Causes and costs of delayed closure of ileostomies in rectal cancer patients in Australasian units

• Published in: ANZ journal of surgery Vol. 93; no. 3; pp. 636 - 642
• Main Authors: Barnard, Jon, Milne, Tony, Teo, Keith, Weston, Maree, Israel, Lincoln, Peng, Sze‐Lin
• Format: Journal Article
• Language: English
• Published: Melbourne John Wiley & Sons Australia, Ltd 01.03.2023; Blackwell Publishing Ltd
• Subjects: Anastomosis, Surgical - adverse effects; Cancer; Chemotherapy; Colorectal cancer; Colorectal carcinoma; cost; Cost analysis; Costs; defunctioning loop ileostomy; economic analysis; Humans; Ileostomy - adverse effects; Morbidity; Ostomy; Patients; Postoperative Complications - epidemiology; Postoperative Complications - etiology; rectal cancer; Rectal Neoplasms - complications; Rectum; Rectum - surgery; Regression analysis; Retrospective Studies; reversal; Risk factors; Surgery; Surgical Stomas - adverse effects; reversal; cost; defunctioning loop ileostomy; economic analysis; rectal cancer
• ISSN: 1445-1433; 1445-2197
• DOI: 10.1111/ans.18092

Background Defunctioning loop ileostomies (DLIs) are a frequent adjunct to rectal cancer surgery. Delayed closure of DLIs is common and associated with increased morbidity. The reasons for delayed DLI closure are often unknown. The economic burden of delayed DLI closure is not quantified. The present study aimed to determine the reasons for, and economic burden of, delayed DLI closure. Methods Clinical and economic data were audited from a prospective database of patients in two Australasian colorectal cancer centres. Patients treated at each unit with low/ultra‐low anterior resection for rectal cancer with formation of DLI between January 2014 and December 2019 were included. Post‐operative complication rate, stoma‐related complication rate and costs of hospital admissions and stoma care were recorded and analysed. Multivariate linear regression analysis was used to investigate risk factors for delay to closure. Results 146 patients underwent low/ultra‐low anterior resection with DLI; 135 patients (92.5%) underwent reversal. The median duration to reversal was 7 months (IQR 4.5–9.5). Sixty‐six percent of patients underwent reversal >6 months after their index surgery. Neoadjuvant and adjuvant chemotherapy were associated with delayed reversal (P < 0.001). Non‐English speakers waited longer for DLI closure (P = 0.028). The costs of outpatient stoma care (P < 0.001), post‐operative care (P = 0.004), and total cost of treatment (P = 0.014) were significantly higher in the delayed closure group, with a total cost of treatment difference of $3854 NZD per patient. Conclusions Causes of delay include systemic factors and demographic factors that can be addressed directly, addressing such causes may alleviate a significant economic burden. Delayed defunctioning loop ileostomy (DLI) closure is as prevalent in Australasia as it is in the UK and other publicly funded healthcare systems. Streamlining pathways to eventual reversal and catering for language barriers could reduce the interval significantly. The economic burden of delayed DLI closure is substantial and could be addressed by relatively simple and inexpensive target‐driven protocols.