A. Sunkerneni1, R. J. Kucejko1, D. E. Stein1, J. L. Poggio1 1Drexel University College Of Medicine,Surgery,Philadelphia, PA, USA
Introduction: Proximal intestinal diversion is often thought to protect colorectal anastomoses from leak, and reduce leak-related morbidity. While data for rectal cancer convincingly shows improvement in outcomes, the results for abdominal anastomoses are mixed. Yet, patients are being diverted, incurring the increased morbidity and mortality surrounding the reversal of stomas without clinical benefit. Prior studies of abdominal anastomoses have been done on limited patient numbers, and did not control for pre-operative morbidity. The American College of Surgeons’ (ACS) National Surgical Quality Improvement Program (NSQIP) has collected the largest dataset on anastomotic leak to date. Our aim is to determine risk-adjusted post-operative outcomes including anastomotic leak on patients undergoing colorectal anastomosis to determine which patients receive the most benefit from diversion.
Methods: A retrospective analysis of the ACS NSQIP Procedure Targeted Colectomy database from 2012 to 2015 was performed. All patients 18 to 90+ years old in the targeted colectomy database were included. Patients were excluded if any CPT code corresponded to a surgery that did not have an anastomosis, or a surgery with a pelvic anastomosis, or if their leak status was unknown. Post-operative outcomes were analyzed using chi-squared and Mann-Whitney U tests. Propensity score-matched cohorts were developed using the NSQIP morbidity score. The primary outcomes were 30-day mortality, 30-day reoperation rate, and anastomotic leak.
Results: 61,161 patients underwent abdominal colorectal anastomosis over the 4-year period. 8,352 (13.7%) underwent emergent surgery, and were diverted 30.5% of the time, compared to the non-emergent diversion rate of 11.4%. Matched patients who were emergently diverted had significant improvements in prolonged intubation, septic shock, 30-day return to OR, mortality rate, and operative leak rate, with no significant difference in other outcome measures. Matched patients who were non-emergently diverted were only noted to have significant improvements in post-operative pneumonia, rate of reintubation, mortality and operative leak rate. More importantly, these patients had significantly worse rates of organ space infections, AKI, UTI, DVT, sepsis, return to OR and 30-day readmission.
Conclusion: Proximal fecal diversion for abdominal colorectal anastomosis is a known trade-off between immediate protection and long-term morbidity. In emergent cases, significant improvements in mortality and leak rate are seen without significant rises of other complications, suggesting the right patients are being diverted. But, in non-emergent cases, many operative sequela are made worse by diversion, with only modest improvements in leak rates and 30-day mortality. Surgeons would benefit from a decision tool to better stratify patients undergoing non-emergent abdominal anastomoses to aid in optimal patient selection.