Implementation of guideline recommendations in coloanal anastomosis: results from the Tender Loving Care in Coloanal Anastomosis survey

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The Tender Loving Care in Coloanal Anastomosis (TLC-COLA) survey provides an overview of current surgical practices and perioperative strategies for coloanal anastomosis (CA) following low rectal cancer resection. Despite numerous advances in minimally invasive techniques and the establishment of evidence-based guidelines, real-world surgical management of CA shows considerable variability and persistent deviation from international recommendations. A total of 106 colorectal surgeons from 28 countries responded to a structured questionnaire covering surgical techniques, perioperative care, and preferences in CA, revealing differences between daily practice and newer techniques described in various guidelines (Fig. S1). Whereas 79 respondents reported the use of minimally invasive approaches—including laparoscopy, robotic surgery, and transanal techniques—open surgery remains common (Table 1). Surgical and peri-/postoperative practices in TME Values are n (%). TME, total mesorectal excision; CA, coloanal anastomosis. Surgical and peri-/postoperative practices in TME Values are n (%). TME, total mesorectal excision; CA, coloanal anastomosis. Despite clear recommendations from the Enhanced Recovery After Surgery (ERAS®) Society against their routine use, 82 surgeons still regularly place abdominal drains1. The GRECCAR 5 trial2 and subsequent meta-analyses have demonstrated no significant benefit of routine drainage, and similar evidence3 challenges the routine formation of a diverting stoma in all patients undergoing CA. These findings emphasize a critical discrepancy between high-level evidence and routine clinical practice. The role of diverting stomas remains controversial: although they may reduce reinterventions, recent data show comparable anastomotic leak rates with or without ileostomy after low anterior resection. There are differences in antibiotic usage: 102 surgeons administer standard preoperative intravenous antibiotic prophylaxis and 19 extend this into the postoperative period, contrary to global guidelines. Although mechanical bowel preparation (MBP) is nearly universally applied, the combined use of MBP with oral antibiotics—proven to reduce surgical site infections in recent trials such as MOBILE24—is still not consistently practised: only 64 respondents reported using both. This illustrates delays in the adoption of updated evidence-based protocols (Fig. S2). Postoperative management showed high compliance with ERAS principles regarding mobilization: 94 respondents allow early mobilization and 90 do not restrict sitting. There is wide variation in the use of prokinetics, laxatives, and transanal drainage tubes in current practice (Table 1). The central issue highlighted by this survey is the lack of a clear, standardized definition of what constitutes a CA. Respondents differed in how they define the anastomotic level, choose between hand-sewn versus stapled techniques, and determine the extent of intersphincteric dissection. For example, whereas 45 surgeons adapt their technique based on anatomical constraints, 59 consistently use one method regardless of the level of dissection. Preferences in suture materials and stapler sizes are also influenced more by individual experience than by standardized criteria (Table S1). These variations may result from institutional tradition, resource availability, or lack of consensus within the surgical community. In qualitative assessments, barriers to guideline implementation included colleague disagreement, limited institutional support, and resistance to change. This is in line with previous work5 identifying behavioural and structural challenges in guideline implementation. In conclusion, whereas CA is increasingly performed with modern techniques and ERAS-oriented care, important gaps between evidence and practice remain. The routine use of stomas, abdominal drains, and prolonged antibiotics reflects lingering uncertainty or hesitation, despite contrary data. Most critically, the absence of a universal definition of CA complicates both surgical decision-making and research, especially when looking at patient-level outcome data. To improve outcomes and harmonize global practice, the colorectal community must strive toward clear definitions, standardized protocols, and better implementation strategies for guideline-based care. An international expert consensus should be actively pursued to define technical standards and perioperative management in CA and to support global alignment in practice. S. B. Abebe (Department of Surgery, Addis Ababa University, Addis Ababa, Ethiopia), F. Aigner (Department of Surgery, Barmherzige Brüder Krankenhaus Graz, Graz, Austria), C. Akyol (Department of Surgery, Ankara University School of Medicine, Ankara, Turkey), K. Alexiou (Department of Surgery, Central Clinic, Central Clinic, Greece), A. Alotaibi (Department of Surgery, University of Jeddah, Jeddah, Saudi Arabia), E. Anestiadou (Department of Surgery, Papanikolaou General Hospital of Thessaloniki, Thessaloniki, Greece), A. Arezzo (Department of Surgery, University of Turin, Turin, Italy), A. Benkabbou (Department of Surgery, Institut national d'oncologie, Rabat, Morocco), H. W. Bhatti (Department of Surgery, Benazir Bhutto Hospital Rawalpindi, Rawalpindi, Pakistan), M. Biebl (Department of Surgery, Ordensklinikum Linz, Linz, Austria), S. Bischofberger (Department of Surgery, Health Ostschweiz Kantonsspital St. Gallen, St. Gallen, Switzerland), P. Botelho (Department of Surgery, Centro hospitalar Lisboa central, Lisbon, Portugal), G. Brisinda (Department of Surgery, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy), N. C. Buchs (Department of Surgery, Hôpital de La Tour, Meyrin, Switzerland), P. Buchwald (Department of Surgery, Skåne University Hospital Malmö, Malmö, Sweden), V. Calu (Department of Surgery, Elias Emergency University Hospital, Bucharest, Romania), M. Cariati (Department of Surgery, Presso Ospedaliero San Giovanni di Dio, Presso Ospedaliero San Giovanni di Dio, Florence, Italy), M. Carpelan-Holmström (Department of Surgery, Helsinki University Hospital, Helsinki, Finland), M. Carvello (Department of Surgery, Humanitas University, Rozzano, Italy), C. de Chaisemartin (Department of Surgery, Institut Paoli Calmettes, Marseille, France), P. Chandrasinghe (Department of Surgery, University of Kelaniya, Kelaniya, Sri Lanka), L. Chardalias (Department of Surgery, Aretaieion University Hospital of Athens, Athens, Greece), P. Christensen (Department of Surgery, Aarhus University Hospital, Aarhus, Denmark), I. Chukwu (Department of Surgery, Federal Medical Centre Umuahia, Umuahia, Nigeria), M. de Cillia (Department of Surgery, Barmherzige Brüder Salzburg, Salzburg, Austria), D. Clerc (Department of Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland), R. Colombari (Department of Surgery, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain), B. Dauser (Department of Surgery, St John of God Hospital, Vienna, Austria), T. Delko (Department of Surgery, Chirurgie Zentrum St. Anna, Luzern, Switzerland), G. Dimopoulou (Department of Surgery, General Hospital of Volos, Volos, Greece), N. Drakos (Department of Surgery, University Hospital Patras, Patras, Greece), M. Elshafei (Department of Surgery, Krankenhaus Nordwest, Frankfurt, Germany), S. Ersoz (Department of Surgery, Ankara University Hospital, Ankara, Turkey), A. Foxius (Department of Surgery, Centre Hospitalier du Nord, Ettelbruck, Luxembourg), I. N. Galanis (Department of Surgery, Ippokrateio General Hospital, Thessaloniki, Greece), C. Gallardo (Department of Surgery, Hospital San Borja Arriarán, Santiago, Chile), A. Gonçalves (Department of Surgery, University Hospital São João, Porto, Portugal), F. Grama (Department of Surgery, Coltea Clinical Hospital, Coltea, Romania), B. Guendil (Department of Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland), D. Hahnloser (Department of Surger

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