First, Do No Harm: Rethinking Routine Diversion in Sphincter-Preserving Rectal Cancer Resection - 17/03/19

Doi : 10.1016/j.jamcollsurg.2018.12.012

William C. Chapman, MD, MPHS ^a,^⁎ , Melanie Subramanian, MD ^a, Senthil Jayarajan, MD ^a, Bilal Makhdoom, BS ^a, Matthew G. Mutch, MD, FACS ^a, Steven Hunt, MD, FACS ^a, Matthew L. Silviera, MD ^a, Sean C. Glasgow, MD, FACS ^a, Margaret A. Olsen, PhD MPH ^b, Paul E. Wise, MD, FACS ^a
^a Department of Surgery, Division of General Surgery, Washington University School of Medicine, St Louis, MO
^b Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St Louis, MO

^∗Correspondence address: William C Chapman Jr, MD, MPHS, Department of Surgery, Division of General Surgery, Washington University School of Medicine, Campus Box 8109, 660 S Euclid Ave, St Louis, MO 63110.Department of SurgeryDivision of General SurgeryWashington University School of MedicineCampus Box 8109660 S Euclid AveSt LouisMO63110

Abstract

Background

Although diverting stomas have reduced anastomotic leak rates after sphincter-preserving proctectomy in some series, the effectiveness of routine diversion among a broad population of rectal cancer patients remains controversial. We hypothesized that routine temporary diversion is not associated with decreased rates of leak or reintervention in cancer patients at large undergoing sphincter-sparing procedures.

Study Design

The Florida State Inpatient Database (AHRQ, Healthcare Cost and Utilization Project) was queried for patients undergoing sphincter-preserving proctectomy for cancer (2005 to 2014). Matched cohorts defined by diversion status were created using propensity scores based on patient and hospital characteristics. Incidence of anastomotic leak, nonelective reintervention, and readmission were compared, and cumulative 90-day inpatient costs were calculated.

Results

Of 8,620 eligible sphincter-sparing proctectomy patients, 1,992 matched pairs were analyzed. Leak rates did not significantly vary between groups (4.5% vs 4.3%; p = 0.76), but diversion was associated with significantly higher odds of nonelective reintervention (2.37; 95% CI 1.90 to 2.96) and readmission (1.55; 95% CI 1.33 to 1.81) compared with undiverted patients. Median costs were higher among those diverted (US$21,325 vs US$15,050; p < 0.01).

Conclusions

No association between diversion and anastomotic leak was found. However, temporary diversion was associated with increased incidence of nonelective reinterventions, readmissions, and higher costs. We therefore challenge the paradigm of routine diversion in rectal cancer operations. Additional study is needed to identify which patients would benefit most from diversion.

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Plan

Methods

Patient selection and exclusion

Independent variables

Propensity score matching

Disclosure Information: Nothing to disclose.

Support: Research reported in this publication was supported by the Washington University School of Medicine Surgical Oncology Basic Science and Translational Research Training Program grant T32CA009621 from the National Cancer Institute. The Washington University Center for Administrative Data Research is supported in part by the Washington University Institute of Clinical and Translational Sciences grant UL1 TR002345 from the National Center for Advancing Translational Sciences of the NIH, and grant number R24 HS19455 through the AHRQ.