Do older Americans undergo stoma reversal following low anterior resection for rectal cancer?

Impact of pandemic and socioeconomic influences on decision-making for emergency ostomy procedures: Key factors affecting hospital visit decisions

Emergency surgeries are linked with increased morbidity and reduced life expectancy, often associated with low socioeconomic status, limited access to healthcare, and delayed hospital admissions. While the influence of socioeconomic status on elective surgery outcomes is well-established, its impact on emergency surgeries, including ostomy creation and closure, is less clear. This study aimed to explore how the pandemic and socioeconomic status affect emergency ostomy procedures, seeking to determine which has a greater effect. It emphasizes the importance of considering socioeconomic factors in patient care pathways for ostomy procedures. A total of 542 patients who underwent emergency ostomy formation between 2016 and 2022 were retrospectively analyzed and divided into pre-pandemic and pandemic periods. The pre-pandemic and pandemic periods were compared between themselves and against each other. Demographic data (age and sex), comorbidities, socioeconomic status, etiology of the primary disease, type of surgery, stoma type, length of hospital stay, ostomy closure time, and postoperative complications were retrospectively analyzed for all patients. In total, 290 (53%) patients underwent surgery during the pandemic period, whereas 252 (47%) underwent surgery during the pre-pandemic period. Emergency surgery was performed for malignancy in 366 (67%) patients. The number of days patients underwent ostomy closure was significantly higher in the low-income group (P = .038, 95% CI: 293,2, 386-945). The risk of failure of stoma closure was 3-fold (95% CI: 1.8-5.2) in patients with metastasis. The risk of mortality was 12.4-fold (95% CI: 6.5-23.7) when there was failure of stoma closure. When compared to pandemic period, the mortality risk was 6.3-fold (95% CI: 3.9-10.2) in pre-pandemic period. Pandemic patients had a shorter hospital stay than before the pandemic (P = .044). A high socioeconomic status was significantly associated with early hospital admission for ostomy closure, and lower probability of mortality. More metastases and perforations were observed during the pandemic period and mortality was increased during pandemic and in patients without ostomy closure. The socioeconomic status lost its effect in cases of emergency ostomy creation and had no impact on length of hospital stay in either the pre-pandemic or pandemic period.

Prophylactic defunctioning stomas improve clinical outcomes of anastomotic leak following rectal cancer resections: An analysis of the US Rectal Cancer Consortium

PURPOSE

Anastomotic leak (AL) is a complication of low anterior resection (LAR) that results in substantial morbidity. There is immense interest in evaluating immediate postoperative and long-term oncologic outcomes in patients who undergo diverting loop ileostomies (DLI). The purpose of this study is to understand the relationship between fecal diversion, AL, and oncologic outcomes.

METHODS

This is a retrospective multicenter cohort study using patient data obtained from the US Rectal Cancer Consortium database compiled from six academic institutions. The study population included patients with rectal adenocarcinoma undergoing LAR. The primary outcome was the incidence of AL among patients who did or did not receive DLI during LAR. Secondary outcomes included risk factors for AL, receipt of adjuvant therapy, 3-year overall survival, and 3-year recurrence.

RESULTS

Of 815 patients, 38 (4.7%) suffered AL after LAR. Patients with AL were more likely to be male, have unintentional preoperative weight loss, and are less likely to undergo DLI. On multivariable analysis, DLI remained protective against AL (p < 0.001). Diverted patients were less likely to undergo future surgical procedures including additional ostomy creation, completion proctectomy, or pelvic washout for AL. Subgroup analysis of 456 patients with locally advanced disease showed that DLI was correlated with increased receipt of adjuvant therapy for patients with and without AL on univariate analysis (SHR:1.59; [95% CI 1.19-2.14]; p = 0.002), but significance was not met in multivariate models.

CONCLUSION

Lack of DLI and preoperative weight loss was associated with anastomotic leak. Fecal diversion may improve the timely initiation of adjuvant oncologic therapy. The long-term outcomes following routine diverting stomas warrant further study.

Cost associated with diverting ostomy after rectal cancer surgery: a transnational analysis

BACKGROUND

Diverting ileostomy and colostomy after total mesorectal excision reduces the risk of complications related to anastomotic leakages but is associated with a reduction in health-related quality of life and long-term economic consequences that are unknown. Our objective was to estimate the lifetime costs of stoma placement after rectal cancer resection in the U.S., England, and Germany.

METHODS

Input parameters were derived from quasi-systematic literature searches. Decision-analytic models with survival from colorectal cancer-adjusted life tables and country-specific stoma reversal proportions were created for the three countries to calculate lifetime costs. Main cost items were stoma maintenance costs and reimbursement for reversal procedures. Discounting was applied according to respective national guidelines. Sensitivity analysis was conducted to explore the impact of parameter uncertainty onto the results.

RESULTS

The cohort starting ages and median survival were 63 and 11.5 years for the U.S., 69 years and 8.5 years for England, and 71 and 6.5 years for Germany. Lifetime discounted stoma-related costs were $26,311, £9512, and €10,021, respectively. All three models were most sensitive to the proportion of ostomy reversal, age at baseline, and discount rate applied.

CONCLUSION

Conservative model-based projections suggest that stoma care leads to significant long-term costs. Efforts to reduce the number of patients who need to undergo a diverting ostomy could result in meaningful cost savings.

Protective ileostomy after low anterior resection for extraperitoneal rectal cancer: does the reversal surgery timing affect closure failure?

Loop ileostomy is commonly performed after LAR with TME to temporarily protect the anastomosis. Usually, defunctioning stoma is closed after 1-6 months, although sometimes it becomes definitive de facto. The aim of this study is to investigate the long-term risk of no-reversal of protective ileostomy after LAR for middle-low rectal cancer and the predictive risk factors. A retrospective analysis of a consecutive cohort of patients who underwent curative LAR with covering ileostomy for extraperitoneal rectal cancer in two colorectal units was performed. A different policy for scheduling stoma closure was applied between centers. All the data were collected through an electronic database (Microsoft Excel®). Descriptive statistical analysis was performed using Fisher's exact and Student's t test. Multivariate logistic regression analysis was conducted. Two-hundred twenty-two patients were analysed: reversal procedure was carried out in 193 patients, in 29 cases stoma was never closed. The mean interval time from index surgery was 4.9 months (Center1: 3 vs. Center2: 7.8). At the univariate analysis, mean age and tumor stage were significantly higher in the "no-reversal" group. Unclosed ostomies were significantly lower in Center 1 than Center 2 (8% vs. 19.6%). At the multivariate analysis female gender, anastomotic leakage and Center 2 had significant higher risk of unclosed ileostomy. Currently, no clinical recommendations have been established and the policy of scheduling stoma reversal is variable. Our study suggests that an established protocol could avoid closure delay, decreasing permanent stomas. Consequently, ileostomy closure should be weighed as standardized step in cancer therapeutic pathway.

Renal dysfunction occurs following ileostomy formation and is independent of readmission

BACKGROUND

Ileostomy formation may be permanent or intended as temporary to defunction a high-risk pelvic anastomosis to reduce the risk of septic consequences of anastomotic leak. However, these procedures have a high rate of readmission, most commonly due to dehydration and associated with acute kidney injury (AKI).

METHODS

A single centre retrospective cohort study of patients who underwent ileostomy formation from 2015 to 2020 and analysed in two groups: those who needed readmission within 60 days and those who did not. Data collected included demographics and renal function and electrolytes at baseline (ileostomy formation) and at elective ileostomy closure.

RESULTS

A total of 171 patients were included in the analysis, with a readmission rate 38% within 60 days of discharge. There was a significant increase in creatinine from baseline blood tests compared to date of elective ileostomy closure in both the readmission and no readmission arms. There was a significant decrease in eGFR from baseline blood tests compared with date of ileostomy closure in both readmission and no readmission arms. There was no significant difference in creatinine or eGFR between readmission and no readmission arms at date of ileostomy closure. Baseline serum sodium levels were lower in the readmission arm compared to no readmission arm.

CONCLUSION

Ileostomy formation is associated with a deterioration in renal function, which occurs independent of whether the patient requires readmission to hospital. Low serum sodium may be used as a predictor for patients with an increased risk of readmission.

Patient and surgeon preferences for early ileostomy closure following restorative proctectomy for rectal cancer: why aren't we doing it?

BACKGROUND

Early ileostomy closure (EIC), ≤ 2 weeks from creation, is a relatively new practice. Multiple studies have demonstrated that this approach is safe, feasible, and cost-effective. Despite the demonstrated benefits, this is neither routine practice, nor has it been studied, in North America. This study aimed to assess patient and surgeon perspectives about EIC.

METHODS

A mixed-methods, cross-sectional study of patients and surgeons was performed. Rectal cancer survivors from a single institution who underwent restorative proctectomy with diverting loop ileostomy and subsequent closure within the last 5 years were contacted. North American surgeons with high rectal cancer volumes (> 20 cases/year) were included. Surveys (patients) and semi-structured interviews (surgeons) were conducted. Analysis employed descriptive statistics and thematic analysis, respectively.

RESULTS

Forty-eight patients were surveyed (mean age 65.1 ± 11.8 years; 54.2% male). Stoma closure occurred after a median of 7.7 months (IQR 4.8-10.9) and 50.0% (24) found it "difficult" or "very difficult" to live with their stoma. Patients considered improvement in quality of life and quicker return to normal function the most important advantages of EIC, whereas the idea of two operations in two weeks being too taxing on the body was deemed the biggest disadvantage. Most patients (35, 72.9%) would have opted for EIC. Surgeon interviews (15) revealed 4 overarching themes: (1) there are many benefits to EIC; (2) specific patient characteristics would make EIC an appropriate option; (3) many barriers to implementing EIC exist; and (4) many logistical hurdles need to be addressed for successful implementation. Most surgeons (12, 80.0%) would "definitely want to participate" in a North American randomized-controlled trial (RCT) on EIC for rectal cancer patients.

CONCLUSIONS

Implementing EIC poses many logistical challenges. Both patients and surgeons are interested in further exploring EIC and believe it warrants a North American RCT to motivate a change in practice.

Factors impacting time to ileostomy closure after anterior resection: the UK closure of ileostomy timing cohort study (CLOSE-IT)

AIM

Delay to closure of ileostomy following anterior resection for rectal cancer may impair postoperative bowel function and quality of life. We analysed time to ileostomy closure across the UK and investigated factors delaying closure.

METHODS

For the retrospective cohort we assessed time to closure and incidence of non-closure for patients who underwent anterior resection with defunctioning ileostomy during 2015. Multivariate linear/Cox regression analyses were performed. For the prospective cohort we captured patients undergoing ileostomy closure during a 3-month period in 2018 to validate retrospective findings.

RESULTS

The retrospective cohort involved 788 patients of whom 669 (84.9%) had bowel continuity restored, median time to closure 259 days. Recognized factors associated with delay and risk of non-closure included anastomotic leak (hazard ratio [HR] 3.65, 2.61-5.08), chemotherapy (HR 2.62, 2.17-3.15) and cancer progression (HR 2.05, 1.62-2.58). Crucially, specific aspects of the surgical pathway were associated with time to closure; for example, waiting list entry prior to outpatient clinic review/imaging was associated with an estimated 133-day shorter interval to closure (P < 0.001). In the prospective cohort 288 patients underwent closure, at a median of 271 days. Chemotherapy use and cancer progression were associated with delay to closure while listing for surgery prior to clinic and imaging was associated with an estimated shorter interval to closure of 168 days (P = 0.008).

CONCLUSIONS

Delays to closure of ileostomy are common in the UK. Listing patients for surgery only after follow-up outpatient appointment, imaging or chemotherapy delays closure. Findings will inform consensus guidelines towards an optimum treatment pathway to reduce delay and improve post-closure quality of life.

Socioeconomic disparities in ostomy reversal among older adults with diverticulitis are more substantial among non-Hispanic Black patients

BACKGROUND

While ostomies for diverticulitis are often intended to be temporary, ostomy reversal rates can be as low as 46%. There are few comprehensive studies evaluating the effects of socioeconomic status as a disparity in ostomy reversal. We hypothesized that among the elderly Medicare population undergoing partial colectomy for diverticulitis, lower socioeconomic status would be associated with reduced reversal rates.

METHODS

Retrospective cohort study using a 20% representative sample of Medicare beneficiaries >65 years old with diverticulitis who received ostomies between January 1, 2010, to December 31, 2017. We evaluated the effect of neighborhood socioeconomic status, measured by the Social Deprivation Index, on ostomy reversal within 1 year. Secondary outcomes were complications and mortality.

RESULTS

Of 10,572 patients, ostomy reversals ranged from 21.2% (low socioeconomic status) to 29.8% (highest socioeconomic status), with a shorter time to reversal among higher socioeconomic status groups. Patients with low socioeconomic status were less likely to have their ostomies reversed, compared with the highest socioeconomic status group (hazard ratio 0.83, 95% confidence interval 0.74-0.93) and were more likely to die (hazard ratio 1.21, 95% confidence interval 1.10-1.33). When stratified by race/ethnicity and socioeconomic status, non-Hispanic White patients at every socioeconomic status had a higher reversal rate than non-Hispanic Black patients (White patients 32.0%-24.8% vs Black patients 19.6%-14.7%). Socioeconomic status appeared to have a higher relative impact among non-Hispanic Black patients.

CONCLUSION

Among Medicare diverticulitis patients, ostomy reversal rates are low. Patients with lower socioeconomic status are less likely to undergo stoma reversal and are more likely to die; Black patients are least likely to have an ostomy reversal.

Comparative study between ghost ileostomy and defunctioning ileostomy in terms of morbidity and cost-effectiveness in low anterior resection for rectal cancer

PURPOSE

The aim of this study was to compare ghost ileostomy (GI) and defunctioning ileostomy (DI) in patients who underwent low anterior resection (LAR) for rectal cancer in terms of postoperative morbidity, rehospitalization rates, and total costs.

METHODS

Patients with an anastomosis level between 5 and 10 cm from the anal verge after LAR were analyzed retrospectively. Clinical characteristics, operative outcomes, postoperative morbidity, rehospitalization rates, and total costs were compared.

RESULTS

A total of 123 patients were enrolled as follows: 42 patients in the GI group and 81 patients in the DI group. Anastomotic leakage (AL) was identified in three patients who underwent GI, and in all of them, GI was easily converted to DI. There were 96.3% of the patients with DI rehospitalized at least one time because of surgery-related and/or stoma-related complications or stoma closure. When we did not take into account the patients who were rehospitalized for stoma closure, the rates of rehospitalization were 4.7% and 22.2% in the GI and DI groups, respectively (P= 0.01). The mean total costs calculated by removing additional surgical procedures and adding all of the rehospitalization costs were 25,767 USD and 41,875 USD in the GI and DI groups, respectively (P= 0.0001).

CONCLUSION

GI may be a safe and cost-effective method in patients who underwent LAR with low or medium risk factors for AL. It is possible to avoid unnecessary ileostomy and reduce unwanted outcomes due to it, such as postoperative complications, rehospitalizations, and increased total costs by performing GI.

Assessment of the risk of permanent stoma after low anterior resection in rectal cancer patients

Background

One of the most severe complications of low anterior rectal resection is anastomotic leakage (AL). The creation of a loop ileostomy (LI) reduces the prevalence of AL requiring surgical intervention. However, up to one-third of temporary stomas may never be closed.

The first aim of the study was to perform a retrospective assessment of the impact of LI on the risk of permanent stoma (PS) and symptomatic AL. The second aim of the study was to assess preoperative PS risk factors in patients with LI.

Methods

A total of 286 consecutive patients who underwent low anterior rectal resection were subjected to retrospective analysis. In 101 (35.3%) patients, diverting LI was performed due to low anastomosis, while in the remaining 185 (64.7%) patients, no ileostomy was performed. LIs were reversed after adjuvant treatment. Analyses of the effect of LI on symptomatic AL and PS were performed. Among the potential risk factors for PS, clinical factors and the values of selected peripheral blood parameters were analysed.

Results

PS occurred in 37.6% and 21.1% of the patients with LI and without LI, respectively (p < 0.01). Symptomatic ALs were significantly more common in patients without LI. In this group, symptomatic ALs occurred in 23.8% of patients, while in the LI group, they occurred in 5% of patients (p < 0.001). In the LI group, the only significant risk factor for PS in the multivariate analysis was preoperative plasma fibrinogen concentration (OR = 1.007, 97.5% CI 1.002–1.013, p = 0.013).

Conclusions

Although protective LI may reduce the incidence of symptomatic AL, it can be related to a higher risk of PS in this group of patients. The preoperative plasma fibrinogen concentration can be a risk factor for PS in LI patients and may be a useful variable in decision-making models.

Long distance to hospital is not a risk factor for non-reversal of a defunctioning stoma

PURPOSE

To see if road distance to hospital influences stoma reversal rate, time from index operation to stoma reversal, and occurrence of permanent stoma.

METHODS

Data from all diagnosed cases of rectal cancer from three counties in northern Sweden were extracted from the Swedish Rectal Cancer Registry. The three counties are sparsely populated, with a population density roughly one fifth the average density in Sweden. Distances to nearest, operating, and largest hospital were obtained using Google Maps™. Matched data on socioeconomic variables were retrieved from Statistics Sweden.

RESULTS

In univariate logistic regression analysis, patients living closer to the operating hospital had a higher likelihood of non-reversal than those living farther away (OR 0.3; 95% CI 0.12-0.76). However, no difference was seen in the multivariate analysis. Of the 717 cases included, 54% received a permanent stoma and 38% a defunctioning stoma at index surgery. The reversal rate of a defunctioning stoma was 83%. At follow-up, 61% still had a stoma, 89% of these were permanent, and 11% non-reversed defunctioning stomas. Median time to stoma reversal was 287 days (82-1557 days). Of all 227 stoma reversals, 77% were done more than 6 months after index surgery.

CONCLUSIONS

Longer distance to hospital is not a risk factor for non-reversal of a defunctioning stoma. Only 23% had their defunctioning stoma reversed within 6 months after index surgery. Future studies aiming to determine reversal rate need to extend their follow-up time in order to receive accurate results.

Factors preventing restoration of bowel continuity in patients with rectal cancer submitted to anterior rectal resection and protective ileostomy

OBJECTIVE

to evaluate the factors associated with non-closure of protective ileostomy after anterior resection of the rectum with total mesorectum excision for rectal cancer, the morbidity associated with the closure of ileostomies and the rate of permanent ileostomy in patients with rectal adenocarcinoma.

METHODS

we conducted a retrospective study with 174 consecutive patients diagnosed with rectal tumors, of whom 92 underwent anterior resection of the rectum with coloanal or colorectal anastomosis and protective ileostomy, with curative intent. We carried out a multivariate analysis to determine the factors associated with definite permanence of the stoma, as well as studied the morbidity of patients who underwent bowel continuity restoration.

RESULTS

In the 84-month follow-up period, 54 of the 92 patients evaluated (58.7%) had the ileostomy closed and 38 (41.3%) remained with the stoma. Among the 62 patients who had the ileostomy closed, 11 (17.7%) presented some type of postoperative complication: three had ileal anastomosis dehiscence, five had intestinal obstruction, two had surgical wound infection, and one, pneumonia. Eight of these patients required a new stoma.

CONCLUSION

according to the multivariate analysis, the factors associated with stoma permanence were anastomotic fistula, presence of metastases and closure of the ileostomy during chemotherapy.

Racial Disparities After Stoma Construction Exist in Time to Closure After 1 Year but Not in Overall Stoma Reversal Rates

INTRODUCTION

Conflicting data exist on racial disparities in stoma reversal (SR) rates. Our aim was to investigate the role of race in SR rates, and time to closure, in a longitudinal, racially diverse database.

METHODS

All adult patients (>18 years) who received an ileostomy or colostomy from 1999 to 2016 at a single institution were identified. Primary outcomes were SR rates and time to closure. Failure to reverse and time to closure was modeled using Cox regression. Kaplan-Meier survival curves, stratified by race, were generated for time to closure and hazard ratios (HRs) calculated.

RESULTS

Of 770 patients with stomas, 65.6% of patients underwent SR; 76.6% were white and 23.4% were black. On adjusted analysis, race did not predict overall SR rates or time to closure if performed less than 1 year. Instead, significant predictors for failure in SR included age, insurance status, end colostomy/ileostomy, and loop colostomy (p < 0.05). Predictors of delay in time to closure included insurance, end colostomy/ileostomy, and loop colostomy (p < 0.05). In patients who underwent reversal after 1 year, black race was an independent predictor of time to closure (HR 0.21, 95% CI 0.07-0.63, p < 0.05).

CONCLUSION

SR rates were equal between black and white patients. Disparities in time to closure existed only for black patients if reversed more than 1 year after index stoma construction. While equitable outcomes were achieved for most patients, further investigation is necessary to understand stoma disparities after 1 year.

Loop-ileostomy reversal-patient-related characteristics influencing time to closure

PURPOSE

To identify factors associated with timing of stoma reversal after rectal cancer surgery in a large Swedish register-based cohort.

METHODS

Three thousand five hundred sixty-four patients with rectal cancer who received a protective stoma during surgery in 2007-2013 were identified in the Swedish colorectal cancer register. Time to stoma reversal was evaluated over a follow-up period of one and a half years. Factors associated with timing of stoma reversal were analysed using Cox regression analysis. Reversal within 9 months (12 months if adjuvant chemotherapy) was considered latest expected time to closure.

RESULTS

Stoma reversal was performed in 2954 (82.9%) patients during follow-up. Patients with post-secondary education had an increased chance for early stoma reversal (HR 1.13; 95% CI 1.02-1.25). Postoperative complications (0.67; 0.62-0.73), adjuvant chemotherapy (0.63; 0.57-0.69), more advanced cancer stage (stage III 0.74; 0.66-0.83 and stage IV 0.38; 0.32-0.46) and higher ASA score (0.80; 0.71-0.90 for ASA 3-4) were associated with longer time to reversal. Two thousand four hundred thirty-seven (68.4%) patients had stoma reversal within latest expected time to closure. Factors associated to decreased chance of timely reversal were more advanced cancer stage (stage III 0.64; 0.50-0.81 and stage IV 0.19; 0.13-0.27), postoperative complications (0.50; 0.42-0.59) and higher ASA score (0.77; 0.61-0.96 for ASA 3-4).

CONCLUSIONS

Patients with a high level of education had a higher chance of timely reversal but medical factors had a stronger association to time to reversal. Patients with advanced rectal cancer are at high risk for non-reversal and should be considered for permanent stoma.

Determinants of stoma reversal in rectal cancer patients who had an anterior resection between 2009 and 2012 in the English National Health Service

AIM

The rate of ileostomy reversal was estimated in patients undergoing an elective anterior resection for rectal cancer and factors associated with reversal were identified.

METHOD

The records of 4879 rectal patients who had an ileostomy created during anterior resection between 2009 and 2012 were identified in the National Bowel Cancer Audit database and linked to administrative records of the Hospital Episode Statistics. Patients were followed from surgery. Multivariable proportional hazards regression was used to estimate the impact of patient and cancer characteristics on ileostomy reversal with death as the competing risk.

RESULTS

Within 18 months from anterior resection, 3536 (72.5%) patients had undergone ileostomy reversal. The reversal rate was lower in the following circumstances: older patients [hazard ratio (HR) 0.90; 95% CI 0.84-0.96, aged 80 vs 70 years], male gender (HR 0.90; 0.84-0.97), higher American Society of Anesthesiologists (ASA) grade (HR 0.64; 0.56-0.74, ASA 3+ vs 1), more advanced cancer (HR 0.77; 0.69-0.87, T3 vs T1), socioeconomic deprivation (HR 0.83; 0.74-0.93, most vs least deprived quintile), comorbidity (HR 0.92; 0.84-1.00, one vs no comorbidity) and open surgical procedure (HR 0.90; 0.84-0.97, open vs laparoscopic).

CONCLUSION

Overall, two-thirds of ileostomies were reversed within 18 months. Reversal rates were linked to patient and cancer characteristics (age, sex, fitness and stage), mode of surgical access and socioeconomic deprivation. Observed lower reversal rates in patients from poorer backgrounds may indicate inequity in access.

Race and socioeconomic disparities in national stoma reversal rates

BACKGROUND

Many temporary stomas are never reversed leading to significantly worse quality of life. Recent evidence suggests a lower rate of reversal among minority patients. Our study aimed to elucidate disparities in national stoma closure rates by race, medical insurance status, and household income.

METHODS

Five years of data from the Nationwide Inpatient Sample (2008 to 2012) was used to identify the annual rates of stoma formation and annual rates of stoma closure. Stomas labeled as "permanent" or those created secondary to colorectal cancers were excluded. Temporary stoma closure rates were calculated, and differences were tested with the chi-square test. Separate analyses were performed by race/ethnicity, insurance status, and household income. Nationally representative estimates were calculated using discharge-level weights.

RESULTS

The 5-year average annual rate of temporary stoma creation was 76,551 per year (46% colostomies and 54% ileostomies). The annual rate of stoma reversal was 50,155 per year that equated to an annual reversal rate of 65.5%. Reversal rates were higher among white patients compared with black patients (67% vs 56%, P < .001) and among privately insured patients compared with uninsured patients (88% vs 63%, P < .001). Reversal rates increased as the household income increased from 61% in the lowest income quartile to 72% in the highest quartile (P < .001).

CONCLUSIONS

Stark disparities exist in national rates of stoma closure. Stoma closure is associated with race, insurance, and income status. This study highlights the lack of access to surgical health care among patients of minority race and low-income status.

Does ghost ileostomy have a role in the laparoscopic rectal surgery era? A randomized controlled trial

BACKGROUND

Anastomotic leakage following anterior rectal resection is the most important and most commonly faced complication of laparoscopy and open surgery. To prevent this complication, the construction of a preventing stoma is usually adopted. It is not easy to decide whether to construct a protective stoma in patients with a medium risk of anastomotic leakage. In these patients, ghost ileostomy (GI), a pre-stage ileostomy that can be externalized and opened if needed, has proved useful. We conducted a prospective, randomized, controlled study to evaluate the advantages of GI in laparoscopic rectal resection.

METHODS

All patients with surgical indications for laparoscopic rectal resection who were at medium risk for anastomotic leakage from January 2007 to January 2013 were included and were randomly divided in 2 groups. All of the patients were subjected to laparoscopic anterior rectal resection with the performance of GI (group A) or without the construction of any protective stoma (group B). The presence and severity of clinically evident postoperative anastomotic leakage and other postoperative complications and reinterventions were investigated.

RESULTS

Of the 55 patients allocated to group A, 3 experienced anastomotic leakage compared with 4 in group B. The patients with GI experienced a lower severity of anastomotic leakage and shorter hospitalization compared with the patients in group B. None of the patients with GI and anastomotic leakage required laparotomy to treat the dehiscence.

CONCLUSIONS

The use of GI in laparoscopic rectal resections in patients at medium risk for anastomotic leakage was useful because it allowed for the avoidance of stoma creation in all of the patients, thus reducing the number of stomas performed, improving the quality of life of the patients and preserving, in most cases, the benefits gained by laparoscopy.

Hospital variation in sphincter preservation for elderly rectal cancer patients

BACKGROUND

The primary goal of an operation for rectal cancer is to cure cancer and, where possible, preserve continence. A wide range of sphincter preservation rates have been reported. This study evaluated hospital variation in the use of low anterior resection (LAR), local excision (LE), and abdominoperineal resection (APR) in the treatment of elderly rectal cancer patients.

METHODS

Using Surveillance, Epidemiology, and End Results-Medicare linked data, we identified 4959 patients older than 65 y with stage I-III rectal cancer diagnosed from 2000-2005 who underwent operative intervention at one of 370 hospitals. We evaluated the distribution of hospital-specific procedure rates and used generalized mixed models with random hospital effects to examine the influence of patient characteristics and hospital on operation type, using APR as a reference.

RESULTS

The median hospital performed APR on 33% of elderly patients with rectal cancer. Hospital was a stronger predictor of LAR receipt than any patient characteristic, explaining 32% of procedure choice, but not a strong predictor of LE, explaining only 3.8%. Receipt of LE was primarily related to tumor size and tumor stage, which combined explained 31% of procedure variation.

CONCLUSIONS

Receipt of LE is primarily determined by patient characteristics. In contrast, the hospital where surgery is performed significantly influences whether a patient undergoes an LAR or APR. Understanding the factors that cause this institutional variation is crucial to ensuring equitable availability of sphincter preservation.

Survival outcome of operated and non-operated elderly patients with rectal cancer: A Surveillance, Epidemiology, and End Results analysis

BACKGROUND

With an ageing population, surgery is increasingly offered to elderly patients with rectal cancer, although outcomes for the oldest patients remain poorly defined. This study aimed to determine whether operative intervention improves outcome in elderly patients.

METHOD

Patients aged 18+ years diagnosed with rectal adenocarcinoma between 1998 and 2009 were identified from the Surveillance, Epidemiology, and End Results database. The primary endpoint was adjusted hazard ratios (HR) for 5-year cancer specific survival (CSS); the secondary endpoint was 5-year overall survival (OS).

RESULTS

With increasing age, patients were less likely to undergo surgery, receive a complete stage or receive neoadjuvant radiotherapy. CSS and OS increasingly diverged with age in patients undergoing surgery. Those aged 80+ had reduced CSS compared to those aged 70-79 years (stages I-III, respective adjusted HR 2.14, 1.58, 1.48, all p < 0.001). However, stage II patients aged 80+ treated with resection and neoadjuvant therapy had similar survival to those aged 70-79 years (adjusted HR 1.26, p = 0.149). For only patients aged 80+ years, those treated non-operatively had lower survival than those undergoing surgery, who in turn had the best survival when treated with neoadjuvant radiotherapy (adjusted HR 0.74, p = 0.001).

CONCLUSION

Contrary to common expectation, in patients aged over 80 with rectal cancer, surgery with or without other modalities was associated with better survival than non-operative treatment. Despite selection bias in this observational study, these findings support consideration of maximal therapy regardless of age in selected patients deemed to be fit, since this leads to outcomes equivalent to younger patients.