STOMA CLOSURE RATE AND POSTOPERATIVE OUTCOMES IN OLDER ADULTS UNDERGOING RECTAL CANCER SURGERY
Deborah S. Keller*, Hela Saidi, Taylor Ikner, Thais Reif De Paula, John H. Marks
Lankenau Institute for Medical Research, Wynnewood, PA
Background: Temporary diversion can mitigate the impact of anastomotic complications following rectal cancer surgery, but there are high rates of stoma-related morbidity and non-closure. Eligible older adults are reported to experience higher rates of permanent stomas and lower stoma reversal rates than younger patients. As older adults constitute the majority of procedures, reevaluating these rates is critical to guide quality improvement. Our goal was to evaluate ileostomy reversal rates and outcomes in older adults undergoing surgery for rectal cancer. The hypothesis was there are higher closure and lower morbidity rates in older adults than previously reported, showing the feasibility and factors associated with successful closure.
Methods: Review of a prospective cancer registry from a tertiary referral center was performed for patients who underwent curative resection for rectal cancer from 1994-2022. Patients were included if a temporary diverting ileostomy was created at the index operation. Univariate analysis was performed on demographics, clinical, and post-operative outcomes overall and on the older adult cohort(65 and greater). Kaplan-Meier survival analysis evaluated time to stoma closure for age and treatment groups. Cox regression analysis assessed factors associated with non-closure. The main outcome measure was the ileostomy closure rate. Secondary outcomes were time to ileostomy closure and morbidity.
Results: 321 patients were included. Patients were 66.4% male(n=213) with a mean age of 59.2(SD 11.9). 33%(n=107) were older adults. The majority of index operations were laparoscopic overall (59.2%) and robotic in older adults (43.8%). The overall ileostomy reversal rate was 83%(n=265); the rate was similar for younger 84%(n=179) and older adults 80%(n=86, p=.467). Median time to reversal was 7.1[IQR 5.8-10.1] months; reversal times were similar for younger and older patients (7.3[IQR 5.9-10] and 7.0[IQR 5.6-10.4] months, respectively, p=.879). No significant difference in closure time was seen for patients who received adjuvant chemotherapy(p=.121). The morbidity rate was 13.1% overall and in each age cohort. There were 7(2.2%) reoperations, 5(4.7%) in older adults(p<.001). There was no mortality. On regression, there was no independent association for closure or time to closure across age, body mass index, tumor level, comorbidity, operative platform, pathologic T stage, or receipt of adjuvant treatment.
Conclusions: The majority of diverting ileostomies created during rectal cancer surgery are closed despite unfavorable patient and disease characteristics. Specifically, older adults have comparable closure and morbidity rates. Larger scale studies are needed to validate these results so temporary rather than permanent stomas become the standard of care in appropriate patient populations.
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