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Predictors of Surgical Site Infection After Ostomy Reversal: Lessons From ACS-NSQIP
Kevin Kuruvilla*2, Neil Hyman2, Stefan D. Holubar1
1Colon & Rectal Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; 2Surgery, University of Vermont College of Medicine, Burlington, VT
PURPOSE: The use of proximal fecal diversion may minimize the impact of anastomotic leak after primary anastomosis. However, subsequent closure of a diverting stoma is associated with its own morbidity such as surgical site infection (SSI). In order to quantify this morbidity, we aimed to identify predictors of SSI after ostomy reversal surgery from the largest dataset of ostomy reversal procedures reported to date.
METHODS: The ACS-NSQIP database from 2005-2011 was used to identify all patients who underwent ostomy reversal procedures with- and without-bowel resection and anastomosis (CPT codes 44625 or 44620, respectively). Exclusion criteria included inpatients, patients not admitted from home, emergencies, patients with any concurrent procedure, and patients with any other major synchronous procedure (e.g. other solid or hollow organ operation, hernia repair). Demographics, comorbidities, operative outcomes and complications were collected. Patients were grouped into those with colorectal cancer (CA), chronic ulcerative colitis (CUC), diverticular disease (DD), and Crohn disease (CD). Univariate and multivariate analysis was used to assess the rate of SSI in each of the 4 diagnostic groups, as well as predictors of SSI.
RESULTS: A total of 10,950 patients were included: 5078 (46.4%) without bowel resection, 5872 (53.6%) with bowel resection. The mean patient age was 53 (±16) years, 45% were women, and the mean BMI was 26 kg/m2. Demographic features and rate of SSI in the four groups are presented in Table 1. Overall 987 (9%) patients suffered SSI. Age, BMI, diabetes, smoking status, COPD, hypertension requiring medication, weight loss, steroid use, recent chemotherapy or radiation therapy, ASA classification, wound classification, and operative time were associated with a higher risk of SSI on univariate analysis. A saturated multivariate analysis limited to the 1479 patients with a known diagnosis of CA, CUC, DD, or CD identified only steroids (p=0.002), anti-hypertensive medication use (p=0.01), and the diagnosis of Crohn disease (p=0.01) as independent predictors of any SSI. The risk of SSI if 0, 1, 2, or all 3 risk factors were presents was 5.9%, 8.9%, 31.6%, and 66.7%, respectively (p<0.0001).
CONCLUSIONS: Surgical site infections occur in approximately 10% of ostomy reversal procedures, but if multiple risk factors are present may be anticipated to occur in the majority of cases. Knowledge of these factors may help surgeons develop strategies to reduce SSI in those at highest-risk.
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