Assessing Risk and Related Complications after Reversal of Combat-Associated Ostomies

Luke R Johnston; Matthew J Bradley; Carlos J Rodriguez; Michael P McNally; Eric A Elster; James E Duncan

doi:10.1016/j.jamcollsurg.2018.05.008

Assessing Risk and Related Complications after Reversal of Combat-Associated Ostomies

J Am Coll Surg. 2018 Sep;227(3):367-373. doi: 10.1016/j.jamcollsurg.2018.05.008. Epub 2018 Jun 12.

Authors

Luke R Johnston¹, Matthew J Bradley², Carlos J Rodriguez³, Michael P McNally³, Eric A Elster⁴, James E Duncan³

Affiliations

¹ Department of Surgery, Uniformed Services University of the Health Sciences-Walter Reed National Military Medical Center, Bethesda, MD. Electronic address: luke.r.johnston.mil@mail.mil.
² Department of Surgery, Uniformed Services University of the Health Sciences-Walter Reed National Military Medical Center, Bethesda, MD; Surgical Critical Care Initiative, Uniformed Services University, Bethesda, MD; Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD.
³ Department of Surgery, Uniformed Services University of the Health Sciences-Walter Reed National Military Medical Center, Bethesda, MD.
⁴ Department of Surgery, Uniformed Services University of the Health Sciences-Walter Reed National Military Medical Center, Bethesda, MD; Surgical Critical Care Initiative, Uniformed Services University, Bethesda, MD.

PMID: 29906614
DOI: 10.1016/j.jamcollsurg.2018.05.008

Abstract

Background: During the past decade of conflict, numerous patients with combat-associated injuries required the formation of an ostomy. However, outcomes in those patients undergoing ostomy reversal have yet to be analyzed. We review the experience and identify risk factors for complications after ostomy reversal in a series of patients with combat injuries at our military treatment facility.

Study design: A retrospective review of patients with combat-associated injuries managed with a diverting ostomy who underwent ostomy reversal at our military treatment facility during a 13-year period. Demographic and clinical data were collected for all patients and postoperative complications were identified. Multivariate analysis was performed to identify independent risk factors for complications after reversal. Complication rates were calculated for 90-day periods of time after ostomy creation and best-fit curve analysis was conducted.

Results: Ninety-nine patients were identified who underwent ostomy reversal. Forty patients (40.4%) suffered a post-reversal complication. On multivariate analysis, older age (odds ratio 1.11/y; p = 0.038), severe perineal injury indication for diversion (odds ratio 4.37; p = 0.028), and increased time interval between ostomy creation and reversal (odds ratio 1.005/d; p = 0.037), were independently associated with postoperative complications. A cubic regression best fit quarterly complication rate data (R² 0.526; p < 0.001) and calculates a minimum complication rate for reversal 90 to 180 days after ostomy creation.

Conclusions: Ostomy reversal in patients wounded in combat is a major undertaking with a high complication rate. The finding of a shorter interval from ostomy creation to reversal independently associated with a reduction in complications provides a modifiable risk factor to guide future practice and potentially reduce complications. Our modeling suggests reversal in the 3- to 6-month time frame can have the lowest rate of complications. Future research to reduce complications is indicated, especially in older patients with perineal wounds.

MeSH terms

Adult
Colostomy*
Humans
Ileostomy*
Male
Military Personnel*
Postoperative Complications / etiology*
Registries
Retrospective Studies
Risk Assessment
Risk Factors
War-Related Injuries / surgery*