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Perioperative ostomies among rural and urban patients undergoing colon cancer resection
Sara Myers
*, Elizabeth Davis, Sing Chau Ng, Jennifer Davids, Kelly Kenzik
Boston Medical Center, Boston, MA
Introduction: Rural populations experience higher colorectal cancer (CRC) mortality compared to urban populations. Among individuals who undergo colon cancer (CC) resection, a diverting ostomy performed at the time of oncologic resection may be associated with reduced risk of an anastomotic leak, however this practice is surgeon-dependent. Differences in perioperative diverting ostomies and anastomotic leaks following CC resection among rural and urban patients are not clear.
Methods: We identified patients who underwent CC resection between 2014-2019 from the SEER-Medicare database. We used CPT codes to identify patients who received a stoma at the time of their index operation, as well as those who received a stoma pre-operatively and post-operatively. ICD9/10 codes were used to define the complication of anastomotic leak. We used multivariable logistic regression models to evaluate rural-urban differences in receipt of a perioperative stoma and of experiencing an anastomotic leak. Covariates included age, sex, race, Charlson Comorbidity Index (CCI), and stage of cancer.
Results: Among 31,629 individuals (rural n=5,637, 18%; urban n=25,992, 82%), 38% (n=12,060) received a stoma within 6 months of diagnosis; 5% had a pre-operative stoma, 90% of had a stoma at the time of their index operation, and 5% received stomas post-operatively. Rural individuals had lower odds of receiving a stoma at their index operation compared to urban (OR 0.78, 95%CI 0.63-0.97). However, rural individuals had higher odds of anastomotic leak (OR 1.28, 95%CI 1.09-1.50) as well as higher odds of undergoing a post-operative ileostomy or colostomy (OR 1.28, 95%CI 1.03-1.60). Individuals without an ostomy at the time of their index operation also had higher odds of anastomotic leak (OR 3.77, 95% CI 3.08-4.61) when controlling for age, sex, race, rurality, CCI, and stage.
Conclusions: Diverting ostomies were associated with lower odds of postoperative anastomotic leaks, but rural patients had lower odds of receiving a stoma at the index operation and higher odds of anastomotic leak. Subsequently, rural patients had higher odds of requiring a diverting ostomy post-operatively. To avoid both the morbidity of an anastomotic leak and a return to the operating room for a post-operative ostomy, rural patients may benefit from diverting ostomies at the index operation.
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