National Bowel Cancer Audit 2016 Report for 18 month stoma rates (2011-2014) Louise Hunt Consultant Colorectal Surgeon Taunton

In the Audit’s 2016 Annual Report, we plan to publish 18 month stoma rates for participating NHS trusts.   The report will be published in December 2016 and we wanted to notify you in advance of our findings. The Audit has found that your trust had a higher than expected rate of 18 month stoma. The adjusted 18 month stoma rate of 70.1% for TAUNTON AND SOMERSET NHS FOUNDATION TRUST compares to an overall 18 month stoma rate for England of 49.7%. The unadjusted 18 month stoma rate at your trust was 73.0%.

Inclusion criteria: All rectal cancer patients aged 18 or over undergoing a major resection between 1 April 2011 and 31 March 2014 (according to NBOCA) who could be linked to HES.18-month stoma rate was estimated for rectal cancer patients undergoing major surgery. Patients undergoing an abdominoperineal excision of the rectum (APER) or Hartmann’s procedure according to the Audit were assumed to have had a stoma at the time of their primary procedure; this was assumed to be permanent in patients having an APER.

HES data is used to capture whether anterior resection (AR) patients received a stoma and the type of stoma that was created in all patients. In patients having an AR or Hartmann’s procedure, information on subsequent stoma reversal was also obtained. A procedure code for reversal of ileostomy or colostomy within 18-months of surgery was assumed to mean that the patient had their stoma reversed, regardless of whether the stoma was originally coded as an ileostomy or colostomy.

Management of patients having major resection Trust Network National Trust denominator 97 Distant metastases % 6 7 9 Urgent or emergency surgery % 12 15 16 Median number of lymph nodes excised 17 Laparoscopic surgery attempted % 73 72 61 Length of stay > 5 days % 42 59 69

AGE Group Percentage MPH 75-84 age 29.7 % vs 23% nationally

ASA Grades MPH ASA 2 56% nationally, MPH 32%

No of Comorbidities 0 Nationally 65% MPH 57% 1 Nationally 26% MPH 27%

Potential Reasons Low defunctioning loop ileostomy rate for Anterior resections Potentially older population More comorbidities Higher ASA

Differences in last few years 3 surgeons to do Rectal cancer surgery (out of 6) More localised procedures (TAMIS/ TaTME) Less short course radiotherapy

Some data inaccuracies 24 additional rectal cancers identified by our systems that were not on the list (but had the same percentage of permanent stomas) All of the APER had tumours within 4 cm of the dentate line on the histological specimens Number of TME Hartmann’s have reduced (now part of a National Trial)

5/74 records from NBOCAP were wrong (7%) Only 3 ileostomies not reversed in time – 2 for patient choice, and 1 as a patient died before reversal 5/74 records from NBOCAP were wrong (7%) 4 Ant resections DID NOT have a stoma 1 Ant res with ileostomy reversed at 9/12 - data suggests not reversed

Stomas 2000-2016

APER mean 14

Hartmann’s mean 41

Ileostomies mean 48

April 14- March 2015 Rectal cancers 41 Stoma reversed APR 12 na Hartmann's 7 1 LAR 22 15

April 14- March 15 Total 41 Left with stoma =22 If out of all rectal cancers then stoma rate = 51% (21/41) If out of all stomas then 62% (21/34)

April 15- March 16 Rectal cancers 34 Stoma reversed APR 9 na Hartmann's 6 LAR 19 11 8

April 15- March 16 Total left with stoma = 18 If out of all rectal cancers then stoma rate = 53% (18/34) If out of all stomas then 67% (18/26)

April 16 – March 17 Rectal cancers 40 Stoma reversed APR 15 Hartmann's Hartmann's 5 LAR 20 12 2 4 on w/l