Do older Americans undergo stoma reversal following low anterior resection for rectal cancer?

Abstract

3656 Background: Recent studies demonstrate that proximal diversion can decrease rates of anastomotic leak and subsequent morbidity and mortality after sphincter-preserving surgery for low lying rectal cancer. However, not all patients who receive a “temporary” diverting stoma undergo reversal. Studies suggest that delay and failure to undergo reversal may be associated with age among other factors. Methods: This is a retrospective population-based cohort study. Using SEER-Medicare linked data, we identified 1028 primary stage I-III rectal cancer patients diagnosed 1991-2005 and undergoing low anterior resection (LAR) with creation of a diverting stoma. We evaluated the proportion of patients who had stoma reversal within 18 months of primary resection and the timing of reversal with respect to initial surgery. Patient, clinical and hospital characteristics were included in a multivariable logistic regression model with random hospital effects to determine likelihood of reversal. A Cox proportional hazard model was fit for time to reversal, accounting for clustering within hospitals when calculating p-values. Results: Within 18 months of LAR, 49% (502/1,028) of patients underwent stoma reversal. Patients were more likely to have their stoma reversed if they were <80 years old (OR 2.8 [95% CI 2.1, 3.9]), had no comorbidities (OR 1.7 [95% CI 1.3, 2.2]), lower tumor stage (1 vs. 3; OR 2.0 [95% CI 1.3, 3.0]), received neoadjuvant radiation (OR 2.4 [95% CI 1.7, 3.4]), and were married (OR 1.5 [95% CI 1.1, 2.0]). Median time to reversal was 288 days (95% CI: 237- 385). Shorter time to reversal was associated with younger age (p < 0.0001) less comorbidity (p = 0.013), lower tumor stage (p = 0.0003), receipt of neoadjuvant radiation (p < 0.0001), and rectal tumor location (vs. rectosigmoid, p = 0.022). Conclusions: Over half of rectal cancer patients over the age of 65 who undergo sphincter-sparing surgery with temporary stoma have not undergone stoma reversal by 18 months. For those reversed, this usually is performed 8-12 months after LAR. Identifiable risk factors predict both delay and nonreversal. It is critical that providers are aware of and include this information in preoperative discussions with elderly rectal cancer patients. No significant financial relationships to disclose.