Oncologic colorectal surgery and concomitant inflammatory bowel disease: NSQIP analysis of C. Diff infection.

Author(s):
Jason Sciarretta; John Davis; Georgina Alizo

Background:

Clostridium difficile infections (CDI) are associated with serious complications with approximately 453,000 cases of CDIs and 29,000 deaths identified each year in the United States. Specific risk factors of C. difficile colonization in hospitalized colorectal cancer (CRC) and inflammatory bowel disease (IBD) patients remains unclear.  

Hypothesis:

This study aimed to evaluate the incidence of CDI on the after colectomy for CRC in IBD patients and determine those at risk during the preoperative period.

Methods:

We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) 2016 database for all colorectal surgery for CRC with concomitant IBD. These patients were then reviewed for CDI infection. Cases were recorded as emergent and elective. Standard statistical analysis, including multivariate regression, was performed to determine factors associated with complications.

Results:

55,236 colorectal surgeries (CRS) were reported at > 800 participating ACS-NSQIP hospitals. A total of 841 patients were identified with CDI of which 247 (29.3%) reported complications following CRS for neoplasm. Of these, fifty patients (20.2%) were identified with a history of IBD: 41 (82%) Crohn’s disease and 9 (18%) ulcerative colitis. Overall median age was 73.5 ± 16.3 years (range, 24 to >90), with 33 (66%) females and 82.0% identified as Caucasian. Majority of patients underwent elective surgery (66%), most commonly partial colectomy w/removal of terminal ileum & ileocolonic anastamosis ([n=39, 78%], CPT: 44160). Patients requiring emergency surgery were more likely to be males (p=0.042), have preoperative hypoalbuminemia (p=0.003) and longer hospital length of stays (LOS) (p=0.014). Wound classification was predictive of increased LOS (p= 0.049). We found no differences with transfusions (p= 0.677), age (p=0.935), diabetes (p= 0.700), and BMI (p=0.093). All patients were discharged alive following CRS however two deaths (4%) did occur the same year (p=0.044) in the emergent Crohns patients.

Conclusions:

Patients with underlying IBD completing CRC surgery are at risk for developing acute CDI. Crohns patients have a highest incidence of CDI following emergency CRC surgery.  Further research is needed to investigate the attributable risks of surgery due to CDI among patients with Crohn’s disease.