Skip to main content
SpringerLink
Log in

The Status of Radical Proctectomy and Sphincter-Sparing Surgery in the United States

  • Original Contributions
  • Published:
Diseases of the Colon & Rectum

Purpose

Worldwide, “centers of excellence” in rectal cancer surgery report high rates of anal sphincter-sparing surgery (70–90 percent) after proctectomy. The rate of sphincter-sparing surgery with reestablishment of intestinal continuity in the general population of the United Stares is unknown.

Methods

We used data from the Nationwide Inpatient Sample, a 20 percent stratified random sample of patients admitted to hospitals in the United States. We identified patients with rectal cancer from 1988 through 2003 who underwent sphincter-sparing surgery with reestablishment of intestinal continuity or proctectomy with colostomy. To determine predictors of sphincter-sparing surgery with reestablishment of intestinal continuity, we constructed a multivariate model that analyzed patients’ age, gender, race, insurance status, and income level.

Results

During our 16-year study period, radical extirpative procedures were performed in 41,631 patients: 16,510 (39.7 percent) sphincter-sparing surgery with reestablishment of intestinal continuity, and 25,121 (60.3 percent) sphincter-sacrificing procedures. The proportion of sphincter-sparing procedures increased from 26.9 percent in 1988 to 48.3 percent in 2003 (P < 0.001). There has been no significant change in the rate of sphincter-sparing surgery since 1999 (P = not significant). Logistic regression revealed that patients who were older, male, black, used Medicaid insurance, or lived in lower-income zip codes were less likely to have sphincter-sparing surgery with reestablishment of intestinal continuity (P < 0.001).

Conclusions

Despite a significant increase in the rate of sphincter-sparing surgery with reestablishment of intestinal continuity, most radical resections for rectal cancer in hospitals in the United States result in a colostomy. Patients vulnerable to proctectomy without sphincter preservation were older, male, black, used Medicaid insurance, or lived in lower income zip codes.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1
Figure 2

Similar content being viewed by others

References

  1. MA Sprangers BG Taal NK Aaronson A te Velde (1995) ArticleTitleQuality of life in colorectal cancer. Stoma vs. nonstoma patients Dis Colon Rectum 38 361–369 Occurrence Handle7720441 Occurrence Handle10.1007/BF02054222 Occurrence Handle1:STN:280:DyaK2M3js1ylsw%3D%3D

    Article  PubMed  CAS  Google Scholar 

  2. J Camilleri-Brennan RJ Steele (1998) ArticleTitleQuality of life after treatment for rectal cancer Br J Surg 85 1036–1043 Occurrence Handle9717993 Occurrence Handle10.1046/j.1365-2168.1998.00808.x Occurrence Handle1:STN:280:DyaK1czot1SqsQ%3D%3D

    Article  PubMed  CAS  Google Scholar 

  3. NS Williams D Johnston (1983) ArticleTitleThe quality of life after rectal excision for low rectal cancer Br J Surg 70 460–462 Occurrence Handle6871635 Occurrence Handle10.1002/bjs.1800700805 Occurrence Handle1:STN:280:DyaL3s3lvValtg%3D%3D

    Article  PubMed  CAS  Google Scholar 

  4. M Mohiuddin WF Regine GJ Marks JW Marks (1998) ArticleTitleHigh-dose preoperative radiation and the challenge of sphincter-preservation surgery for cancer of the distal 2 cm of the rectum Int J Radiat Oncol Biol Phys 40 569–574 Occurrence Handle9486606 Occurrence Handle10.1016/S0360-3016(97)00842-0 Occurrence Handle1:STN:280:DyaK1c7ks1Sisw%3D%3D

    Article  PubMed  CAS  Google Scholar 

  5. A Grann BD Minsky AM Cohen et al. (1997) ArticleTitlePreliminary results of preoperative 5-fluorouracil (5-FU), low-dose leucovorin, and concurrent radiation therapy for resectable T3 rectal cancer Dis Colon Rectum 40 515–522 Occurrence Handle9152176 Occurrence Handle10.1007/BF02055370 Occurrence Handle1:STN:280:DyaK2s3ps1OjtQ%3D%3D

    Article  PubMed  CAS  Google Scholar 

  6. SB Lim SC Heo MR Lee et al. (2005) ArticleTitleChanges in outcome with sphincter preserving surgery for rectal cancer in Korea, 1991–2000 Eur J Surg Oncol 31 242–249 Occurrence Handle15780558 Occurrence Handle10.1016/j.ejso.2004.11.011

    Article  PubMed  Google Scholar 

  7. JP Gerard O Chapet C Nemoz et al. (2004) ArticleTitleImproved sphincter preservation in low rectal cancer with high-dose preoperative radiotherapy: the Lyon R96-02 randomized trial J Clin Oncol 22 2404–2409 Occurrence Handle15197202 Occurrence Handle10.1200/JCO.2004.08.170

    Article  PubMed  Google Scholar 

  8. RJ Heald RD Ryall (1986) ArticleTitleRecurrence and survival after total mesorectal excision for rectal cancer Lancet 1 1479–1482 Occurrence Handle2425199 Occurrence Handle10.1016/S0140-6736(86)91510-2 Occurrence Handle1:STN:280:DyaL283lsFylug%3D%3D

    Article  PubMed  CAS  Google Scholar 

  9. Agency for Healthcare Research and Quality. HCUP-US NIS Overview. Available at: http://www.hcup-us.ahrq.gov/nisoverview.jsp. Accessed March 1, 2006

  10. JB Dimick RM Wainess JA Cowan GR Upchurch SuffixJr KA Knol LM Colletti (2004) ArticleTitleNational trends in the use and outcomes of hepatic resection J Am Coll Surg 199 31–38 Occurrence Handle15217626 Occurrence Handle10.1016/j.jamcollsurg.2004.03.005

    Article  PubMed  Google Scholar 

  11. SS Rathore AJ Epstein KG Volpp HM Krumholz (2004) ArticleTitleHospital coronary artery bypass graft surgery volume and patient mortality Ann Surg 239 110–117 Occurrence Handle14685108 Occurrence Handle10.1097/01.sla.0000103066.22732.b8

    Article  PubMed  Google Scholar 

  12. JJ Shen EL Washington L Aponte-Soto (2004) ArticleTitleRacial disparities in the pathogenesis and outcomes for patients with ischemic stroke Manag Care Interface 17 28–34 Occurrence Handle15098548

    PubMed  Google Scholar 

  13. ND Nigro VK Vaitkevicius B Considine SuffixJr (1974) ArticleTitleCombined therapy for cancer of the anal canal: a preliminary report Dis Colon Rectum 17 354–356 Occurrence Handle4830803 Occurrence Handle10.1007/BF02586980 Occurrence Handle1:STN:280:DyaE2c7ntFelsA%3D%3D

    Article  PubMed  CAS  Google Scholar 

  14. AS Allal FM Laurencet MA Reymond JM Kurtz MC Marti (1999) ArticleTitleEffectiveness of surgical salvage therapy for patients with locally uncontrolled anal carcinoma after sphincter-conserving treatment Cancer 86 405–409 Occurrence Handle10430247 Occurrence Handle10.1002/(SICI)1097-0142(19990801)86:3<405::AID-CNCR7>3.0.CO;2-Q Occurrence Handle1:STN:280:DyaK1MzlsleitA%3D%3D

    Article  PubMed  CAS  Google Scholar 

  15. DC Hodgson W Zhang AM Zaslavsky CS Fuchs WE Wright JZ Ayanian (2003) ArticleTitleRelation of hospital volume to colostomy rates and survival for patients with rectal cancer J Natl Cancer Inst 95 708–716 Occurrence Handle12759388 Occurrence Handle10.1093/jnci/95.10.708

    Article  PubMed  Google Scholar 

  16. Surveillance, Epidemiology, and End Results Program website. Statistical Research & Applications Branch-Joinpoint Home. Available at: http://srab.cancer.gov/joinpoint/. Accessed February 20, 2006

  17. Kim HJ, Fay MP, Feuer EJ, Midthune DN. Permutation tests for joinpoint regression with applications to cancer rates. Stat Med 2000;19:335–51. Erratum in. Stat Med 2001;20:655

    Google Scholar 

  18. Rothenberger DA, Ricciardi R. Procedures for rectal cancer. In: Souba WW, ed. ACS surgery principles and practice. WEBMD, 2005, pp. 697–712

  19. NS Abraham JA Davila L Rabeneck DH Berger HB El-Serag (2005) ArticleTitleIncreased use of low anterior resection for veterans with rectal cancer Aliment Pharmacol Ther 21 35–41 Occurrence Handle15644043 Occurrence Handle10.1111/j.1365-2036.2004.02286.x Occurrence Handle1:STN:280:DC%2BD2M%2FhvVSnug%3D%3D

    Article  PubMed  CAS  Google Scholar 

  20. BJ Moran (1996) ArticleTitleStapling instruments for intestinal anastomosis in colorectal surgery Br J Surg 83 902–909 Occurrence Handle8813772 Occurrence Handle10.1002/bjs.1800830707 Occurrence Handle1:STN:280:DyaK28vgvVOrtQ%3D%3D

    Article  PubMed  CAS  Google Scholar 

  21. MM Ravitch FM Steichen R Welter (1991) Current practice of surgical stapling Lea & Febeiger Philadelphia

    Google Scholar 

  22. NN Baxter DA Rothenberger AM Morris KM Bullard (2005) ArticleTitleAdjuvant radiation for rectal cancer: do we measure up to the standard of care? An epidemiologic analysis of trends over 25 years in the United States Dis Colon Rectum 48 9–15 Occurrence Handle15690651 Occurrence Handle10.1007/s10350-004-0792-8 Occurrence Handle1:STN:280:DC%2BD2M%2Fmt1WmsA%3D%3D

    Article  PubMed  CAS  Google Scholar 

  23. R Sauer H Becker W Hohenberger et al. (2004) ArticleTitlePreoperative versus postoperative chemoradiotherapy for rectal cancer N Engl J Med 351 1731–1740 Occurrence Handle15496622 Occurrence Handle10.1056/NEJMoa040694 Occurrence Handle1:CAS:528:DC%2BD2cXovFSksbo%3D

    Article  PubMed  CAS  Google Scholar 

  24. AM Morris KG Billingsley NN Baxter et al. (2004) ArticleTitleRacial disparities in rectal cancer treatment: a population-based analysis Arch Surg 139 151–156 Occurrence Handle14769572 Occurrence Handle10.1001/archsurg.139.2.151

    Article  PubMed  Google Scholar 

  25. LJ Wudel SuffixJr WC Chapman Y Shyr et al. (2002) ArticleTitleDisparate outcomes in patients with colorectal cancer: effect of race on long-term survival Arch Surg 137 550–556 Occurrence Handle11982467 Occurrence Handle10.1001/archsurg.137.5.550

    Article  PubMed  Google Scholar 

  26. ML Margolis JD Christie GA Silvestri L Kaiser S Santiago J Hansen-Flaschen (2003) ArticleTitleRacial differences pertaining to a belief about lung cancer surgery Ann Intern Med 139 558–563 Occurrence Handle14530226

    PubMed  Google Scholar 

  27. JZ Ayanian PD Cleary JS Weissman AM Epstein (1999) ArticleTitleThe effect of patients’ preferences on racial differences in access to renal transplantation N Engl J Med 341 1661–1669 Occurrence Handle10572155 Occurrence Handle10.1056/NEJM199911253412206 Occurrence Handle1:STN:280:DC%2BD3c%2FjslOnug%3D%3D

    Article  PubMed  CAS  Google Scholar 

  28. TC Collins JA Clark LA Petersen NR Kressin (2002) ArticleTitleRacial differences in how patients perceive physician communication regarding cardiac testing Med Care 40S I27–I34

    Google Scholar 

  29. MP Doescher BG Saver P Franks K Fiscella (2000) ArticleTitleRacial and ethnic disparities in perceptions of physician style and trust Arch Fam Med 9 1156–1163 Occurrence Handle11115223 Occurrence Handle10.1001/archfami.9.10.1156 Occurrence Handle1:STN:280:DC%2BD3M%2FoslWitA%3D%3D

    Article  PubMed  CAS  Google Scholar 

  30. JE Carrillo AR Green JR Betancourt (1999) ArticleTitleCross-cultural primary care: a patient-based approach Ann Intern Med 130 829–834 Occurrence Handle10366373 Occurrence Handle1:STN:280:DyaK1M3kt1ajtA%3D%3D

    PubMed  CAS  Google Scholar 

  31. PB Bach HH Pham D Schrag RC Tate JL Hargraves (2004) ArticleTitlePrimary care physicians who treat blacks and whites N Engl J Med 351 575–584 Occurrence Handle15295050 Occurrence Handle10.1056/NEJMsa040609 Occurrence Handle1:CAS:528:DC%2BD2cXmtF2ru70%3D

    Article  PubMed  CAS  Google Scholar 

  32. WL Law KW Chu (2004) ArticleTitleAbdominoperineal resection is associated with poor oncological outcome Br J Surg 91 1493–1499 Occurrence Handle15455362 Occurrence Handle10.1002/bjs.4723 Occurrence Handle1:STN:280:DC%2BD2crksVyjsA%3D%3D

    Article  PubMed  CAS  Google Scholar 

  33. A Martling B Cedermark H Johansson LE Rutqvist T Holm (2002) ArticleTitleThe surgeon as a prognostic factor after the introduction of total mesorectal excision in the treatment of rectal cancer Br J Surg 89 1008–1013 Occurrence Handle12153626 Occurrence Handle10.1046/j.1365-2168.2002.02151.x Occurrence Handle1:STN:280:DC%2BD38vgsVaquw%3D%3D

    Article  PubMed  CAS  Google Scholar 

  34. ZA Murrell MR Dixon H Vargas TD Arnell R Kumar MJ Stamos (2005) ArticleTitleContemporary indications for and early outcomes of abdominoperineal resection Am Surg 71 837–840 Occurrence Handle16468531

    PubMed  Google Scholar 

To the Invited Commentary

  1. H Purves R Pietrobon S Hervey U Guller W Miller K Ludwig (2005) ArticleTitleRelationship between surgeon caseload and sphincter preservation in patients with rectal cancer Dis Colon Rectum 48 195–204 Occurrence Handle15812583 Occurrence Handle10.1007/s10350-004-0793-7

    Article  PubMed  Google Scholar 

  2. N Hyman (2002) ArticleTitleHow much colorectal surgery do general surgeons do J Am Coll Surg 194 37–39 Occurrence Handle11800338 Occurrence Handle10.1016/S1072-7515(01)01116-4

    Article  PubMed  Google Scholar 

  3. JB Dimick JD Birkmeyer GR Upchurch SuffixJr (2005) ArticleTitleMeasuring surgical quality: what’s the role of provider volume World J Surg 29 1217–1221 Occurrence Handle16132399 Occurrence Handle10.1007/s00268-005-7989-4

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA

    Rocco Ricciardi M.D., M.P.H., Beth A. Virnig Ph.D., M.P.H., Robert D. Madoff M.D. & David A. Rothenberger M.D.

  2. Department of Colon and Rectal Surgery, Lahey Clinic, 41 Mall Road, Burlington, Massachusetts, 01805, USA

    Rocco Ricciardi M.D., M.P.H.

  3. Division of Health Services Research and Policy, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA

    Beth A. Virnig Ph.D., M.P.H.

  4. Department of Surgery, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada

    Nancy N. Baxter M.D., Ph.D.

Authors
  1. Rocco Ricciardi M.D., M.P.H.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Beth A. Virnig Ph.D., M.P.H.
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Robert D. Madoff M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. David A. Rothenberger M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Nancy N. Baxter M.D., Ph.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Rocco Ricciardi M.D., M.P.H..

Additional information

Sponsored by the Clinical Scholars Research Grant from the Academic Health Center, University of Minnesota, Minneapolis, Minnesota.

About this article

Cite this article

Ricciardi, R., Virnig, B.A., Madoff, R.D. et al. The Status of Radical Proctectomy and Sphincter-Sparing Surgery in the United States. Dis Colon Rectum 50, 1119–1127 (2007). https://doi.org/10.1007/s10350-007-0250-5

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10350-007-0250-5

Key words

Search

Navigation