Significant morbidity is associated with proximal fecal diversion among high-risk patients who undergo colectomy: A NSQIP analysis

• Published in: The American journal of surgery Vol. 220; no. 4; pp. 830 - 835
• Main Authors: Chang, Yu-Wei Wayne, Davenport, Daniel, Dugan, Adam, Patel, Jitesh A.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.10.2020; Elsevier Limited
• Subjects: Adult; Aged; Anastomotic leak; Anastomotic Leak - epidemiology; Anastomotic Leak - prevention & control; Body weight; Colectomy; Colectomy - methods; Colorectal surgery; Demographics; Demography; Diabetes mellitus; Diverting ileostomy; Female; Humans; Hypertension; Ileostomy; Ileostomy - methods; Leukocytosis; Male; Middle Aged; Morbidity; Mortality; NSQIP; Ostomy; Overweight; Patients; Pulmonary embolisms; Quality Improvement; Risk analysis; Risk Assessment; Risk Factors; Risk groups; Sepsis; Smoking; Steroids; Surgeons; Surgery; Thrombosis; Transfusion; United States; Variables; Weight loss; United States; NSQIP; Colectomy; Diverting ileostomy; Anastomotic leak; Morbidity
• DOI: 10.1016/j.amjsurg.2020.05.007
• ISSN: 0002-9610

The value of proximal fecal diversion for patients undergoing colectomies is an ongoing debate. Previous studies have shown a benefit in decreased anastomotic leak rates and mitigation of the morbidity of a leak, especially in high-risk populations. However, more recent data suggests increased morbidity with fecal diversion, creating a complication with an unknown degree of anastomotic leak reduction. Therefore, we aimed to determine the impact on morbidity of a diverting loop ileostomy (DLI) in patients with a high risk of anastomotic leak. The ACS-NSQIP database was queried (via CPT code) for adult patients (age ≥18 years) who underwent a colectomy only or colectomy with ileostomy (CWI) between Jan 2013 and Dec 2016. We compared thirty-day outcomes between a 3:1 propensity-matched colectomy only group to patients who had a CWI. We used risk factors for anastomotic leak as a basis of our propensity match which included preoperative smoking, steroid use, preoperative weight loss, preoperative transfusion, hypoalbuminemia, and leukocytosis; intraoperative match variables included indication for surgery, wound class, duration of operation, primary CPT code, elective vs. emergent, and inpatient vs. outpatient surgery. We identified 39,588 patients from the NSQIP database who had a colectomy only or a CWI. The colectomy only group was older (age 63 vs 52 years p < 0.001), overweight (BMI 34 vs 26.7, p < 0.001), more likely to be diabetic (16% vs 9.5%, p < 0.001) and hypertensive (49.3% vs 31.4%). However, the CWI group had higher steroid use (36.8% vs 10%, p < 0.001), preoperative sepsis (13.2% vs 2.5%, p < 0.001), smoking rate (25.7% vs 15.4%, p < 0.001), and preoperative weight loss (12.5% vs 4.9%, p < 0.001). Our propensity analysis matched 2274 colectomy only patients and 758 CWI patients. Baseline demographics were similar between groups. While the mortality rate was similar between groups (1.5% vs 1.8%, p = 0.8), CWI patients had longer length of stay (median 8 vs 7 days, p < 0.001), higher renal injury rates (3.2% vs 0.9%, p < 0.001), higher readmission rates (18.8% vs 11%, p < 0.001) and higher overall NSQIP morbidity (44.5% vs 37.6%, p = 0.001). The anastomotic leak rate was 3.8% in the CWI group and 5.1% in the colectomy only group (p = 0.09). Significant thirty-day morbidity exists with a diverting ileostomy among high-risk colectomy patients with minimal benefit in anastomotic leak rates. •Proximal fecal diversion is controversial among patients who undergo colectomy.•Patients at high risk for anastomotic leak commonly receive proximal diversion.•Diversion is associated with significant morbidity.•Diversion is not associated with significant reduction in anastomotic leak.