This analysis's principal findings show that several factors are associated with the odds of receiving a permanent stoma when undergoing surgery for rectal cancer. In our study, these included: age, a higher number of comorbidities, metastatic disease, open surgery, being uninsured or having Medicaid insurance, and having surgery in South West Florida compared to the other parts of Florida.
A post anastomotic leak is one of the most dreaded complications due to an increased risk of mortality and morbidity for the patients (5). A temporary stoma is primarily created to reduce contamination from a leak at the primary anastomosis (9). These are usually reversed in 8 weeks (or sooner), generally following confirmation of satisfactory anastomotic healing by contrast studies (2). In contrast, permanent stomas are most often created in situations where the cancer involves the sphincter, when a negative margin cannot be achieved, in widely metastatic or unresectable diseases, and in prohibitive comorbidities of the patient that preclude anastomoses (10). The most commonly associated complaint with these stomas is an inferior quality of life (11, 12). Reasons for this potentially include a patient’s worsened body image, stoma-specific long and short-term complications, and limitations to daily activities, to name a few (2).
Our study found a higher rate of permanent stomas in patients with comorbidities and the elderly. The surgical approach for these patients should be made on a case-by-case basis, considering the extent of the disease, overall health condition of the patient, preoperative anorectal function, and the surgeon’s experience in dealing with such cases. Suboptimal disease control in these patients can result in a local recurrence; local recurrence being the most consistent risk factor for permanent stoma in the literature (13). Despite the extensive efforts in sphincter preservation, some patients eventually require a permanent stoma. Elderly patients with a poor sphincter would have a poor quality of life if intestinal continuity restoration resulted in fecal incontinence. Sometimes an anastomosis is technically doable, but even if that was the case, in some patients we would not want to do an anastomosis in the off chance that they have a leak, which would be a life ending event for them(13).
Our analysis of socioeconomic factors revealed that individuals on Medicaid insurance had a higher odds of receiving a permanent stoma than those on Commercial insurance. Multiple studies have previously reported similar findings (14, 15). These results may be explained by differences associated with the severity of disease. Previous work has identified that Medicaid patients tend to seek or receive care in the more advanced stages of the disease (4), making them more likely to receive a permanent stoma as an outcome of surgery. Though there are other possible factors involved, these are likely the main contributors for this cohort of patients.
The second part of our analysis focused on evaluating the factors that impact LOS for patients undergoing surgery for rectal cancer. We found these to be both patient and treatment specific. In recent years, LOS has progressively decreased. While this aspect is promising and not wholly unexpected, it is multifactorial and isn't easy to fully understand based solely on the data provided in this analysis. The literature has already widely described that patients with more comorbidities, metastatic cancer, or receiving open surgery often require a more extended stay in the hospital (16, 17). These aspects directly impact the clinical recovery of such patients as longer perioperative treatments, multidisciplinary procedures or exams, and additional care is needed. Our analysis further reflected these facts.
Significant disparities were reported for African American patients and those covered by Medicaid. Race and insurance status are among the most common variables associated with healthcare disparities (18, 19). These findings have been previously reported in different settings and conditions (20, 21). Sharp et al. demonstrated that African American patients undergoing the creation of an intestinal stoma had a higher complication rate and a longer LOS than Caucasian patients (22). Further, Hecht et al. suggested that race and socioeconomic status, such as low income, could predict who may suffer from poorer surgical outcomes (23).It is not entirely clear how such factors interact and, ultimately, how disparities occur. Merely looking at the healthcare policies might not be enough, since a more complex interaction of social, cultural, and psychological factors is also responsible. This interaction may differ from state to state, given the population’s heterogeneity in many of these aspects, including racial distribution, median income, level of education, and healthcare facilities distribution.
Limitations of this study include those involved in retrospective analyses of the database available on AHCA. For example, limited control of confounders, selection bias, and a high reliance on accurate data-keeping have to be considered. It is well known that types and the stage of cancer significantly influence the type of surgery performed on patients. Given the database's nature, we could not adjust for disease stage except for patients with metastatic cancer. This inability to adjust for the cancer stage could represent a confounder as more advanced stages may require a more extended procedure and a justified need for a permanent stoma. Additionally, lack of this information also limits our scope to accurately capture data about those temporary stomas, which were not reversed eventually. Since this critical information was unavailable to us, it forms a major limitation of our study. The available dataset also did not provide information regarding postoperative complications and readmissions. The availability of this data would have helped form better associations with the LOS in these patients. This study's findings can be used to formulate prospective studies in the future to establish these associations further. Additionally, since this database represents patients only in Florida, it may have limited generalizability at the national level.