title: Is a diverting ostomy needed in mid-high rectal cancer patients undergoing a low anterior resection after neoadjuvant chemoradiation? An NSQIP analysis.
abstract: BACKGROUND
  A diverting stoma is often performed at the time of low anterior resection (LAR) for rectal cancer after neoadjuvant chemoradiation (nCRT) to protect the anastomosis. The aim of this study was to compare surgical outcomes in large cohorts of mid-high rectal cancer patients undergoing LAR after nCRT with and without a diverting stoma.
  
  
  METHODS
  Patients undergoing LAR for rectal cancer (ICD-9 diagnosis code 154.1) after nCRT were identified from the American College of Surgeons National Surgical Quality Improvement Program database records from 2005 to 2012. Using Current Procedural Terminology (CPT) codes for LAR for mid-high rectal tumors, patients were stratified into diverting stoma (CPT: 44146, 44208) or no diverting stoma (CPT: 44145, 44207) cohorts. Emergency resection, stage IV disease, and permanent end colostomy patients were excluded.
  
  
  RESULTS
  We included 1,406 patients in the analysis. All patients received nCRT; 607 (43%) received a diverting stoma and 799 (57%) were not diverted. The diverted group was more likely to have a higher body mass index (28.3 vs 27.4 kg/m(2); P = .02) and hypertension (46% vs 39%; P = .002). Otherwise, the group demographics and comorbidities were comparable. Overall morbidity was 28% for the entire cohort with no differences in deep organ space infection, sepsis and septic shock, unplanned reoperation, duration of stay, or overall mortality between the groups.
  
  
  CONCLUSIONS
  Diverting stoma does not decrease mortality or infectious complications in mid-high rectal cancer patients undergoing LAR after nCRT. The decision to construct a protective stoma should not be driven solely on the receipt of nCRT.
authors.affiliation: Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA. Electronic address: emessaris@hmc.psu.edu.
authors.forename: Evangelos
authors.initials: E
authors.lastname: Messaris
authors.affiliation: Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA.
authors.forename: Tara M
authors.initials: TM
authors.lastname: Connelly
authors.affiliation: Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA.
authors.forename: Afif N
authors.initials: AN
authors.lastname: Kulaylat
authors.affiliation: Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Miller
authors.affiliation: Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA.
authors.forename: Niraj J
authors.initials: NJ
authors.lastname: Gusani
authors.affiliation: Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA.
authors.forename: Gail
authors.initials: G
authors.lastname: Ortenzi
authors.affiliation: Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA.
authors.forename: Joyce
authors.initials: J
authors.lastname: Wong
authors.affiliation: Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA.
authors.forename: Neil
authors.initials: N
authors.lastname: Bhayani
mesh_terms: D000328:Adult; D000368:Aged; D059186:Chemoradiotherapy, Adjuvant; D016208:Databases, Factual; D005260:Female; D006801:Humans; D007081:Ileostomy; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D011183:Postoperative Complications / Q000517:prevention & control; D012004:Rectal Neoplasms / Q000601:surgery* / Q000628:therapy; D012007:Rectum / Q000601:surgery*; D012189:Retrospective Studies; D016896:Treatment Outcome