P-345 - Temporary stoma rates as a marker of quality in rectal cancer surgery in a high volume UK hospital

Date 04 July 2015
Event WorldGI 2015
Session Posters
Topics Rectal Cancer
Surgery and/or Radiotherapy of Cancer
Presenter S. Yoganathan
Citation Annals of Oncology (2015) 26 (suppl_4): 1-100. 10.1093/annonc/mdv233
Authors S. Yoganathan1, K. Goonetilleke2, S. Bassiony1, S. Pandey1
  • 1Worcester Royal Hospital, Worcester/UK
  • 2Worcestershire Acute Hospitals NHS Trust, Worcester/UK

Abstract

Introduction

Permanent stoma rate continues to be one of the quality indicators for rectal cancer management. National Bowel Cancer Audit 2013 (United Kingdom) annual report quotes a non-closure rate 30% or more of “temporary” stomas in rectal cancer surgery. This is considered to be reflective of poor quality of rectal cancer care. Temporary defunctioning ileostomy can reduce the consequences of anastomotic leak following anterior resection. However some patients never have their ileostomy reversed and in other cases the time to reversal of ileostomy can be delayed. The aim of this study was to identify the ileostomy closure rate following anterior resection.

Methods

A prospectively maintained data base of patients undergoing colorectal cancer resections in one of the large volume hospital trusts in the UK was analysed from 2011 to 2014 to assess the stoma rates, recanalisation and timings to reversal. The data base was verified against electronic records of radiology, endoscopy and clinic letters to ensure accuracy.

Results

A total of 278 patients underwent curative surgery for rectal cancer. 207 had anterior resections (74.5%), 30 Hartmanns (10.7%) and 41 (14.8%) abdomino perineal resections. Overall 53.6 per cent of rectal cancer patients had a stoma at the time of a surgical resection. This included all cases of APER and Hartman's but in addition 28.5 per cent of all anterior resections were covered by an ileostomy. Out of the ileostomies 52.5% were reversed. The mean time to reversal was 6 months (2-14 month). The mean time delay from clinic decision to contrast enema/endoscopy and actual reversal were 34.5 days and 5 months respectively. The main reasons for delayed reversal were adjuvant chemotherapy and for non reversal was that patients were still awaiting reversal although they had been seen in clinic.

Conclusion

Restorative resection rate per se (low permanent stoma rate) for low rectal cancers continues to be regarded as a national surrogate marker of surgical quality. One in two defunctioning ileostomies is not closed following anterior resection. Of those that are closed, approximately 50% have delayed closure beyond 6 months. An outcome audit is the best performance indicator for a colorectal unit. However, due consideration should be given to prevalence of ultra low rectal cancers, site of the tumour, preoperative poor sphincter function and patient fitness. Permanent stoma may not necessarily be a true depiction of quality of surgical care especially in the presence of MDT decisions where management plans are made preoperatively.