A. N. Kulaylat1, T. M. Connelly1, J. Miller2, N. J. Gusani2, G. Ortenzi1, J. Wong2, N. H. Bhayani2, E. Messaris1 1Penn State Hershey Medical Center,Division Of Colon And Rectal Surgery,Hershey, PA, USA 2Penn State Hershey Medical Center,Division Of General Surgical Specialties & Surgical Oncology,Hershey, PA, USA
Introduction: A diverting stoma is often performed at the time of low anterior resection (LAR) for rectal cancer in patients that have undergone neoadjuvant chemoradiation (nRT) thus protecting the newly created anastomosis by diverting the fecal stream. The aim of this study was to examine large cohort of rectal cancer patients undergoing elective LAR after nRT.
Methods: The National Surgical Quality Improvement Program database records from 2005 – 2012 were utilized to identify patients undergoing LAR for rectal cancer following nRT (ICD-9 diagnosis code 154.*). Patients who underwent emergency resection, had Stage IV disease and/or had a permanent end colostomy were excluded. Patients were grouped for comparison based on Current Procedural Terminology (CPT) codes: diverting stoma (CPT code 44146, 44208) or no diverting stoma (CPT code 44145, 44207). The primary outcomes were postoperative infectious complications, reoperation and mortality.
Results: 1,406 patients were included in the analysis: 607 (43.2%) received a protective stoma and 799 (56.8%) were not diverted. There were no significant differences between the stoma and no stoma groups in demographic variables, comorbidities (except hypertension) or weight loss (p>0.05). The mean body mass index was greater in the stoma group (28.3±7.2 m/kg2 versus no stoma, 27.4±6.6 m/kg2, p=0.02). Although operative time was increased in patients that received a stoma (230±94 minutes versus no ostomy, 218±99 minutes, p=0.02), there were no differences in overall anesthesia time or hospital length of stay (p>0.05). Overall morbidity was 27.3% in the LAR cohort vs 29.7% in the stoma cohort (p>.05). There were no significant differences in deep organ space infection, sepsis and septic shock, unplanned reoperation and overall mortality between the groups (p>0.05).
Conclusion: 1) Diverting stoma does not decrease mortality or infectious complications in rectal cancer patients undergoing a low anterior resection after neoadjuvant radiation. 2) No factors were identified that could assist surgeons in deciding whether to perform a protective ostomy in patients undergoing neoadjuvant radiation and subsequent LAR for rectal cancer. Patients with higher body mass index have higher chances of receiving a protective stoma.