EP194 - Innovating in Hostile Territory - An Evaluation of the Safety and Efficacy of MIS Colostomy Takedown

Purpose/Background: Colostomy takedown is an inherently challenging operation as stomas are often created in emergent situations, for complicated pathologies, and in patients who medically are not candidates for an anastomosis at their index operation. Despite high utilization of MIS approaches for most colorectal surgeries, colostomy takedown is usually approached open. We hypothesized robotic colostomy takedown (RCT) and laparoscopic colostomy takedown (LCT) would demonstrate similar rates of 30-day complications as compared to open and that RCT would improve the rate of conversion to open as compared to LCT.

Methods/Interventions: The 2023 NSQIP database was reviewed for cases with CPT code for colostomy takedown with colorectal anastomosis (CPT 44626). To limit baseline differences in case complexity, exclusion criteria included an urgent/emergent designation, the presence of preoperative SIRS/sepsis, and patients not operated on hospital day zero. Operations utilizing a hand-assisted / open-assisted technique were excluded to allow for a direct comparison of operative platforms and to more accurately evaluate the need for conversion to an open approach. 30-Day outcomes measures were compared individually and globally as the ability to achieve a textbook outcome (TBO).

Results/Outcomes: Demographics in the 1,298 identified patients were similar with 71.6% of patients undergoing open colostomy takedown, 19.7% LCT, and 8.6% RCT. Patients were on average middle-age, overweight or obese by BMI, equally male/female, ASA II/III, with the most common medical comorbidities being hypertension, smoking, and diabetes. Operative times were significantly longer in LCT and RCT as compared to open (245 vs. 273 vs. 210 min respectively, p< 0.001). Differences in mean operative time in LCT and RCT trended towards significance (p=0.06). LCT was more likely to convert to open compared to RCT (50.3% vs. 29.4%, p< 0.001). RCT and LCT were more likely to need small bowel repair or resection vs. open (6.2% vs. 7.0% vs. 3.4% respectively, p=0.03). The proportion of patients with secondary CPT codes for diverting ileostomy creation were similar for open, LCT, and RCT (6.6%, 5.4%, and 4.4% respectively, p=0.56). The incidences of 30-day complications were similar including reoperation ( < 6% for all, p=0.6) and readmission ( < 11% for all, p=0.4) (Table 1). The proportions of patients achieving TBO were similar between RCT, LCT, and open (63.4%, 54.7%, and 52.3% respectively, p=0.08). RCT had a shorter average length of stay compared to LCT and open (4 ± 3 vs. 6 ± 4 vs. 6 ± 4, p< 0.001).

Conclusion/Discussion: Colostomy takedown remains a challenging operation as evidenced by low rates of TBO across all operative approaches. Complication profiles including readmission and reoperation do not appear to be affected by an attempt at RCT or LCT. Properly selected patients can be considered for MIS colostomy takedown and RCT may facility reversal in suitable patients by reducing the rate of conversion to open.

Table 1. Demographics and Complication Data