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FECAL DIVERSION IN RECTAL CANCER PATIENTS UNDERGOING SPHINCTER SAVING RESECTION IS ASSOCIATED WITH A HIGHER MORBIDITY AND READMISSION RATE BUT A LOWER REOPERATION RATE VS NON-DIVERTED PATIENTS.
Hiromichi Miyagaki*1,2, Chandana Herath Mudiyanselage2, Erica Pettke2, Abhinit Shah2, Xiaohong Yan2, Vesna Cekic2, Richard L. Whelan2
1Surgery, Saisekai Senri Hospital, Suita, Osaka, Japan; 2Surgery, Mount Sinai West Hospital, New York, NY
Introduction: A diverting stoma is thought to minimize the consequences of anastomotic leakage after rectal surgery. This study’s purpose was to compare the outcomes of diverted vs non-diverted rectal cancer patients who underwent proctectomy and anastomosis.
Methods: The data used for this study was obtained from the NSQIP database which was queried for elective low anterior resection (LAR) for rectal cancer in 2012-14. Exclusion criteria were: totally dependent health status, ventilator dependence, sepsis, emergency cases and ASA status 5. Reasons for first reoperation or first readmission were judged comprehensively with ICD9, CPT codes provided in the database. Demographic parameters, comorbidities, postoperative complications and reasons for reoperation/ readmission were assessed. The log regression analysis was used for multivariate analysis regarding risk factors for organ space SSI, reoperation and readmission with demographic data, >1 comorbidities and operative data.
Result: A total of 6137 cases were identified; the cancer location was rectosigmoid (ICD-9:154.0) in 2007 and rectum (154.1) in 4130. Laparoscopic methods used in 3441 patients (56.1%) and fecal diversion (FD) was carried out in 2696 (43.9%). Risk factors for FD were male sex, young age, smoking, higher ASA class, and rectal cancer diagnosis(ICD-9: 154.1). The FD group had a longer mean LOS (7.4±6.2 days) vs the non-diverted (ND) group (5.9±4.9, p<0.0001), a higher morbidity rate (26.2% vs.19.3%, p<0.0001) and higher readmission rate (15.1% vs. 7.9%, p<0.0001). The FD group (vs ND group) had significantly higher rates of sSSi (6.6 vs 4.4%), organ space SSI (7.2 vs 5.4%), renal complications (3.3 vs 1.2%), bleeding/transfusion (8.3 vs 6.1%), and DVT(1.4 vs 0.5%). Of note, despite the notably higher organ space SSI rate, the FD reoperation rate (4.8%) was lower than that of the ND group (6.0%, p=0.0321). Multivariate analysis revealed that FD was an independent risk factor for readmission and reoperation. Yet, significantly fewer FD patients with organ space SSI underwent reoperation (vs ND group). Also the FD group had more readmissions for SBO and dehydration/electrolyte imbalance (P<0.001).
Conclusions: The lack of information about the precise cancer location (distal, middle, proximal) and reason for diversion are study weaknesses that makes direct comparison of FD and ND groups difficult. It is likely that, in general, the FD group had more distal cancers and more challenging pathology and operations. Thus, the higher rate of complications (including organ space SSI) in the FD group cannot be attributed to diversion alone. This analysis does demonstrate that fecal diversion is associated with a decreased risk of reoperation despite the notably higher morbidity and readmission rates. Also, diverted patients have a higher risk of readmission for SBO and dehydration.
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