title: The status of radical proctectomy and sphincter-sparing surgery in the United States.
abstract: OBJECTIVE
  Worldwide, "centers of excellence" in rectal cancer surgery report high rates of anal sphincter-sparing surgery (70-90 percent) after proctectomy. The rate of sphincter-sparing surgery with reestablishment of intestinal continuity in the general population of the United Stares is unknown.
  
  
  METHODS
  We used data from the Nationwide Inpatient Sample, a 20 percent stratified random sample of patients admitted to hospitals in the United States. We identified patients with rectal cancer from 1988 through 2003 who underwent sphincter-sparing surgery with reestablishment of intestinal continuity or proctectomy with colostomy. To determine predictors of sphincter-sparing surgery with reestablishment of intestinal continuity, we constructed a multivariate model that analyzed patients' age, gender, race, insurance status, and income level.
  
  
  RESULTS
  During our 16-year study period, radical extirpative procedures were performed in 41,631 patients: 16,510 (39.7 percent) sphincter-sparing surgery with reestablishment of intestinal continuity, and 25,121 (60.3 percent) sphincter-sacrificing procedures. The proportion of sphincter-sparing procedures increased from 26.9 percent in 1988 to 48.3 percent in 2003 (P < 0.001). There has been no significant change in the rate of sphincter-sparing surgery since 1999 (P = not significant). Logistic regression revealed that patients who were older, male, black, used Medicaid insurance, or lived in lower-income zip codes were less likely to have sphincter-sparing surgery with reestablishment of intestinal continuity (P < 0.001).
  
  
  CONCLUSIONS
  Despite a significant increase in the rate of sphincter-sparing surgery with reestablishment of intestinal continuity, most radical resections for rectal cancer in hospitals in the United States result in a colostomy. Patients vulnerable to proctectomy without sphincter preservation were older, male, black, used Medicaid insurance, or lived in lower income zip codes.
authors.affiliation: Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA.
authors.forename: Rocco
authors.initials: R
authors.lastname: Ricciardi
authors.forename: Beth A
authors.initials: BA
authors.lastname: Virnig
authors.forename: Robert D
authors.initials: RD
authors.lastname: Madoff
authors.forename: David A
authors.initials: DA
authors.lastname: Rothenberger
authors.forename: Nancy N
authors.initials: NN
authors.lastname: Baxter
mesh_terms: D000367:Age Factors; D000368:Aged; D003082:Colectomy / Q000379:methods / Q000706:statistics & numerical data*; D016208:Databases, Factual; D005260:Female; D006801:Humans; D019458:Insurance Coverage; D007348:Insurance, Health; D008297:Male; D008875:Middle Aged; D012004:Rectal Neoplasms / Q000453:epidemiology / Q000601:surgery*; D012737:Sex Factors; D012959:Socioeconomic Factors; D014481:United States / Q000453:epidemiology