title: Surgical site infections (SSIs) after stoma reversal (SR): risk factors, implications, and protective strategies.
abstract: BACKGROUND
  Stoma reversals (SRs) are commonly performed with potentially significant postoperative complications including surgical site infections (SSIs). Our aim was to determine the incidence and risk factors for SSIs in a large cohort of SR patients.
  
  
  METHODS
  We reviewed our institutional 2006-2011 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for 30-day SSIs in patients undergoing SR. Records were additionally reviewed for 10 non-ACS-NSQIP variables. The primary outcome was SSI after SR. Secondary outcomes were additional 30-day postoperative complications and length-of-stay. Predictors of SSIs were identified using multivariable logistic regression.
  
  
  RESULTS
  From 528 SR patients, 36 patients developed a SSI (6.8 %). Most patients underwent SR for loop ileostomies (76.5 %) after index operations for ulcerative colitis (38.6 %) and colorectal cancer (27.8 %). SSI patients had fewer subcutaneous drains compared to patients with no SSI and had significantly higher rates of smoking, ASA 3-4 classification and laparotomies at SR (p < 0.05). Patients with SSI had increased length-of-stay and 30-day morbidities including sepsis and returns to the operating room (p < 0.05) compared to no-SSI patients. On multivariable analysis, subcutaneous drain placement was suggestive of SSI protection (odds ratio [OR] 0.52, 95 % confidence interval [CI] 0.2-1.1), but only smoking was significantly associated with an increased risk for SSI (OR 2.4, 95 % CI 1.1-5.4).
  
  
  CONCLUSIONS
  Smoking increased the risk of SR SSIs in patients by over twofold, and SR SSIs are associated with additional significant morbidities. Smoking cessation should be an important part of any SSI risk-reduction strategy.
authors.affiliation: Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, 1720 2nd Avenue South, KB427, Birmingham, AL, 35294, USA, daniel.chu@aya.yale.edu.
authors.forename: Daniel I
authors.initials: DI
authors.lastname: Chu
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Schlieve
authors.forename: Dorin T
authors.initials: DT
authors.lastname: Colibaseanu
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Simpson
authors.forename: Amy E
authors.initials: AE
authors.lastname: Wagie
authors.forename: Robert R
authors.initials: RR
authors.lastname: Cima
authors.forename: Elizabeth B
authors.initials: EB
authors.lastname: Habermann
mesh_terms: D004322:Drainage / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D007081:Ileostomy; D015994:Incidence; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D012086:Reoperation; D012307:Risk Factors; D018805:Sepsis / Q000209:etiology; D012907:Smoking / Q000453:epidemiology*; D013530:Surgical Wound Infection / Q000150:complications / Q000453:epidemiology* / Q000517:prevention & control*