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. 2015 Oct;22(11):3582-9.
doi: 10.1245/s10434-015-4385-7. Epub 2015 Feb 18.

Optimal Treatment Strategy in Rectal Cancer Surgery: Should We Be Cowboys or Chickens?

Heleen S Snijders  1 , Nicoline J van Leersum  2 , Daan Henneman  2 , Alexander C de Vries  3 , Rob A E M Tollenaar  2 , Anne M Stiggelbout  4 , Michel W J M Wouters  5 , Jan Willem T Dekker  6
Affiliations

Optimal Treatment Strategy in Rectal Cancer Surgery: Should We Be Cowboys or Chickens?

Heleen S Snijders et al. Ann Surg Oncol. 2015 Oct.

Abstract

Background and purpose: Surgeons and hospitals are increasingly accountable for their postoperative complication rates, which may lead to risk adverse treatment strategies in rectal cancer surgery. It is not known whether a risk adverse strategy leads to providing better care. In this study, the association between the strategy of hospitals regarding defunctioning stoma construction and postoperative outcomes in rectal cancer treatment was evaluated.

Methods: Population-based data of the Dutch Surgical Colorectal Audit, including 3,104 patients undergoing rectal cancer resection between January 2009 and July 2012 in 92 hospitals, were used. Hospital variation in (case-mix-adjusted) defunctioning stoma rates was calculated. Anastomotic leakage and 30-day mortality rates were compared in hospitals with a high and low tendency towards stoma construction.

Results: Of all patients, 76 % received a defunctioning stoma; 9.6 % of all patients developed anastomotic leakage. Overall postoperative mortality rate was 1.8 %. The hospitals' adjusted proportion of defunctioning stomas varied from 0 to 100 %, and there was no significant correlation between the hospitals' adjusted stoma and anastomotic leakage rate. Severe anastomotic leakage was similar (7.0 vs. 7.1 %; p = 0.95) in hospitals with the lowest and highest stoma rates. Mild leakage and postoperative mortality rates were higher in hospitals with high stoma rates.

Conclusions: A high tendency towards stoma construction in rectal cancer surgery did not result in lower overall anastomotic leakage or mortality rates. It seems that the ability to select patients for stoma construction is the key towards preferable outcomes, not a risk adverse strategy.

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Figures

Fig. 1
Fig. 1
Hospitals ranked by their case-mix-adjusted defunctioning stoma rate. Based on quintiles, groups of low (left) and high (right) stoma rates were identified
Fig. 2
Fig. 2
Adjusted defunctioning stoma O/E rates of hospitals, plotted against their anastomotic leakage rates. O/E observed/expected
Fig. 3
Fig. 3
Comparison of outcomes between the groups identified as low and high stoma rates. Results with an asterisk are considered statistically significant (p < 0.05)
See this image and copyright information in PMC

References

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