R. J. Kucejko1, M. E. Pontell1, D. Scantling1, M. Weingarten1, D. E. Stein1 1Drexel University College Of Medicine,Surgery,Philadelphia, PA, USA
Introduction: Stomas are routinely created for fecal diversion in chronic, non-healing wounds of the sacrum, ischium and perineum. Aside from re-routing stool from the wound bed, they also improve quality of life and prepare the patient for future reconstructive surgery. While these procedures are commonplace, little is published about their safety, with only two studies in the last twenty years. This study aims to analyze patients from our institutional database as well as the NSQIP national database who underwent fecal diversion for non-healing wounds to clarify the safety of fecal diversion in this group of patients and to identify factors that contribute to elevations in perioperative risk.
Methods: A retrospective analysis was performed using data from the American College of Surgeons National Surgical Quality Improvement Project database between 2005 and 2015. Patients were selected based on a postoperative diagnosis of chronic ulcer of the skin. Patients were considered to have undergone diversion if the entry contained the procedure code for ileostomy or colostomy. Propensity score matching was conducted based on the NSQIP morbidity score. An additional retrospective analysis was performed on our institutions patient database spanning from 2000 until 2017. All patients who underwent fecal diversion for chronic, non-healing wounds were included.
Results: 4,849 patients meeting inclusion criteria were identified in the NSQIP database. 859 underwent diversion compared to 3,990 patients who did not. In unmatched data, comparison of the two groups revealed no significant differences in mortality rate, postoperative stroke, need for cardiopulmonary resuscitation, myocardial infarction, need for blood transfusion, deep venous thrombosis, renal failure, organ space or superficial surgical site infection. In matched data, diverted patients had a significantly lower 30 day mortality. 56 patients were identified at our institution that underwent fecal diversion for non-healing wounds. 50% of patients with a preoperative ejection fraction of less than 30% died within 30 days of surgery (p = 0.045, likelihood ratio 6.58).
Conclusion: Fecal diversion in patients with chronic non-healing sacral wounds does not increase 30 day morbidity and mortality, based on NSQIP data. While the 30 day morbidity does remain high, the subgroup of patients with severe cardiac dysfunction likely represent the majority of these cases and remain at a disproportionately elevated risk, based on our institutional data. It is reasonable to suggest that patients with cardiac risk factors undergoing fecal diversion for chronic wounds should undergo preoperative echocardiography. We propose that a preoperative ejection fraction less than 30% should be seen as a relative contraindication to immediate diversion without further optimization.