Abstract
Background
Surgeons are often asked to provide a diverting colostomy to enable healing or simplify management of sacral pressure ulcers. However, little evidence exists regarding the safety of a diversion in this often compromised patient population. We hypothesized that malnourished patients with sacral pressure ulcers have poor outcomes with fecal diversion.
Methods
ACS-NSQIP (2012–2018) was used to identify patients who underwent elective diverting colostomy for sacral pressure ulcers. Demographics, comorbidities, and perioperative details were recorded. Postoperative complications and 30-day mortality were compared between patients with moderate/severe hypoalbuminemia (< 2.5 g/dL) vs those with albumin > 2.5 g/dL.
Results
We identified a total of 863 patients who underwent elective diverting colostomy for sacral pressure ulcer. Mean age was 57.5 years old. Rate of associated comorbidities was high, with most patients classified as ASA class 3 or 4. Over 40% of patients had a preoperative albumin level < 2.5 g/dL. Thirty-day overall postoperative mortality was 6.7%. This was significantly higher in patients with hypoalbuminemia (11.4% vs. 3.5%, p < 0.001). On multivariable regression analysis, preoperative albumin < 2.5 g/dL was independently associated with mortality (OR 1.92, p = 0.039). Other factors associated with mortality included increased age (OR 1.04 per year, p < 0.001), preoperative sepsis (OR 1.66, p = 0.003), and Black race (OR 2.2, p = 0.01).
Conclusions
Diverting colostomy performed for patients with sacral pressure ulcers is associated with a substantial risk of postoperative death. Surgeons should carefully consider risks of diversion in this patient population, especially in malnourished patients with hypoalbuminemia.
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References
Chaboyer WP, Thalib L, Harbeck EL, Coyer FM, Blot S, Bull CF, et al. Incidence and prevalence of pressure injuries in adult intensive care patients: a systematic review and meta-analysis. Crit Care Med. 2018 Nov;46(11):e1074–81.
Labeau SO, Afonso E, Benbenishty J, Blackwood B, Boulanger C, Brett SJ, et al. Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study. Intensive Care Med. 2021 Feb;47(2):160–9.
Smith MEB, Totten A, Hickam DH, Fu R, Wasson N, Rahman B, et al. Pressure ulcer treatment strategies: a systematic comparative effectiveness review. Ann Intern Med. 2013 Jul 2;159(1):39–50.
Tran BNN, Chen AD, Kamali P, Singhal D, Lee BT, Fukudome EY. National perioperative outcomes of flap coverage for pressure ulcers from 2005 to 2015 using American College of Surgeons National Surgical Quality Improvement Program. Arch Plast Surg. 2018 Sep;45(5):418–24.
Agrawal K, Chauhan N. Pressure ulcers: back to the basics. Indian J Plast Surg. 2012 May;45(02):244–54.
Munoz N, Posthauer ME, Cereda E, Schols JMGA, Haesler E. The role of nutrition for pressure injury prevention and healing: The 2019 International Clinical Practice Guideline Recommendations. Adv Skin Wound Care. 2020 Mar;33(3):123–36.
Lim S, Kim BD, Kim JYS, Ver Halen JP. Preoperative albumin alone is not a predictor of 30-day outcomes in pressure ulcer patients: a matched propensity-score analysis of the 2006-2011 NSQIP datasets. Ann Plast Surg. 2015 Oct;75(4):439–47.
Karahan A, AAbbasoğlu A, Işık SA, Çevik B, Saltan Ç, Elbaş NÖ, et al. Factors affecting wound healing in individuals with pressure ulcers: a retrospective study. Ostomy Wound Manage. 2018 Feb;64(2):32–9.
Beam DM, Courtney DM, Kabrhel C, Moore CL, Richman PB, Kline JA. Risk of thromboembolism varies, depending on category of immobility in outpatients. Ann Emerg Med. 2009 Aug;54(2):147–52.
Lindqvist EK, Sommar P, Stenius M, Lagergren JF. Complications after pressure ulcer surgery - a study of 118 operations in spinal cord injured patients. J Plast Surg Hand Surg. 2020 Jun;54(3):145–50.
Chiu YJ, Liao WC, Wang TH, Shih YC, Ma H, Lin CH, et al. A retrospective study: multivariate logistic regression analysis of the outcomes after pressure sores reconstruction with fasciocutaneous, myocutaneous, and perforator flaps. J Plast Reconstr Aesthet Surg. 2017 Aug;70(8):1038–43.
Wall BM, Mangold T, Huch KM, Corbett C, Cooke CR. Bacteremia in the chronic spinal cord injury population: risk factors for mortality. J Spinal Cord Med. 2003;26(3):248–53.
Akinyemiju T, Meng Q, Vin-Raviv N. Race/ethnicity and socio-economic differences in colorectal cancer surgery outcomes: analysis of the nationwide inpatient sample. BMC Cancer. 2016 Sep 5;16:715.
Esnaola NF, Hall BL, Hosokawa PW, Ayanian JZ, Henderson WG, Khuri SF, et al. Race and surgical outcomes: it is not all black and white. Annals of Surgery. 2008 Oct;248(4):647–55.
Best MJ, McFarland EG, Thakkar SC, Srikumaran U. Racial disparities in the use of surgical procedures in the US. JAMA Surg. 2021 Mar 1;156(3):274–81.
Akinyemiju T, Meng Q, Vin-Raviv N. Race/ethnicity and socio-economic differences in colorectal cancer surgery outcomes: analysis of the nationwide inpatient sample. BMC Cancer. 2016 Dec;16(1):715.
Hawn MT, Houston TK, Campagna EJ, Graham LA, Singh J, Bishop M, et al. The attributable risk of smoking on surgical complications. Annals of Surgery. 2011 Dec;254(6):914–20.
Pussin AM, Lichtenthäler LC, Aach M, Schildhauer TA, Brechmann T. Fecal diversion does not support healing of anus-near pressure ulcers in patients with spinal cord injury-results of a retrospective cohort study. Spinal Cord. 2021 Oct 7;
Deshmukh GR, Barkel DC, Sevo D, Hergenroeder P. Use or misuse of colostomy to heal pressure ulcers. Dis Colon Rectum. 1996 Jul;39(7):737–8.
de la Fuente SG, Levin LS, Reynolds JD, Olivares C, Pappas TN, Ludwig KA, et al. Elective stoma construction improves outcomes in medically intractable pressure ulcers. Dis Colon Rectum. 2003 Nov;46(11):1525–30.
Cooper EA, Bonne Lee B, Muhlmann M. Outcomes following stoma formation in patients with spinal cord injury. Colorectal Dis. 2019 Dec;21(12):1415–20.
Groah SL, Schladen M, Pineda CG, Hsieh CHJ. Prevention of pressure ulcers among people with spinal cord injury: a systematic review. PM R. 2015 Jun;7(6):613–36.
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Rubio, G.A., Shogan, B.D., Umanskiy, K. et al. Simple Diverting Colostomy for Sacral Pressure Ulcers: Not So Simple After All. J Gastrointest Surg 27, 382–389 (2023). https://doi.org/10.1007/s11605-022-05522-7
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DOI: https://doi.org/10.1007/s11605-022-05522-7