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Elective Stoma Reversal Has a Higher Incidence of Postoperative Clostridium Difficile Infection Compared With Elective Colectomy

An Analysis Using the American College of Surgeons National Surgical Quality Improvement Program and Targeted Colectomy Databases

Skancke, Matthew M.D.; Vaziri, Khashayar M.D.; Umapathi, Bindu M.D.; Amdur, Richard Ph.D.; Radomski, Michal M.D.; Obias, Vincent M.D.

Diseases of the Colon & Rectum: May 2018 - Volume 61 - Issue 5 - p 593–598
doi: 10.1097/DCR.0000000000001041
Original Contributions: Benign
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BACKGROUND: Clostridium difficile infection is caused by the proliferation of a gram-positive anaerobic bacteria after medical or surgical intervention and can result in toxic complications, emergent surgery, and death.

OBJECTIVE: This analysis evaluates the incidence of C difficile infection in elective restoration of intestinal continuity compared with elective colon resection.

DESIGN: This was a retrospective database review of the 2015 American College of Surgeons National Surgical Quality Improvement Project and targeted colectomy database.

SETTINGS: The intervention cohort was defined as the primary Current Procedural Terminology codes for ileostomy/colostomy reversal (44227, 44620, 44625, and 44626) and International Classification of Diseases codes for ileostomy/colostomy status (VV44.2, VV44.3, VV55.2, VV55.3, Z93.2, Z93.3, Z43.3, and Z43.2).

PATIENTS: A total of 2235 patients underwent elective stoma reversal compared with 10403 patients who underwent elective colon resection.

INTERVENTION: Multivariate regression modeling of the impact of stoma reversal on postoperative C difficile infection risk was used as the study intervention.

MAIN OUTCOME MEASURES: The incidence of C difficile infection in the 30 days after surgery was measured.

RESULTS: The incidence of C difficile infection in the 30-day postoperative period was significantly higher (3.04% vs 1.25%; p < 0.001) in patients undergoing stoma reversal. After controlling for differences in cohorts, regression analysis suggested that stoma reversal (OR = 2.701 (95% CI, 1.966–3.711); p < 0.001), smoking (OR = 1.520 (95% CI, 1.063–2.174); p = 0.022), steroids (OR = 1.677 (95% CI, 1.005–2.779); p = 0.048), and disseminated cancer (OR = 2.312 (95% CI, 1.437–3.719); p = 0.001) were associated with C difficile infection incidence in the 30-day postoperative period.

LIMITATIONS: The study was limited because it was a retrospective database review with observational bias.

CONCLUSIONS: Patients who undergo elective stoma reversal have a higher incidence of postoperative C difficile infection compared with patients who undergo an elective colectomy. Given the impact of postoperative C difficile infection, a heightened sense of suspicion should be given to symptomatic patients after stoma reversal. See at Video Abstract at

Department of General Surgery and Colorectal Surgery, George Washington University Hospital, Washington, D.C.

Funding/Support: None reported.

Financial Disclosure: None reported.

Correspondence: Matthew Skancke, M.D., George Washington University Hospital, 22nd and I Streets, NW, 6th Floor Suite 6B, Washington, DC 20037. E-mail:

© 2018 The American Society of Colon and Rectal Surgeons