Cost matters. Extra safety must be paid for. Koperna's article provides an excellent example. Protecting an LAR increases the cost of an anterior resection in Mistelbach, Austria, from US $10 000 to US $15 000. An unprotected leak requiring a Hartmann operation costs US $50 000. A clinician might add that it may cost the patient his or her life and is very likely to mean a permanent stoma—costing perhaps US $4000 per year thereafter.
Patients care little about initial cost: they want the lowest possible long-term outcome costs—0 for a cure with no stoma! I believe that outcome cost accounting would be even more valuable. In this article it is most interesting that the principal cost drivers after LAR are 1 initial cost (defunctioning) and 1 short-term outcome cost (leakage). However, most surgeons construct a defunction because they are afraid of the occasional death from leakage—this defies cost analysis except on very large series. On my total mesorectal excision travels, these deaths from delayed leaks by 1 surgeon were called "weekend mortalities" in Holland; the surgeon was away, another team was on call, and the deep pelvis sepsis was missed until multiorgan failure rendered intervention ineffective. Analyze all that for cost!
Heald RJ. Cost-effectiveness of Defunctioning Stomas in Low Anterior Resections for Rectal Cancer—Invited Critique. Arch Surg. 2003;138(12):1339. doi:10.1001/archsurg.138.12.1339