Loop-ileostomy reversal—patient-related characteristics influencing time to closure

Abstract

PurposeTo identify factors associated with timing of stoma reversal after rectal cancer surgery in a large Swedish register-based cohort.MethodsThree thousand five hundred sixty-four patients with rectal cancer who received a protective stoma during surgery in 2007–2013 were identified in the Swedish colorectal cancer register. Time to stoma reversal was evaluated over a follow-up period of one and a half years. Factors associated with timing of stoma reversal were analysed using Cox regression analysis. Reversal within 9 months (12 months if adjuvant chemotherapy) was considered latest expected time to closure.ResultsStoma reversal was performed in 2954 (82.9%) patients during follow-up. Patients with post-secondary education had an increased chance for early stoma reversal (HR 1.13; 95% CI 1.02–1.25). Postoperative complications (0.67; 0.62–0.73), adjuvant chemotherapy (0.63; 0.57–0.69), more advanced cancer stage (stage III 0.74; 0.66–0.83 and stage IV 0.38; 0.32–0.46) and higher ASA score (0.80; 0.71–0.90 for ASA 3–4) were associated with longer time to reversal. Two thousand four hundred thirty-seven (68.4%) patients had stoma reversal within latest expected time to closure. Factors associated to decreased chance of timely reversal were more advanced cancer stage (stage III 0.64; 0.50–0.81 and stage IV 0.19; 0.13–0.27), postoperative complications (0.50; 0.42–0.59) and higher ASA score (0.77; 0.61–0.96 for ASA 3–4).ConclusionsPatients with a high level of education had a higher chance of timely reversal but medical factors had a stronger association to time to reversal. Patients with advanced rectal cancer are at high risk for non-reversal and should be considered for permanent stoma.

Long distance to hospital is not a risk factor for non-reversal of a defunctioning stoma

“…The reversal rate in this study was 83%. Compared to other studies, the reversal rate in the present study was normal to high [9,26,27]. Gustafsson et al used a purely registry-based method and showed that the overall reversal rate in Sweden 2007-2013 was 82.9% which is very similar to the reversal rate in the present study.…”

“…Many studies, including ours, have been designed using a follow-up period based on this definition. A previous study published by our research group had a follow-up time of 18 months after stoma creation [9]. However, in the present study, 17 of 273 stomas were reversed after 18 months.…”

“…Delayed reversal was defined as > 6 months (182 days). This time was chosen since it was the median time to reversal in a larger study in Sweden that included data from around the same period [9]. That study, however, did not assess the effect of distance.…”

“…Despite the initial intention of restoring bowel continuity, previous studies have shown that a significant proportion of defunctioning stomas will become permanent [2][3][4][5][6]. Anastomotic leakage is the best studied risk factor for non-reversal, but high age and advanced tumor stage is also described [6][7][8][9]. Studies from countries with a social structure similar to Sweden have indicated that socioeconomic factors may also affect stoma reversal rates [9][10][11].…”

“…Anastomotic leakage is the best studied risk factor for non-reversal, but high age and advanced tumor stage is also described [6][7][8][9]. Studies from countries with a social structure similar to Sweden have indicated that socioeconomic factors may also affect stoma reversal rates [9][10][11]. Road distance between home and hospital has not been studied as a risk factor for non-reversal.…”