CASE STUDY

Outcomes After Surgery Resulting In A Stoma: An Analysis Of The ACS-NSQIP Dataset.

I. Sapci1, R. Fearn2, S. Mehta2, I. Dorofeeva2, K. Grayson2, E. Gorgun1

1Cleveland Clinic, Cleveland OH, 211 Health and Technologies Inc., Tustin, California

Introduction

Intestinal stomas have previously been associated with complications that can have a large impact on quality of life. Leakage occurs in 68% and peristomal skin complications in 41% (1) (2).

Furthermore increased length of stay, increased hospital readmissions for dehydration and acute kidney injury (up to 15%) are frequently reported (3).

The reported rates of complication vary considerably between studies and depend on definition and methodology. We aimed to evaluate the impact of the formation of an ostomy on rates of readmission and acute renal failure following major colorectal surgery.

Methods

Using the American College of Surgeons- National Surgical Quality Improvement Program (ACS-NSQIP) 2016 dataset we identified 16,670 individuals who underwent a colorectal surgery resulting in a stoma.

Identification was based on the presence of CPT codes describing the formation of a stoma in their narrative. 26 relevant codes were identified of which 16 mention colostomy, 5 mention ileostomy, 4 mention other small bowel stoma and 1 mentions both ileostomy and colostomy.

A matched comparison cohort of 16,701 individuals was derived from CPT codes of 46 similarly complex procedures that do not result in ileostomy or colostomy. 15 procedures that may or may not result in a stoma were excluded. The groups were compared for demographic characteristics and outcomes.

Results

Figure 1: Length of stay is greater in stoma patients

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Figure 2: Length of stay is affected by stoma type

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Figure 3: Mortality is not predicted by the presence of a stoma

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Figure 4: Renal failure is more common in small bowel vs large bowel stoma

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Figure 5: SSI and wound dehiscence is more common in stoma

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Figure 6: 30d Readmission is more common in stoma patients

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Figure 7: 30d Readmission is more common in patients with small bowel vs large bowel stoma

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Conclusions

This is the first time ACS-NSQIP data has been used to investigate outcomes in patients with both large and small bowel stomas in comparison with patients having abdominal surgery for other reasons.

Our findings data suggests that complications such as renal failure, surgical site infection and readmission are over-represented in stoma patients. In the case of SSI, renal failure and all-cause readmission the type of stoma (small bowel vs large bowel) confers an additional risk.

This is consistent with previously published data at hospital level, but is the first to demonstrate the problem on a national scale. Improved education and better monitoring of stoma output, along with better mechanisms to identify patients at risk are essential in the addressing these issues.

References

1. Phatak UR, Li LT, Karanjawala B, Chang GJ, Kao LS. Systematic review of educational interventions for ostomates. Dis Colon Rectum. 2014;57(4):529-37.

2. Martins L, Ayello EA, Claessens I, Steen Hansen A, Hentze Poulsen L, Sibbald RG, et al. The ostomy skin tool: tracking peristomal skin changes. Br J Nurs. 2010;19(15):960, 32-4.

3. Kwiatt M, Kawata M. Avoidance and management of stomal complications. Clin Colon Rectal Surg. 2013;26(2):112-21