Routine diversion after sphincter-sparing rectal surgery tied to poorer outcomes

By Will Boggs MD

NEW YORK (Reuters Health) - 22/2/2019

Routine diversion after sphincter-sparing rectal cancer resection does not reduce anastomotic leaks and is associated with more reinterventions, readmissions, and higher costs, according to a database study.

"These results really highlight the negative sequelae of temporary diversion when used across a population of rectal cancer patients, especially in light of the marginal benefit of stomas," Dr. William C. Chapman, Jr. from Washington University School of Medicine, St. Louis, Missouri told Reuters Health in an email interview.

Studies investigating the effect of diverting stomas on anastomotic leak rates after sphincter-preserving proctectomy have yielded inconsistent results, yet many surgeons routinely divert patients with the intent of decreasing the frequency and severity of these leaks.

Dr. Chapman's team used administrative billing data from the Florida State Inpatient Database for 2005 through 2014 to evaluate outcomes of sphincter-sparing rectal cancer resection among diverted and undiverted patients.

Among 1992 propensity score-matched pairs of patients, the incidence of anastomotic leak did not differ significantly between diverted patients (4.5%) and undiverted patients (4.3%), according to the January 9th online report in the Journal of the American College of Surgeons.

In contrast, significantly more diverted patients than undiverted patients underwent nonelective reintervention (14.1% vs 6.4%, respectively) and readmission (25.7% vs 18.3%) within 90 days of resection.

Median total costs were significantly higher among diverted patients ($21,325 vs $15,050). These differences persisted in multivariable analyses.

"Diverting stomas are not 'free,'" Dr. Chapman said. "Though technically simple to perform, they are associated with a host of negative outcomes, including readmissions, reinterventions, increased costs, and decreased quality of life. Additionally, anastomotic leaks seem to be devastating regardless of whether or not a patient was initially diverted."

"With patients paying such a high price for diverting stomas, surgeons must really consider the benefit they add to a patient's overall care," he said.

"Important clinical variables, namely tumor height, were missing from this dataset and were not able to be analyzed," Dr. Chapman cautioned. "This may have introduced some bias that could not otherwise be accounted for by our study design. Therefore, it would be unwise to apply these results to every patient undergoing rectal surgery for cancer. Instead, we hope that readers will consider the diversion decision carefully and stay tuned to our future efforts to better understand the specific clinical factors that should influence the decision to divert."

The results were presented at the Southern Surgical Association annual meeting, Palm Beach, Florida, in December 2018.

SOURCE: J Am Coll Surg 2019.

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