Optimal Treatment Strategy in Rectal Cancer Surgery: Should We Be Cowboys or Chickens?
Optimal Treatment Strategy in Rectal Cancer Surgery: Should We Be Cowboys or Chickens?
Heleen S. Snijders 2
Nicoline J. van Leersum 2
Daan Henneman 2
Alexander C. de Vries 1
Rob A. E. M. Tollenaar 2
Anne M. Stiggelbout 0
Michel W. J. M. Wouters 4
Jan Willem T. Dekker 3
H. S. Snijders
0 Department of Medical Decision Making, Leiden University Medical Center , Leiden , The Netherlands
1 Department of Surgery, Medical Center Haaglanden , The Hague , The Netherlands
2 Department of Surgery, Leiden University Medical Centre , Leiden , The Netherlands
3 Department of Surgery, Reinier de Graaf Gasthuis , Delft , The Netherlands
4 Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital , Amsterdam , The Netherlands
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 Heleen S. Snijders and Nicoline J. van Leersum contributed equally to this work.
The Author(s) 2015. This article is published with open access
Surgical resection is the cornerstone of rectal cancer
treatment. If tumor size, stage, and location allow for a
sphincter-preserving resection, and bowel continuity is
restored, the surgeon has to decide whether or not to
defunction the anastomosis. The advantage of a defunctioning
stoma can be that it decreases the consequences of
anastomotic leakage, and may also decrease its incidence.1,2
Anastomotic leakage is a serious complication causing
reoperation, prolonged hospital stay, morbidity, mortality,
and possibly worse oncological outcome35 On the other
hand, a stoma has evident disadvantages; defunctioning
stomas can induce morbidity, discomfort (decreased
quality of life), higher costs,6 longer hospitalization,7 and even
mortality from surgery to close the stoma812 Furthermore,
80 % of defunctioning stomas are only reversed after
4 months, and 20 % are never reversed.13
Nowadays, quality of care has become a major topic,
and surgeons and hospitals are increasingly accountable for
their postoperative complication rates. This may lead to
risk adverse treatment strategies. Previous research
suggests that differences in professional opinion may lead to
variation in healthcare delivery1421 The threshold for the
decision to construct a stoma to avoid the risk for
anastomotic leakage may also vary between surgeons. Some
surgeons may be bigger risk takers or more risk adverse
than others. However, attempts to avoid or limit the risk for
anastomotic leakage after colorectal surgery by frequent
use of stomas is only in the patients interest if it in fact
lowers clinically relevant anastomotic leakage and
The objective of this study was to investigate whether
hospitals differ in their treatment strategy regarding
construction of defunctioning stomas in rectal cancer surgery,
and to assess if a hospitals treatment strategy is related to
its postoperative outcomes, such as clinically relevant
anastomotic leakage and mortality rates.
Data were derived from the Dutch Surgical Colorectal
Audit (DSCA). The DSCA contains data registered by 92
hospitals (representing all hospitals performing colorectal
cancer surgery in The Netherlands), and over 90 % of all
eligible patients are included. The dataset is disease-specific
for colorectal cancer and has shown a nearly 100 %
concordance on most items upon validation against the
Netherlands Cancer Registry dataset.22 All patients having
undergone anterior resection for primary rectal cancer
between 1 January 2009 and 31 July 2012 were evaluated.
Minimal data requirements for inclusion in the analysis were
information on tumor location, date of surgery, and
mortality. Patients without an anastomosis, with metastasis at the
time of primary surgery, resections for multiple synchronous
colorectal tumors, and with a tumor less than 5 cm from the
anal verge were excluded because these represent subgroups
of patients with specific treatment perspectives and
subsequent different expected outcomes.
Overall anastomotic leakage, as used in the hospital
comparisons, was defined as clinically relevant
anastomotic leak requiring a re-intervention, either radiological
(mild) or surgical (severe). Postoperative mortality was
defined as in-hospital mortality or all deaths within
30 days after primary surgery.
The following case-mix factors were considered: age, sex,
American Society of Anesthesiologists (ASA) classification,
abdominal surgical history, tumor height, preoperative
tumor complications, and urgency of the resection. Considered
treatment factors were surgical procedure (laparoscopic or
open), and neoadjuvant treatment.
Hospitals were stratified into non-teaching and teaching
hospitals. Procedural volume in rectal cancer resections
was calculated for each hospital before the aforementioned
exclusion of patients, and categorized into \25, 2550 and
[50 resections per year.
As patient- and tumor-related case-mix factors may be
responsible for a large part of the hospital variation in the
proportion of patients with a defunctioning stoma, we adjusted
for these differences by calculating the observed/expected (O/
E) stoma rate. The observed outcome was the number of
patients with a defunctioning stoma in a hospital, and the
expected outcome was the sum of all patients estimated
probabilities for a defunctioning stoma. Patients probability
estimates were derived from a backwards stepwise
multivariate logistic regression model, fitted on the data of all
included hospitals, and using all case-mix factors mentioned
above. For an average performing hospital, the observed
outcome will be equal to the expected outcome, resulting in an
O/E outcome ratio of 1. Hospitals that construct more
defunctioning stomas than average have an O/E outcome ratio
higher than 1, while this ratio is lower than 1 in hospitals with
lower than average stoma rates.
The adjusted O/E ratios of the hospitals were plotted
against their anastomotic leakage rates.
The relation between the hospitals strategy and its
outcomes was analyzed by two methods. First, to evaluate whether
stoma rates were related to (lower) anastomotic leakage rates
on a hospital level, a linear correlation was calculated using
Pearsons correlation coefficient R. Second, to evaluate
whether a risk adverse strategy (high stoma rates) is related to better
postoperative outcomes on a hospital level, hospitals were
grouped into equally-sized groups based on quintiles of their
case-mix-adjusted rate of defunctioning stomas.
Differences between groups in outcomes (mild and
severe anastomotic leakage and mortality rates) were
analyzed using a Chi square test.
The association of patient- and tumor-related case-mix
factors, hospital factors (teaching status, volume), and
treatment factors (neoadjuvant therapy, laparoscopic surgery) with
being in the high stoma group was assessed with a Chi square
test and multivariate logistic regression analysis, considering
the same case-mix factors as mentioned above. All statistical
analyses were performed in PASW Statistics, IBM
Corporation (previously SPSS Software, Armonk, NY, USA).
ASA American Society of Anesthesiologists risk score
After exclusion of ineligible patients, a total of 3,104
patients were included in the analysis. Characteristics of the
included patients and hospitals are shown in Table 1.
Overall, 67 % (n = 2,080) of all patients received an
anastomosis with a defunctioning stoma.
In total, 302 patients (9.6 %) developed anastomotic
leakage. The majority (187 of 302, 62 %) were severe
leakages requiring surgical reintervention. Anastomotic
leakage rates were somewhat higher in patients with a
defunctioning stoma (9.3 vs. 10.4 %), but this difference
was not statistically significant (p = 0.35). Fifteen of 302
patients who developed anastomotic leakage died during
their hospital stay or within 30 days after surgery (5 %).
Overall postoperative mortality rate was 1.8 % (n = 187);
anastomotic leakage caused one-quarter of overall
mortality. There was no difference in overall mortality rate
between both groups1.3 % in patients without stoma
versus 2.1 % in patients with stoma (p = 0.11).
Relevant case-mix factors were selected by backward
stepwise logistic regression analysis. Relevant factors for
the proportion of defunctioning stomas were sex,
preoperative complications, tumor location, and laparoscopic
The hospitals unadjusted proportion of defunctioning
stomas varied considerably: percentages ranged from 0 to
100 % (Fig. 1). Figure 2 shows the relation between the
hospitals adjusted proportion (O/E ratio) of defunctioning
stomas and their overall anastomotic leakage rate (which
varied from 3 to 18 %). There was a weak positive
correlation between the hospitals adjusted O/E stoma ratio and
anastomotic leakage rates (r = 0.032), although this was
not statistically significant (p = 0.76).
Low Versus High Stoma Rate
Eighteen hospitals with a total of 604 patients were
identified as the group with low stoma rates. This group
had a mean percentage of 26 % of patients with a
defunctioning stoma. The group with high stoma rates
consisted of 18 hospitals, which treated 521 patients in
total, and had an 88 % mean defunctioning stoma rate
A slight difference in overall anastomotic leakage rates
was found between groups, although this not statistically
significant (8.4 vs.11.3 %; p = 0.11). Severe anastomotic
leakage rates were similar in both groups (7.1 vs. 7.5 %;
p = 0.95, while mild anastomotic leakage rates were
significantly higher in the group with high stoma rates (1.5 vs.
3.8 %; p \ 0.001). Postoperative mortality rates were
significantly higher in the group with high stoma rates (2.9 vs.
1.0 %; p = 0.02). The remaining hospitals formed a group
with intermediate stoma rates (67 %), and had outcomes
between the low and high stoma groups (9.7 %
anastomotic leakage, 1.7 % mortality).
Table 2 shows the results of univariate and multivariate
analysis for factors contributing to the odds of being in the
group with high stoma rates. The percentage of patients
treated with short-course radiation therapy (SCRT) was
higher in the group with high stoma rates, as was the
percentage of patients treated in teaching hospitals.
In addition, in multivariate analysis these patients had
higher odds of being in the group with high stoma rates. In
FIG. 1 Hospitals ranked by their
casemix-adjusted defunctioning stoma rate.
Based on quintiles, groups of low (left)
and high (right) stoma rates were
FIG. 2 Adjusted defunctioning stoma
O/E rates of hospitals, plotted against
their anastomotic leakage rates. O/E
both univariate and multivariate analysis, urgent resections
and volume were associated with a lower risk of being
treated in a hospital with a high stoma rate (Table 2). Other
case-mix factors, such as age, ASA score and tumor
characteristics, were not statistically different in both
Overview of Findings
This study demonstrates a large variation between
hospitals in treatment strategy concerning defunctioning stoma
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)
Low stoma rate (n=604)
High stoma rate (n=521)
Anastomotic Severe anastomotic Mild anastomotic Postoperative
leakage leakage leakage mortality
construction after surgical resection of rectal cancer, even
after adjustment for relevant case-mix factors. Hospitals
with a low threshold for defunctioning stoma construction
after rectal cancer resection did not have lower anastomotic
leakage rates in comparison with hospitals with an opposite
strategy. Interestingly, mortality and anastomotic leakage
rates requiring radiological drainage were even higher in
hospitals with a high stoma rate. The latter may be partly
due to the slight difference in SCRT between both groups.
Although a direct correlation between clinically apparent
anastomotic leakage and neoadjuvant therapy has not been
demonstrated4,2326 den Dulk et al. showed SCRT to be a
limiting factor for reversal of a (secondary) constructed
stoma, suggesting that it increases the risk for subclinical
or mild anastomotic leakage.10
An explanation for the remarkable correlation between a
risk adverse strategy and low hospital volume or teaching
status cannot be provided within the scope of this article.
These hospitals may possibly use other selection criteria
for defunctioning stomas, or treat patients with an impaired
condition which could not be adjusted in this study.
Comparison with Other Studies
There is ongoing debate on the differences in treatment
approach despite ample data describing the direct
correlation between the rate of both defunctioning stomas on the
one hand and anastomotic leakage and postoperative
mortality on the other. The discussion focuses mainly on
whether defunctioning stomas should be used routinely
after low anterior resection to decrease anastomotic
leakage rates. A meta-analysis from Hu ser et al.1 mainly
based on the results of a randomized controlled trial from
Matthiessen et al.2 clarifies the advantage of a
defunctioning stoma on lowering anastomotic leakage rates. This
is confirmed by a number of retrospective studies.4,2729 On
the contrary, a study from Fielding et al.30 observed a
higher leakage rate in patients with a defunctioning stoma
(18 vs. 7 %) and suggested that surgeons with an individual
anastomotic leakage rate less than 5 % do not need to
create a defunctioning stoma at all. Both Enker et al. and
Matthiessen et al. showed that a defunctioning stoma did
not reduce the incidence of anastomotic leakage in patients
undergoing low or ultralow anterior resection.7,31
Strengths and Limitations of the Study
We retrospectively evaluated a prospectively
maintained, population-based database to determine the
association between the hospitals strategy regarding
defunctioning stoma construction and postoperative outcome
in rectal cancer. It could be argued that comparing patient
outcomes for patients with and without a stoma is not valid
because of confounding by indication; patients may have
received a stoma because they were considered to be high
risk patients and are therefore not comparable to patients
who did not receive a defunctioning stoma. This bias could
also explain the relatively high mortality in the group with
high stoma rates; however, in our study this bias is largely
overcome by comparing hospitals at both ends of the
spectrum (either very high or very low defunctioning stoma
rates). Defunctioning stoma rates of 88 and 26 %,
TABLE 2 Univariate and multivariate analysis for factors contributing to being in the group with high stoma rates
Cowboys [n (%)]
Chickens [n (%)]
Bolded data indicate statistically significant (p \ 0.05)
OR odds ratio, CI confidence interval, ASA American Society of Anesthesiologists
a ORs display the odds for being in the group with high stoma rates
respectively, reflect a strategic approach (standard with a
stoma or standard without a stoma), which is only slightly
based on individual decision making concerning patient
characteristics. It is likely that only very high risk patients
received a stoma in both groups, and very low-risk patients
in both groups did not. For other patients, the decision was
mainly based on the strategic approach of the hospitals.
Therefore the method we used resembles a pseudo
randomization. This is supported by the fact that baseline
characteristics were similar for both groups in our study.
These findings are very useful for clinical practice because
they strengthen the concept that the decision of stoma
formation after anterior rectal resection cannot be standardized
but requires careful evaluation of individual risk factors. Data
represent current surgical practice at a population level since
all hospitals participate in the DSCA and the percentage of
eligible patients registered is over 90 %.
A limitation of this study is that analyses were
performed at a hospital level, while the surgical strategy may
differ between surgeons within a hospital. Information on a
surgeons level is not available in the DSCA and individual
volumes may be low, introducing more impact of chance
variation in the analyses.
Should we then be cowboys or chickens, if the latter
does not necessarily result in better outcomes? The results
confirm that the protective effect of a defunctioning stoma
is probably most apparent in high-risk patients, while the
additional benefit for the rest of the population is limited or
even non-existent. There have been numerous studies
identifying risk factors for anastomotic leakage.913 Dekker
et al. developed and tested the colon leakage score (CLS)
in which multiple risk factors were used to provide an
objective prediction of the risk for anastomotic leakage.32
They found that only 20 % of their population could be
considered as high risk. If we take into account the relative
risk reduction of 64 % that was found in the randomized
trial of Matthiessen et al. (reduction in anastomotic leakage
from 28 to 10 %) for high-risk patients with an
hypothetical a priori risk of anastomotic leakage of 20 %, this
would mean an absolute risk reduction (ARR) of 12.8 %,
and therefore eight defunctioning stomas would have to be
constructed in order to prevent one anastomotic leak. In
contrast, for patients with an a priori risk of 5 % (ARR
3.2 %), 31 defunctioning stomas would have to be created
to prevent one leak.
It should therefore be kept in mind that stomas can induce
morbidity, discomfort (quality of life), costs, and even
mortality. Stomal complications cause readmission within
2 months after initial surgery in up to 17 % of all patients,
mostly due to dehydratation.9,11,33,34 Even when a
defunctioning stoma is constructed, there is still a considerable risk
of (late) anastomotic leakage2,4,3537 A recent study from our
group on 1-year follow-up data shows a significant higher
morbidity rate in patients with a defunctioning stoma when
compared with patients without, due to unplanned
readmissions (18 %) and reinterventions (12 %) caused by
anastomotic leakage and drainage of abscesses.37 It is also
recognized that 1530 % of defunctioning stomas are never
closed, resulting in a permanent stoma.10,38 Future studies
are important to gain more evidence on the possible benefits
of defunctioning stomas in high- and low-risk patients.
Finally, we advocate that patients preferences
concerning the risk of morbidity and mortality of anastomotic
leakage versus the consequences of a defunctioning stoma
should be taken into account preoperatively.
A high tendency towards defunctioning stoma
construction in rectal cancer surgery did not result in lower
overall anastomotic leakage or mortality rates. The optimal
treatment strategy can probably be found in hospitals with
both low stoma rates and favorable postoperative
outcomes. It seems that hospitals with low stoma rates were
better in selecting high-risk patients, and that stoma
formation in more patients does not lead to better outcomes.
Adequate identification of high-risk patients should be
the focus of future studies in order to facilitate decision
ACKNOWLEDGMENTS The authors would like to thank all
surgeons, registrars, physician assistants, and administrative nurses
who registered all the patients in the DSCA, as well as the DSCA
Group and the Methodological Board for their advice.
Open Access This article is distributed under the terms of the
Creative Commons Attribution License which permits any use,
distribution, and reproduction in any medium, provided the original
author(s) and the source are credited.
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