title: Permanent stoma rates: a misleading marker of quality in rectal cancer surgery.
abstract: OBJECTIVE
  The latest National Bowel Cancer Audit Programme (NBOCAP) audit identified our colorectal unit as an outlier with regard to the high permanent stoma rate. The aim of this study was to perform an audit of the rationale for stoma formation in patients undergoing rectal cancer resection in our unit.
  
  
  METHODS
  A review was conducted of all rectal cancer operations between April 2011 and March 2013. Preoperative staging investigations and operation reports were reviewed to identify the reasons for nonrestorative surgery. Postoperative histology reports were used to identify circumferential resection margin (CRM) involvement and tumour height.
  
  
  RESULTS
  One-hundred and twenty-five patients underwent surgery for rectal cancer, of whom 102 underwent elective resection with curative intent. The permanent stoma rate was 63.2% when emergency and palliative procedures were included and 54.9% when only elective curative cases were considered. Tertiary referrals made up 31.4% of elective cases. The main reasons for nonrestorative surgery included multivisceral resection (n = 24) for locally advanced cancer and operations for lesions close to the anal sphincter (n = 21). The median length of stay was 8 days, the 90-day mortality was 2.9% and the rate of CRM involvement was 2.0%.
  
  
  CONCLUSIONS
  Our unit provides multivisceral surgery for locally advanced rectal cancer and receives a substantial number of tertiary referrals. Many of the rectal cancers referred are locally advanced or threaten the anal sphincter. This study demonstrates that the complexity of a unit's case-mix can have a profound effect on the permanent stoma rate. Stoma rates taken at face value do not therefore provide an accurate representation of surgical quality. What does this paper add to the literature? The study reviews the practice of a colorectal surgical unit with an interest in multivisceral surgery with regard to the permanent stoma rate. The reasons for nonrestorative surgery are analysed, and the problems associated with the use of stoma rates as a marker of quality in colorectal surgery are highlighted.
authors.affiliation: Department of Colorectal Surgery, Singleton Hospital, Swansea, UK.
authors.forename: R J
authors.initials: RJ
authors.lastname: Codd
authors.forename: M D
authors.initials: MD
authors.lastname: Evans
authors.forename: M
authors.initials: M
authors.lastname: Davies
authors.forename: D A
authors.initials: DA
authors.lastname: Harris
authors.forename: T V
authors.initials: TV
authors.lastname: Chandrasekaran
authors.forename: U P
authors.initials: UP
authors.lastname: Khot
authors.forename: A R
authors.initials: AR
authors.lastname: Morgan
authors.forename: J
authors.initials: J
authors.lastname: Beynon
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001003:Anal Canal / Q000601:surgery*; D000714:Anastomosis, Surgical; D015331:Cohort Studies; D003125:Colostomy / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019984:Quality Indicators, Health Care / Q000592:standards*; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery*; D012007:Rectum / Q000601:surgery*; D012189:Retrospective Studies; D054047:Surgical Stomas / Q000706:statistics & numerical data*; D062606:Tertiary Care Centers; D055815:Young Adult
keywords: Quality markers; rectal cancer; stoma rate