice with recent findings indicating that emotions and personal experiences influence surgical decision making in 22% and 49% of cases respectively[ 12 ]. While technically feasible, the formation of an anastomosis may not always be the best solution. Anastomotic leakage, a feared and relatively common complication with long term follow-up studies reporting rates around 20%[ 8 , 10 ], significantly contributes to post operative morbidity and has also been associated with cancer-specific mortality[ 13 ]. Additionally, concerns regarding long-term bowel function, evidenced by a high prevalence of major low anterior resection syndrome (LARS) among anastomosed patients[ 14 , 15 ], further complicate decision making. In addition, studies have not demonstrated superior health-related quality of life (HRQoL) outcomes in anastomosed patients compared to those with a permanent stoma[ 16 , 17 ], adding to the complexity of selecting the most appropriate surgical strategy for the individual patient. In the present study, rectal cancer surgeons were asked to determine the strategy for the use of stoma, based on available preoperative information, in 12 different clinical cases. To the best of our knowledge, this represents the first multi-center, multi-national case-based investigation into potential variability in stoma utilization in the surgical management of rectal cancer patients. Material and Method Cases Twelve cases of rectal cancer patients with different tumor locations and patient factors likely to impact the decision, like diabetes, obesity, neoadjuvant radiation, fecal incontinence and age, were constructed. The treatment options for each case included: 1) resection with anastomosis without the construction of a diverting stoma; 2) resection with anastomosis and formation of a diverting stoma; or 3) resection without anastomosis, resulting in a permanent colostomy. The risk factors increased, and tumor height decreased from cases one to twelve, making cases one and two likely candidates for direct anastomosis without diversion, while cases eleven and twelve were more likely to result in a permanent colostomy. The order of cases was randomized prior to distribution to obscure this pattern. Respondents were asked to provide a preoperative recommendation for each case based on the clinical information provided, specifying the strength of their recommendation as very strong, strong, or medium. The surgeons were asked for their opinion, before going into discussion with the patient. Distribution Before the study commenced, the research team conducted a pilot study involving ten selected surgeons. The primary objectives were to assess the logistics of email distribution and the survey instrument itself, as well as to ensure that the clinical cases were clear and realistically aligned with everyday practice. The ten responses obtained during the pilot phase were excluded and not incorporated into the main study. The questionnaire was distributed digitally using a well-established, globally recognized platform (SurveyMonkey, San Mateo, CA, USA). Invitations were sent out in two batches between September and October 2024. Each participant received a reminder 14 days after the original invitation. The time (in minutes and seconds) used to complete the form was recorded for each participant. This was done to allow for the exclusion of participants whose response time was so short that they realistically could not have read and adequately evaluated the cases. None of the participants were excluded on this basis. Participants All participants were colorectal surgeons involved in the treatment of rectal cancer and included after written informed consent. While the study adhered to privacy handling according to EU-GDPR regarding the participating surgeons, no patients were involved, thus no ethical approval was obtained. The data was analyzed and reported anonymously. The e-mail address of the participant was only used for the distribution of the survey and not included in the final dataset for analysis. The respondents were based in Northern Europe, Southern Europe, central Europe, US and Asia. All participating surgeons were either consultants or had consultant-level experience, hence we chose not to categorize participants based on their level of experience. The surgeons were asked to indicate the size of the center they represent in terms of the number of rectal cancer procedures performed per year; 100 cases. Analysis Fleiss’ kappa (κ) was used to determine interrater agreement between the participants. The interpretation of kappa values was based on the guidelines by Landis and Koch, where κ < 0 indicates poor agreement, 0.00–0.20 slight, 0.21–0.40 fair, 0.41–0.60 moderate, 0.61–0.80 substantial, and 0.81–1.00 almost perfect agreement. Cases were categorized based on the following variables to allow comparison of subgroups within patient factors: gender, age, BMI, height of tumor, neoadjuvant radiation, neoadjuvant chemotherapy, preoperative incontinence, diabetes, smoking, and ASA classification. Given the limited number of cases, when comparing patient factors in subgroup analysis, chance-corrected agreement statistics such as Fleiss’ kappa or Gwet’s AC1 were not calculated at the subgroup level. Instead, inter-rater agreement was summarized at the case level and compared descriptively across case-level patient characteristics by reporting mean and range of the proportion of raters selecting the modal response. This approach was chosen to facilitate clinically interpretable comparisons of agreement across cases with different patient characteristics. Cases were categorized based on the following variables to allow comparison of subgroups within surgeon factors: time to complete survey, number of annual procedures (center), region, and the strength of the recommendation. The kappa value for region EU South and ASIA/US should be interpreted with caution because the sample size of objects was small, which may affect the reliability of the estimates. Strength of recommendation was ordinally encoded from very strong, strong, medium to 3, 2 and 1 respectively. Spearman rank correlation coefficient (r) was used to determine correlation between the rater strength of recommendation and the level of agreement. A p-value of < 0.05 was considered significant. IBM SPSS Statistics v26 (IBM Corp., Armonk, NY, USA) was used to analyze the data. The manuscript was prepared according to SURGE guidelines. Results The survey was distributed to a total of 106 surgeons, of whom 53 (50%) completed the twelve cases. The average time spent completing the survey was 6 minutes and 59 seconds. A total of 6, 16, 7, 12 and 12 surgeons represented centers performing 100 rectal cancer operations annually, respectively. The surgeons represented various regions; EU central, EU north, EU south and ASIA/USA in 15, 30, 4 and 4 cases respectively. All case answers (a) and answers regarding the strength of recommendation (b) are presented in table 1 and depicted as a heat map in figure 1. The overall interrater agreement regarding the twelve cases was fair with κ= 0.359. There was a high level of agreement regarding cases one and six which were both high rectal cancers without a high burden of risk factors (modal response 87.8%, range 83.0-92.5). Excluding these two cases designed for maximum level of agreement, the overall agreement for the remaining cases fell (κ= 0.264), reflecting a high level of variability among surgeons in the suggested treatment options. Interestingly, in case four and eight, both with very low tumors only 3 cm above the anal verge, around 30% of surgeons suggested an anastomosis. Table 2 presents an overview sorted with respect to proportion of agreement (%) on the recommended procedure. A high level of agreement on the recommended procedure correlated strongly with the strength of recommendation. (r=0.759, p = 0.004), figure 2. With respect to patient factors, age > 70 years and height of tumor > 12 cm from the anal verge were associated with higher levels of agreement. Regarding other factors there were smaller differences in modal response, table 3. Interestingly, surgeons completing the survey in less than 6 minutes or more than 12 minutes seemed to agree more than surgeons completing in 6-12 minutes. There was no clear pattern as to whether the size of the center (low vs. high volume) affected the level of agreement between the surgeons. Surgeons from EU central or EU north appeared to agree more than surgeons from EU south, but the latter was only represented by four surgeons (table 4). Discussion This survey reveals substantial variance in the recommended treatment strategies for rectal cancer among surgeons, particularly for mid- and low rectal cancers. The treatment options presented in this survey—direct anastomosis without diversion, anastomosis with a diverting stoma, and permanent colostomy—can be classified as follows: the first option represents a “high risk – high reward” scenario, the second entails intermediate risk while accepting the inconveniences and complications associated with a diverting stoma, and the third is the safest option, albeit at the cost of a permanent stoma. For mid-rectal cancers, all three options are technically feasible, and arguments can be made for each approach. Literature on this topic is inconsistent. Although risk factors for anastomotic leakage—such as the level of anastomosis, neoadjuvant radiotherapy, and male gender—are well established [ 8 , 18 ], there remains no consensus on the criteria for diverting stomas [ 9 , 19 ]. Several studies advocate routine diversion [ 4 , 5 , 7 ], demonstrating reduced leak rates and reoperation rates, while others emphasize the extensive complications associated with diverting stomas and recommend a more selective approach [ 9 , 11 , 20 ]. Given the high rates of anastomotic leak [ 4 , 8 ] and LARS [ 14 , 15 , 21 ] associated with low anastomosis, a permanent stoma may be a viable option for many patients, as studies have not shown inferior HRQoL in this group [ 16 , 17 ]. It is emphasized in this study that we are looking for the recommendation given by the surgeon before going into the discussion with the patient. In many cases the choice on whether to put a stoma or not may have become clearer after taking the patient’s preferences into account. Nonetheless, many patients tend to place their trust in the surgeon's expertise to guide this decision. Of course, this study also does not account for intraoperative events or evaluation that may change the plan to divert or not. However, as this is similar for all participants, this will not affect the end point of the study, the interrater agreement. The study has the following limitations: Most notably, the participation rate was unexpectedly low (50%). All participants were personally notified and invited to participate prior to inclusion. The questionnaire was distributed, followed by a reminder sent 14 days later. We chose not to send additional reminders or personal follow-ups for two main reasons. First, we aimed to ensure that participants felt a certain level of engagement in the study, responding truthfully and to the best of their ability, as if they were in a clinical setting. We cannot exclude the possibility that participants who respond after multiple reminders may feel obligated to do so rather than being genuinely willing to participate, which was not desirable. Second, participants had provided informed consent to take part in the study, and additional reminders could have compromised the integrity of that consent. With that in mind, a higher participation rate would not have altered the responses received from the 53 participants or the observed low inter-rater agreement them in-between. We also cannot rule out that the low participation is reflected in the disagreement demonstrated in this study, and that surgeons may therefore hesitate to respond and make decisions in areas where they know, or may assume, that a large proportion of others would disagree with their choices. To conclude, the interrater agreement between 53 rectal cancer surgeons from multiple centers was fair. In clinical decision-making, this is considered insufficient and indicates variability in interpretation or application of criteria. How this impacts patient outcomes is neither the aim nor the purpose of this paper; however, it serves as important background information for all professionals involved in rectal cancer surgery and who face these clinical decisions in everyday practice. Declarations Conflicts of interest: None Funding: Vestfold Hospital Trust Author Contribution L.A.B.G. and K.W.B. wrote the manuscript. K.W.B prepared all tables and figures and together with C.B and C-Y. H. did the statistics.Y.N.Y., L.T.S, F.P, S.N., O.S. and H.M.F all contributed to the design and original idea of the study.All authors reviewed the manuscript and made contributions to the submitted version. Data Availability The datasets generated during the current study were collected using SurveyMonkey. Due to privacy and confidentiality considerations, the raw survey data are not publicly available but are available from the corresponding author upon reasonable request. References Bray, F., et al., Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries . CA Cancer J Clin, 2018. 68(6): p. 394–424. Guren, M.G., et al., Nationwide improvement of rectal cancer treatment outcomes in Norway, 1993–2010 . Acta Oncol, 2015. 54(10): p. 1714–22. Kapiteijn, E., et al., Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer . N Engl J Med, 2001. 345(9): p. 638–46. Matthiessen, P., et al., Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial . Ann Surg, 2007. 246(2): p. 207–14. Hüser, N., et al., Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery . Ann Surg, 2008. 248(1): p. 52–60. Tan, W.S., et al., Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer . Br J Surg, 2009. 96(5): p. 462–72. Gu, W.L. and S.W. Wu, Meta-analysis of defunctioning stoma in low anterior resection with total mesorectal excision for rectal cancer: evidence based on thirteen studies . World J Surg Oncol, 2015. 13: p. 9. Borstlap, W.A.A., et al., Anastomotic Leakage and Chronic Presacral Sinus Formation After Low Anterior Resection: Results From a Large Cross-sectional Study . Ann Surg, 2017. 266(5): p. 870–877. Snijders, H.S., et al., Optimal Treatment Strategy in Rectal Cancer Surgery: Should We Be Cowboys or Chickens? Ann Surg Oncol, 2015. 22(11): p. 3582–9. Anderin, K., et al., The effect of diverting stoma on long-term morbidity and risk for permanent stoma after low anterior resection for rectal cancer . Eur J Surg Oncol, 2016. 42(6): p. 788–93. Blok, R.D., et al., Impact of an institutional change from routine to highly selective diversion of a low anastomosis after TME for rectal cancer . Eur J Surg Oncol, 2018. 44(8): p. 1220–1225. Balla, A., et al., Protective ileostomy creation after anterior resection of the rectum: Shared decision-making or still subjective? Colorectal Dis, 2023. 25(4): p. 647–659. Ha, G.W., J.H. Kim, and M.R. Lee, Oncologic Impact of Anastomotic Leakage Following Colorectal Cancer Surgery: A Systematic Review and Meta-Analysis . Ann Surg Oncol, 2017. 24(11): p. 3289–3299. Sandberg, S., et al., Low anterior resection syndrome in a Scandinavian population of patients with rectal cancer: a longitudinal follow-up within the QoLiRECT study . Colorectal Dis, 2020. 22(10): p. 1367–1378. Christensen, P., et al., Management guidelines for low anterior resection syndrome - the MANUEL project . Colorectal Dis, 2021. 23(2): p. 461–475. Pachler, J. and P. Wille-Jørgensen, Quality of life after rectal resection for cancer, with or without permanent colostomy . Cochrane Database Syst Rev, 2012. 12: p. CD004323. Campos-Lobato, L.F., et al., Abdominoperineal resection does not decrease quality of life in patients with low rectal cancer . Clinics (Sao Paulo), 2011. 66(6): p. 1035–40. Han, Z., et al., Development of a Risk Scoring System for Predicting Anastomotic Leakage Following Laparoscopic Rectal Cancer Surgery . Ther Clin Risk Manag, 2021. 17: p. 145–153. Snijders, H.S., et al., Large variation in the use of defunctioning stomas after rectal cancer surgery. A lack of consensus . Acta Oncol, 2016. 55(4): p. 509–15. Talboom, K., et al., Highly selective diversion with proactive leakage management after low anterior resection for rectal cancer . Br J Surg, 2021. 108(6): p. 609–612. Emmertsen, K.J. and S. Laurberg, Low anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer . Ann Surg, 2012. 255(5): p. 922–8. Tables Table 1 Treatment options and strength of recommendation for each case. Rates of suggested treatment options for each case given in absolute numbers and percentages as distributed among the 53 participants. Anastomosis = anastomosis without diverting stoma; Permanent = permanent colostomy; Diverting = anastomosis with diverting stoma Case recommendation Strength of confidence Anastomosis Permanent Diverting Medium Strong Very strong Case n % n % n % n % n % n % 1 49 92 % 1 2 % 3 6 % 1 2 % 21 40 % 31 58 % 2 6 11 % 21 40 % 26 49 % 22 42 % 22 42 % 9 17 % 3 3 6 % 43 81 % 7 13 % 7 13 % 26 49 % 20 38 % 4 0 0 % 35 66 % 18 34 % 11 21 % 21 40 % 21 40 % 5 4 8 % 12 23 % 37 70 % 18 34 % 20 38 % 15 28 % 6 44 83 % 0 0 % 9 17 % 6 11 % 27 51 % 20 38 % 7 32 60 % 0 0 % 21 40 % 10 19 % 24 45 % 19 36 % 8 1 2 % 37 70 % 15 28 % 10 19 % 18 34 % 25 47 % 9 14 26 % 3 6 % 36 68 % 16 30 % 29 55 % 8 15 % 10 21 40 % 0 0 % 32 60 % 10 19 % 32 60 % 11 21 % 11 20 38 % 4 8 % 29 55 % 19 37 % 27 52 % 6 12 % 12 1 2 % 41 77 % 11 21 % 11 21 % 27 51 % 15 28 % Table 2 Cases arranged according to proportion of agreement (modal response in n and in percentages) from top to bottom. Strength of confidence was ordinally encoded from very strong, strong, medium to 3, 2 and 1, respectively. Rec = recommendation; Ana = anastomosis; Div = diverting stoma; Per = permanent stoma; Strength = mean strength of confidence (by case); Height = distance from the anal verge to the lower edge (or lower margin) of the tumor – rigid scope in cm; NRT = neoadjuvant radio therapy; NACT = neoadjuvant chemotherapy; Incont = preoperative incontinence; Dia = diabetes; Smo = smoking; ASA = American Society of Anesthesiologist Physical Status Classification System. Case Rec n (%) Strength Sex Age BMI Height NRT NACT Incont Dia Smo ASA 1 Ana 49 (92) 2.57 F 75 26 14 no no no No no 2 6 Ana 44 (83) 2.26 M 67 23 15 no no no no yes 2 3 Per 43 (81) 2.25 M 86 23 5 no no yes no no 3 12 Per 41 (77) 2.08 F 83 32 8 yes yes some yes no 3 8 Per 37 (70) 2.28 M 55 37 3 yes no no no yes 2 5 Div 37 (70) 1.94 F 73 36 7 yes yes no yes yes 3 9 Div 36 (68) 1.85 M 76 22 9 no no no no no 3 4 Per 35 (66) 2.19 F 69 24 3 yes no some no no 3 10 Div 32 (60) 2.02 M 68 28 8 no no no no no 2 7 Ana 32 (60) 2.17 F 55 23 8 no no no no no 2 11 Div 29 (55) 1.75 M 55 27 9 no no some no no 2 2 Div 26 (49) 1.75 F 62 30 10 yes no some yes no 2 Table 3 Patient factors and correlated levels of interrater agreement (mean modal response and range). Strength = mean strength of confidence (by subgroup). Height = distance from the anal verge to the lower edge (or lower margin) of the tumor – rigid scope in cm; NRT = neoadjuvant radio therapy; NACT = neoadjuvant chemotherapy. Patient factors Range (%) n (cases) Modal response (%) Lower Upper Strength Sex Female 6 69.2 49.1 92.5 2.12 Male 6 69.5 54.7 83.0 2.06 Age ≤70 years 7 63.3 49.1 83.0 2.14 >70 years 5 77.7 67.9 92.5 2.06 BMI 12 2 87.8 83.0 92.5 2.42 NRT Yes 5 66.4 49.1 77.4 2.05 No 7 71.4 54.7 92.5 2.19 NACT Yes 2 73.6 69.8 77.4 2.01 No 10 68.5 49.1 92.5 2.11 Preoperative incontinence Some/yes 5 65.7 49.1 81.1 2.00 No 7 72.0 60.4 92.5 2.16 Diabetes Yes 3 65.4 49.1 77.4 1.92 No 9 70.6 54.7 92.5 2.14 Smoking Yes 3 74.2 69.8 83.0 2.16 No 9 67.7 49.1 92.5 2.06 ASA Class 2 7 72.5 66.0 81.1 2.11 Class 3 5 67.1 49.1 92.5 2.06 Table 4 Surgeon factors and correlated levels of interrater agreement (Kappa). *Kappa should be interpreted with caution because the sample size of objects was small, which may affect the reliability of the estimates. Mean strength of confidence (by surgeon). Surgeon factors 95% CI n (surgeons) Kappa Lower Upper Time to complete survey 12 min 12 .460 .458 .462 No. of annual procedures (center) 100 12 .283 .281 .285 Region EU Central 15 .303 .301 .304 EU North 30 .383 .383 .384 EU South 4* .138 .133 .143 ASIA / USA 4* .288 .283 .293 Strength of confidence ≤ 2.00 25 .414 .414 .415 > 2.00 28 .311 .310 .312 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 08 May, 2026 Reviews received at journal 01 Apr, 2026 Reviews received at journal 31 Mar, 2026 Reviewers agreed at journal 17 Mar, 2026 Reviewers agreed at journal 16 Mar, 2026 Reviewers invited by journal 13 Mar, 2026 Editor assigned by journal 24 Feb, 2026 Submission checks completed at journal 06 Feb, 2026 First submitted to journal 04 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8787310","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":605645624,"identity":"64d8575e-549b-4ef9-a453-270237547de2","order_by":0,"name":"Lars A. B. Grønvold","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAn0lEQVRIiWNgGAWjYBACPhCRUMHAQ7wWNhDx4AypWhgftpHiMDb249c+JM6rkzE4wHvwAXFaeHKKZyRuO8xjcIAv2YBIh+UkMyRuO8Aj2cBjJkGcFv43QC1z6kjRIpF+mCGxgZmHn4F4LW+YGRKOHebhZ+YxJs4v/Pzpjxl/1NTZs7H3GD4gSgsDAw/UbGYi1QMBO7Fmj4JRMApGwYgFAAtjJAc77+49AAAAAElFTkSuQmCC","orcid":"","institution":"Vestfold Hospital Trust","correspondingAuthor":true,"prefix":"","firstName":"Lars","middleName":"A. B.","lastName":"Grønvold","suffix":""},{"id":605645625,"identity":"3bfdb27f-e0ac-4e10-bdaa-a1acd01fcaf4","order_by":1,"name":"Y. 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Interrater agreement was determined using Fleiss kappa. The overall agreement was fair with κ = 0.359. When excluding cases 1 and 6 the agreement dropped, κ = 0.264.\u003c/p\u003e","description":"","filename":"fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-8787310/v1/2ee2f88cb1c16c30e8dc9029.png"},{"id":104875001,"identity":"9d869879-1e1e-44a7-9b35-350123a979a5","added_by":"auto","created_at":"2026-03-18 08:35:28","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":17945,"visible":true,"origin":"","legend":"\u003cp\u003eScatterplot depicting correlation between agreement on the recommended procedure and the strength of the recommendation, Spearman rank correlation.\u003c/p\u003e","description":"","filename":"fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-8787310/v1/642a734af495f1f38e82db67.png"},{"id":105034262,"identity":"21cfb126-2eaa-43ba-a996-73c7f7ff89c3","added_by":"auto","created_at":"2026-03-20 07:22:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":893422,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8787310/v1/2241c01a-36ef-4527-acc4-b269389c5133.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Stoma Formation in Rectal Cancer Surgery: Findings from an International Case-Based Survey","fulltext":[{"header":"Introduction","content":"\u003cp\u003eColorectal cancer is the third most common cancer worldwide with rectal cancer constituting about 25% of this volume[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The standardization of surgical and oncologic treatment over the last decades has resulted in greatly improved survival and decreased rates of local recurrence[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However significant variability remains in the utilization of stomas in the surgical management of rectal cancer.\u003c/p\u003e \u003cp\u003eControversy persists regarding the necessity of a temporary diverting stoma following the creation of an anastomosis. Proponents argue that such stomas decrease the risk of anastomotic leakage and reoperations, supported by multiple studies[\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Conversely, opponents contend that diverting stomas merely postpone the detection of a leak, and entail a spectrum of stoma-specific complications, also supported by literature[\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Consequently, clinicians face challenges in integrating evidence into practice with recent findings indicating that emotions and personal experiences influence surgical decision making in 22% and 49% of cases respectively[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile technically feasible, the formation of an anastomosis may not always be the best solution. Anastomotic leakage, a feared and relatively common complication with long term follow-up studies reporting rates around 20%[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], significantly contributes to post operative morbidity and has also been associated with cancer-specific mortality[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Additionally, concerns regarding long-term bowel function, evidenced by a high prevalence of major low anterior resection syndrome (LARS) among anastomosed patients[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], further complicate decision making. In addition, studies have not demonstrated superior health-related quality of life (HRQoL) outcomes in anastomosed patients compared to those with a permanent stoma[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], adding to the complexity of selecting the most appropriate surgical strategy for the individual patient.\u003c/p\u003e \u003cp\u003eIn the present study, rectal cancer surgeons were asked to determine the strategy for the use of stoma, based on available preoperative information, in 12 different clinical cases. To the best of our knowledge, this represents the first multi-center, multi-national case-based investigation into potential variability in stoma utilization in the surgical management of rectal cancer patients.\u003c/p\u003e"},{"header":"Material and Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eCases\u003c/h2\u003e \u003cp\u003eTwelve cases of rectal cancer patients with different tumor locations and patient factors likely to impact the decision, like diabetes, obesity, neoadjuvant radiation, fecal incontinence and age, were constructed. The treatment options for each case included: 1) resection with anastomosis without the construction of a diverting stoma; 2) resection with anastomosis and formation of a diverting stoma; or 3) resection without anastomosis, resulting in a permanent colostomy. The risk factors increased, and tumor height decreased from cases one to twelve, making cases one and two likely candidates for direct anastomosis without diversion, while cases eleven and twelve were more likely to result in a permanent colostomy. The order of cases was randomized prior to distribution to obscure this pattern. Respondents were asked to provide a preoperative recommendation for each case based on the clinical information provided, specifying the strength of their recommendation as very strong, strong, or medium. The surgeons were asked for their opinion, before going into discussion with the patient.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDistribution\u003c/h3\u003e\n\u003cp\u003eBefore the study commenced, the research team conducted a pilot study involving ten selected surgeons. The primary objectives were to assess the logistics of email distribution and the survey instrument itself, as well as to ensure that the clinical cases were clear and realistically aligned with everyday practice. The ten responses obtained during the pilot phase were excluded and not incorporated into the main study.\u003c/p\u003e \u003cp\u003eThe questionnaire was distributed digitally using a well-established, globally recognized platform (SurveyMonkey, San Mateo, CA, USA). Invitations were sent out in two batches between September and October 2024. Each participant received a reminder 14 days after the original invitation.\u003c/p\u003e \u003cp\u003eThe time (in minutes and seconds) used to complete the form was recorded for each participant. This was done to allow for the exclusion of participants whose response time was so short that they realistically could not have read and adequately evaluated the cases. None of the participants were excluded on this basis.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eAll participants were colorectal surgeons involved in the treatment of rectal cancer and included after written informed consent. While the study adhered to privacy handling according to EU-GDPR regarding the participating surgeons, no patients were involved, thus no ethical approval was obtained. The data was analyzed and reported anonymously. The e-mail address of the participant was only used for the distribution of the survey and not included in the final dataset for analysis. The respondents were based in Northern Europe, Southern Europe, central Europe, US and Asia. All participating surgeons were either consultants or had consultant-level experience, hence we chose not to categorize participants based on their level of experience. The surgeons were asked to indicate the size of the center they represent in terms of the number of rectal cancer procedures performed per year; \u0026lt;25 cases, 25\u0026ndash;50 cases, 51\u0026ndash;75 cases, 76\u0026ndash;100 cases, and \u0026gt;\u0026thinsp;100 cases.\u003c/p\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cp\u003eFleiss\u0026rsquo; kappa (κ) was used to determine interrater agreement between the participants. The interpretation of kappa values was based on the guidelines by Landis and Koch, where κ\u0026thinsp;\u0026lt;\u0026thinsp;0 indicates poor agreement, 0.00\u0026ndash;0.20 slight, 0.21\u0026ndash;0.40 fair, 0.41\u0026ndash;0.60 moderate, 0.61\u0026ndash;0.80 substantial, and 0.81\u0026ndash;1.00 almost perfect agreement.\u003c/p\u003e \u003cp\u003eCases were categorized based on the following variables to allow comparison of subgroups within patient factors: gender, age, BMI, height of tumor, neoadjuvant radiation, neoadjuvant chemotherapy, preoperative incontinence, diabetes, smoking, and ASA classification. Given the limited number of cases, when comparing patient factors in subgroup analysis, chance-corrected agreement statistics such as Fleiss\u0026rsquo; kappa or Gwet\u0026rsquo;s AC1 were not calculated at the subgroup level. Instead, inter-rater agreement was summarized at the case level and compared descriptively across case-level patient characteristics by reporting mean and range of the proportion of raters selecting the modal response. This approach was chosen to facilitate clinically interpretable comparisons of agreement across cases with different patient characteristics.\u003c/p\u003e \u003cp\u003eCases were categorized based on the following variables to allow comparison of subgroups within surgeon factors: time to complete survey, number of annual procedures (center), region, and the strength of the recommendation. The kappa value for region EU South and ASIA/US should be interpreted with caution because the sample size of objects was small, which may affect the reliability of the estimates.\u003c/p\u003e \u003cp\u003eStrength of recommendation was ordinally encoded from very strong, strong, medium to 3, 2 and 1 respectively. Spearman rank correlation coefficient (r) was used to determine correlation between the rater strength of recommendation and the level of agreement. A p-value of \u0026lt;\u0026thinsp;0.05 was considered significant. IBM SPSS Statistics v26 (IBM Corp., Armonk, NY, USA) was used to analyze the data. The manuscript was prepared according to SURGE guidelines.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe survey was distributed to a total of 106 surgeons, of whom 53 (50%) completed the twelve cases. The average time spent completing the survey was 6 minutes and 59 seconds. A total of 6, 16, 7, 12 and 12 surgeons represented centers performing \u0026lt;25, 25-50, 51-75, 76-100 and \u0026gt;100 rectal cancer operations annually, respectively. The surgeons represented various regions; EU central, EU north, EU south and ASIA/USA in 15, 30, 4 and 4 cases respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll case answers (a) and answers regarding the strength of recommendation (b) are presented in table 1 and depicted as a heat map in figure 1. The overall interrater agreement regarding the twelve cases was fair with \u0026kappa;= 0.359. There was a high level of agreement regarding cases one and six which were both high rectal cancers without a high burden of risk factors (modal response 87.8%, range 83.0-92.5). Excluding these two cases designed for maximum level of agreement, the overall agreement for the remaining cases fell (\u0026kappa;= 0.264), reflecting a high level of variability among surgeons in the suggested treatment options. Interestingly, in case four and eight, both with very low tumors only 3 cm above the anal verge, around 30% of surgeons suggested an anastomosis.\u003c/p\u003e\n\u003cp\u003eTable 2 presents an overview sorted with respect to proportion of agreement (%) on the recommended procedure. A high level of agreement on the recommended procedure correlated strongly with the strength of recommendation. (r=0.759, p = 0.004), figure 2.\u003c/p\u003e\n\u003cp\u003eWith respect to patient factors, age \u0026gt; 70 years and height of tumor \u0026gt; 12 cm from the anal verge were associated with higher levels of agreement. Regarding other factors there were smaller differences in modal response, table 3.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInterestingly, surgeons completing the survey in less than 6 minutes or more than 12 minutes seemed to agree more than surgeons completing in 6-12 minutes. There was no clear pattern as to whether the size of the center (low vs. high volume) affected the level of agreement between the surgeons. Surgeons from EU central or EU north appeared to agree more than surgeons from EU south, but the latter was only represented by four surgeons (table 4).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis survey reveals substantial variance in the recommended treatment strategies for rectal cancer among surgeons, particularly for mid- and low rectal cancers. The treatment options presented in this survey\u0026mdash;direct anastomosis without diversion, anastomosis with a diverting stoma, and permanent colostomy\u0026mdash;can be classified as follows: the first option represents a \u0026ldquo;high risk \u0026ndash; high reward\u0026rdquo; scenario, the second entails intermediate risk while accepting the inconveniences and complications associated with a diverting stoma, and the third is the safest option, albeit at the cost of a permanent stoma. For mid-rectal cancers, all three options are technically feasible, and arguments can be made for each approach.\u003c/p\u003e \u003cp\u003eLiterature on this topic is inconsistent. Although risk factors for anastomotic leakage\u0026mdash;such as the level of anastomosis, neoadjuvant radiotherapy, and male gender\u0026mdash;are well established [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], there remains no consensus on the criteria for diverting stomas [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Several studies advocate routine diversion [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], demonstrating reduced leak rates and reoperation rates, while others emphasize the extensive complications associated with diverting stomas and recommend a more selective approach [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Given the high rates of anastomotic leak [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and LARS [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] associated with low anastomosis, a permanent stoma may be a viable option for many patients, as studies have not shown inferior HRQoL in this group [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is emphasized in this study that we are looking for the recommendation given by the surgeon before going into the discussion with the patient. In many cases the choice on whether to put a stoma or not may have become clearer after taking the patient\u0026rsquo;s preferences into account. Nonetheless, many patients tend to place their trust in the surgeon's expertise to guide this decision. Of course, this study also does not account for intraoperative events or evaluation that may change the plan to divert or not. However, as this is similar for all participants, this will not affect the end point of the study, the interrater agreement.\u003c/p\u003e \u003cp\u003eThe study has the following limitations: Most notably, the participation rate was unexpectedly low (50%). All participants were personally notified and invited to participate prior to inclusion. The questionnaire was distributed, followed by a reminder sent 14 days later. We chose not to send additional reminders or personal follow-ups for two main reasons. First, we aimed to ensure that participants felt a certain level of engagement in the study, responding truthfully and to the best of their ability, as if they were in a clinical setting. We cannot exclude the possibility that participants who respond after multiple reminders may feel obligated to do so rather than being genuinely willing to participate, which was not desirable. Second, participants had provided informed consent to take part in the study, and additional reminders could have compromised the integrity of that consent. With that in mind, a higher participation rate would not have altered the responses received from the 53 participants or the observed low inter-rater agreement them in-between. We also cannot rule out that the low participation is reflected in the disagreement demonstrated in this study, and that surgeons may therefore hesitate to respond and make decisions in areas where they know, or may assume, that a large proportion of others would disagree with their choices.\u003c/p\u003e \u003cp\u003eTo conclude, the interrater agreement between 53 rectal cancer surgeons from multiple centers was fair. In clinical decision-making, this is considered insufficient and indicates variability in interpretation or application of criteria. How this impacts patient outcomes is neither the aim nor the purpose of this paper; however, it serves as important background information for all professionals involved in rectal cancer surgery and who face these clinical decisions in everyday practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of interest:\u003c/strong\u003e None\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eVestfold Hospital Trust\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eL.A.B.G. and K.W.B. wrote the manuscript. K.W.B prepared all tables and figures and together with C.B and C-Y. H. did the statistics.Y.N.Y., L.T.S, F.P, S.N., O.S. and H.M.F all contributed to the design and original idea of the study.All authors reviewed the manuscript and made contributions to the submitted version.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated during the current study were collected using SurveyMonkey. Due to privacy and confidentiality considerations, the raw survey data are not publicly available but are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBray, F., et al., \u003cem\u003eGlobal cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries\u003c/em\u003e. CA Cancer J Clin, 2018. 68(6): p. 394\u0026ndash;424.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuren, M.G., et al., \u003cem\u003eNationwide improvement of rectal cancer treatment outcomes in Norway, 1993\u0026ndash;2010\u003c/em\u003e. Acta Oncol, 2015. 54(10): p. 1714\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKapiteijn, E., et al., \u003cem\u003ePreoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer\u003c/em\u003e. N Engl J Med, 2001. 345(9): p. 638\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatthiessen, P., et al., \u003cem\u003eDefunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial\u003c/em\u003e. Ann Surg, 2007. 246(2): p. 207\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eH\u0026uuml;ser, N., et al., \u003cem\u003eSystematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery\u003c/em\u003e. Ann Surg, 2008. 248(1): p. 52\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTan, W.S., et al., \u003cem\u003eMeta-analysis of defunctioning stomas in low anterior resection for rectal cancer\u003c/em\u003e. Br J Surg, 2009. 96(5): p. 462\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGu, W.L. and S.W. Wu, \u003cem\u003eMeta-analysis of defunctioning stoma in low anterior resection with total mesorectal excision for rectal cancer: evidence based on thirteen studies\u003c/em\u003e. World J Surg Oncol, 2015. 13: p. 9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorstlap, W.A.A., et al., \u003cem\u003eAnastomotic Leakage and Chronic Presacral Sinus Formation After Low Anterior Resection: Results From a Large Cross-sectional Study\u003c/em\u003e. Ann Surg, 2017. 266(5): p. 870\u0026ndash;877.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSnijders, H.S., et al., \u003cem\u003eOptimal Treatment Strategy in Rectal Cancer Surgery: Should We Be Cowboys or Chickens?\u003c/em\u003e Ann Surg Oncol, 2015. 22(11): p. 3582\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderin, K., et al., \u003cem\u003eThe effect of diverting stoma on long-term morbidity and risk for permanent stoma after low anterior resection for rectal cancer\u003c/em\u003e. Eur J Surg Oncol, 2016. 42(6): p. 788\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlok, R.D., et al., \u003cem\u003eImpact of an institutional change from routine to highly selective diversion of a low anastomosis after TME for rectal cancer\u003c/em\u003e. Eur J Surg Oncol, 2018. 44(8): p. 1220\u0026ndash;1225.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalla, A., et al., \u003cem\u003eProtective ileostomy creation after anterior resection of the rectum: Shared decision-making or still subjective?\u003c/em\u003e Colorectal Dis, 2023. 25(4): p. 647\u0026ndash;659.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHa, G.W., J.H. Kim, and M.R. Lee, \u003cem\u003eOncologic Impact of Anastomotic Leakage Following Colorectal Cancer Surgery: A Systematic Review and Meta-Analysis\u003c/em\u003e. Ann Surg Oncol, 2017. 24(11): p. 3289\u0026ndash;3299.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSandberg, S., et al., \u003cem\u003eLow anterior resection syndrome in a Scandinavian population of patients with rectal cancer: a longitudinal follow-up within the QoLiRECT study\u003c/em\u003e. Colorectal Dis, 2020. 22(10): p. 1367\u0026ndash;1378.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristensen, P., et al., \u003cem\u003eManagement guidelines for low anterior resection syndrome - the MANUEL project\u003c/em\u003e. Colorectal Dis, 2021. 23(2): p. 461\u0026ndash;475.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePachler, J. and P. Wille-J\u0026oslash;rgensen, \u003cem\u003eQuality of life after rectal resection for cancer, with or without permanent colostomy\u003c/em\u003e. Cochrane Database Syst Rev, 2012. 12: p. CD004323.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCampos-Lobato, L.F., et al., \u003cem\u003eAbdominoperineal resection does not decrease quality of life in patients with low rectal cancer\u003c/em\u003e. Clinics (Sao Paulo), 2011. 66(6): p. 1035\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHan, Z., et al., \u003cem\u003eDevelopment of a Risk Scoring System for Predicting Anastomotic Leakage Following Laparoscopic Rectal Cancer Surgery\u003c/em\u003e. Ther Clin Risk Manag, 2021. 17: p. 145\u0026ndash;153.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSnijders, H.S., et al., \u003cem\u003eLarge variation in the use of defunctioning stomas after rectal cancer surgery. A lack of consensus\u003c/em\u003e. Acta Oncol, 2016. 55(4): p. 509\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTalboom, K., et al., \u003cem\u003eHighly selective diversion with proactive leakage management after low anterior resection for rectal cancer\u003c/em\u003e. Br J Surg, 2021. 108(6): p. 609\u0026ndash;612.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEmmertsen, K.J. and S. Laurberg, \u003cem\u003eLow anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer\u003c/em\u003e. Ann Surg, 2012. 255(5): p. 922\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003eTreatment options and strength of recommendation for each case. Rates of suggested treatment options for each case given in absolute numbers and percentages as distributed among the 53 participants. Anastomosis = anastomosis without diverting stoma; Permanent = permanent colostomy; Diverting = anastomosis with diverting stoma\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.4514%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"6\" style=\"width: 36.673%;\"\u003e\n \u003cp\u003eCase recommendation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"6\" style=\"width: 32.3367%;\"\u003e\n \u003cp\u003eStrength of confidence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.4514%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 14.248%;\"\u003e\n \u003cp\u003eAnastomosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 11.7701%;\"\u003e\n \u003cp\u003ePermanent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 10.5311%;\"\u003e\n \u003cp\u003eDiverting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.416%;\"\u003e\n \u003cp\u003eMedium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4337%;\"\u003e\n \u003cp\u003eStrong\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.9381%;\"\u003e\n \u003cp\u003eVery strong\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 5.4514%;\"\u003e\n \u003cp\u003eCase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.2036%;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3275%;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.416%;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4337%;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.9381%;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 5.4514%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e92 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e2 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.2036%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3275%;\"\u003e\n \u003cp\u003e6 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.416%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e2 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4337%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e40 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.9381%;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e58 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 5.4514%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e11 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e40 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.2036%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3275%;\"\u003e\n \u003cp\u003e49 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.416%;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e42 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4337%;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e42 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.9381%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e17 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 5.4514%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e6 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e81 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.2036%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3275%;\"\u003e\n \u003cp\u003e13 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.416%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e13 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4337%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e49 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.9381%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e38 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 5.4514%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e0 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e66 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.2036%;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3275%;\"\u003e\n \u003cp\u003e34 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.416%;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e21 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4337%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e40 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.9381%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e40 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 5.4514%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e8 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e23 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.2036%;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3275%;\"\u003e\n \u003cp\u003e70 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.416%;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e34 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4337%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e38 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.9381%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e28 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 5.4514%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e83 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e0 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.2036%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3275%;\"\u003e\n \u003cp\u003e17 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.416%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e11 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4337%;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e51 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.9381%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e38 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 5.4514%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e60 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e0 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.2036%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3275%;\"\u003e\n \u003cp\u003e40 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.416%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e19 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4337%;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e45 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.9381%;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e36 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 5.4514%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e2 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e70 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.2036%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3275%;\"\u003e\n \u003cp\u003e28 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.416%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e19 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4337%;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e34 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.9381%;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e47 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 5.4514%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e26 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e6 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.2036%;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3275%;\"\u003e\n \u003cp\u003e68 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.416%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e30 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4337%;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e55 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.9381%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e15 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 5.4514%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e40 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e0 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.2036%;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3275%;\"\u003e\n \u003cp\u003e60 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.416%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e19 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4337%;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e60 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.9381%;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e21 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 5.4514%;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e38 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e8 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.2036%;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3275%;\"\u003e\n \u003cp\u003e55 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.416%;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e37 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4337%;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e52 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.9381%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e12 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 5.4514%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.1859%;\"\u003e\n \u003cp\u003e2 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.947%;\"\u003e\n \u003cp\u003e77 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.2036%;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3275%;\"\u003e\n \u003cp\u003e21 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.416%;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e21 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4337%;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e51 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.9381%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.8496%;\"\u003e\n \u003cp\u003e28 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003eCases arranged according to proportion of agreement (modal response in n and in percentages) from top to bottom. Strength of confidence was ordinally encoded from very strong, strong, medium to 3, 2 and 1, respectively. Rec = recommendation; Ana = anastomosis; Div = diverting stoma; Per = permanent stoma; Strength = mean strength of confidence (by case); Height = distance from the anal verge to the lower edge (or lower margin) of the tumor \u0026ndash; rigid scope in cm; NRT = neoadjuvant radio therapy; NACT = neoadjuvant chemotherapy; Incont = preoperative incontinence; Dia = diabetes; Smo = smoking; ASA = American Society of Anesthesiologist Physical Status Classification System.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"95%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003eCase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eRec\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eStrength\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eHeight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eNRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003eNACT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eIncont\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eDia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eSmo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eASA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eAna\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e49 (92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eAna\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e44 (83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003ePer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e43 (81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003ePer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e41 (77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003esome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003ePer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e37 (70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eDiv\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e37 (70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e1.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eDiv\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e36 (68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e1.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003ePer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e35 (66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003esome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eDiv\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e32 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eAna\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e32 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eDiv\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e29 (55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e1.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003esome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eDiv\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e26 (49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e1.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003esome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u0026nbsp;\u003c/strong\u003ePatient factors and correlated levels of interrater agreement (mean modal response and range). Strength = mean strength of confidence (by subgroup). Height = distance from the anal verge to the lower edge (or lower margin) of the tumor \u0026ndash; rigid scope in cm; NRT = neoadjuvant radio therapy; NACT = neoadjuvant chemotherapy.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003ePatient factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eRange (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003en (cases)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eModal response (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eLower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eUpper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eStrength\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e69.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e49.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e92.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e69.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e54.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e83.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026le;70 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e63.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e49.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e83.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026gt;70 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e77.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e67.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e92.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e70.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e54.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e92.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026ge;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e66.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e49.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e77.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eHeight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026le;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e72.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e66.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e81.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e6-12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e62.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e49.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e77.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1.93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026gt;12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e87.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e83.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e92.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eNRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e66.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e49.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e77.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e71.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e54.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e92.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eNACT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e73.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e69.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e77.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e68.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e49.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e92.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003ePreoperative incontinence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eSome/yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e65.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e49.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e81.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e72.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e60.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e92.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e65.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e49.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e77.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e70.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e54.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e92.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eSmoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e74.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e69.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e83.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e67.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e49.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e92.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eASA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eClass 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e72.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e66.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e81.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eClass 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e67.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e49.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e92.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4 \u003c/strong\u003eSurgeon factors and correlated levels of interrater agreement (Kappa). *Kappa should be interpreted with caution because the sample size of objects was small, which may affect the reliability of the estimates. Mean strength of confidence (by surgeon).\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"480\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 160px;\"\u003e\n \u003cp\u003eSurgeon factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 160px;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003en (surgeons)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003eKappa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003eLower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003eUpper\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 160px;\"\u003e\n \u003cp\u003eTime to complete survey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026lt; 6 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.390\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.389\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.391\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e6 - 12 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.273\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.272\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.274\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026gt; 12 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.460\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.458\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.462\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 160px;\"\u003e\n \u003cp\u003eNo. of annual procedures (center)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026lt; 25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.372\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.368\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.375\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e25 - 50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.449\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.448\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.451\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e51 - 75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.350\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.348\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.353\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e76 - 100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.254\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.252\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.256\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026gt; 100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.283\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.281\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.285\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 160px;\"\u003e\n \u003cp\u003eRegion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003eEU Central\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.303\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.301\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.304\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003eEU North\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.383\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.383\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.384\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003eEU South\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e4*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.133\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.143\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003eASIA / USA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e4*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.288\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.283\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.293\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003eStrength of confidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026le; 2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.414\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.414\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.415\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026gt; 2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.311\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.310\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.312\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"rectal cancer, stoma, anastomosis, clinical decision making, surgeon variability","lastPublishedDoi":"10.21203/rs.3.rs-8787310/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8787310/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe 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.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eTwelve 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\u0026rsquo; kappa.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf 106 invited surgeons, 53 completed the survey. Agreement on recommended management was fair (κ\u0026thinsp;=\u0026thinsp;0.359). Higher agreement correlated strongly with higher confidence levels (r\u0026thinsp;=\u0026thinsp;0.759, p\u0026thinsp;=\u0026thinsp;0.004). Patient age\u0026thinsp;\u0026gt;\u0026thinsp;70 years and tumor height\u0026thinsp;\u0026gt;\u0026thinsp;12 cm from the anal verge were associated with greater consistency in decision-making.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eInterrater 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\u003c/p\u003e","manuscriptTitle":"Stoma Formation in Rectal Cancer Surgery: Findings from an International Case-Based Survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-18 08:35:23","doi":"10.21203/rs.3.rs-8787310/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-08T15:48:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-01T04:24:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-31T16:37:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"332468655081300942952513898944884881607","date":"2026-03-17T21:24:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"141592435289707367918314199034456344552","date":"2026-03-16T10:36:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-13T12:05:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-24T10:12:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-06T05:04:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"Techniques in Coloproctology","date":"2026-02-04T13:28:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"97b97265-de56-45aa-9d23-5405269ed1cf","owner":[],"postedDate":"March 18th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-08T15:48:40+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T16:34:27+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-18 08:35:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8787310","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8787310","identity":"rs-8787310","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}