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Clostridium Difficile Infection: No Longer the Infection of Antibiotic Associated Diarrhea
Tu1735
ileus was defined as (re)placement of a nasogastric tube in the postop period, no bowel function for more than 6 days, or diet cessation due to distension. An ERP for elective colorectal surgery was implemented at our institution in 3/2015. Outcome variables assessed included postoperative ileus (POI), time to diet, time to flatus, length of stay, mortality, 30 day readmission, and reoperation. Results: Eighty-one patients were identified who met the inclusion criteria. There were 41 males and 40 females. Demographic variables are detailed in Table 1. The most common diagnosis was colorectal cancer (49%) and the most common ileostomy creation procedure was a low anterior resection with ileostomy (43%) (Table 2). Ileostomy reversal was performed after a median interval of 96 days. Median operative time was 81 minutes, and 82.7% (n=67) were stapled closure while 17.3% (n=14) were handsewn. POI occurred in 19.8% (16) of patients. POI was seen more often in diabetics (50% vs 17%, p=0.05) and in hand-sewn closure (50% vs 13%, p=0.001). POI was significantly reduced in the ERP era (after 3/2015) than before (7% ERP era, vs 33% before ERP, p= 0.003). POI was lower when the ERP order set was used (7% with ERP vs 27% no ERP, p=0.023). Length of stay was shorter with ERP (3.1±1.8 vs 5.0±4.5, p=0.026). The readmission rate was higher in the POI (31% vs 8%, p=0.01). Re-operation was 2.5% (n=2) for anastomotic leak, with one death. Conclusions: Implementation of an Enhanced Recovery Pathway significantly improves POI after ileostomy closure. Diabetes and technical factors ( sutured vs stapled ) may increase the risk of POI, however the effect of the ERP appears to improve outcomes even in those patients. The effect may be cumulative from the index procedure as well as the ileostomy closure itself.
NOD2 ALLELE VARIANT AND MICROBIOME DIFFERENCES CONTRIBUTE TO THE OCCURRENCE OF POUCHITIS IN ONE OF TWO FAP SIBLINGS FOLLOWING ILEAL POUCH-ANAL ANASTOMOSIS Kathleen M. Schieffer, Justin Wright, Leonard Harris, Sue Deiling, Gregory S. Yochum, Regina Lamendella, Walter Koltun Introduction Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is a common surgical method for treatment of familial adenomatous polyposis (FAP) and ulcerative colitis (UC). Inflammation of the ileal pouch reservoir, termed pouchitis, is common in UC patients but rare in FAP. This differential disease outcome is thought to be related to both microbial and genetic factors. In 2009, due to a family history of FAP, siblings AP (18 yo) and BP (16 yo) underwent IPAA surgery. Patient BP developed severe pouchitis within 3 months of surgery and has intermittently since, while patient AP has remained pouchitis-free. The mother, CP, also had IPAA surgery and has not developed pouchitis. A remote family history of Crohn's disease was identified, so we investigated this pedigree to elucidate the possible genetic and microbial differences that might explain this unusual picture of pouchitis in a single FAP patient. Methods The family pedigree is shown in Figure 1. The two brothers (AP and BP) were investigated, in addition to their parents (CP and DP). Due to its role in innate mucosal host defense in recognizing bacterial antigens, SNPs in the NOD2 gene [rs2076756, rs17221417, rs2066844, rs2066847] were interrogated using a custom Illumina array. Risk allele variants identified were subsequently confirmed by Sanger sequencing. The composition of mucosa-associated bacteria was defined using 16S rRNA gene sequencing on terminal ileum and rectal tissue obtained immediately after surgical resection from the two brothers (AP and BP) using the Illumina MiSeq and analyzed using QIIME 1.9.0. Results The sibling with pouchitis (BP) carried a single CD-associated risk allele for NOD2 (rs17221417 G), whereas his brother and mother did not. Microbiome sequencing found reduced levels of what has been suggested to be in other studies "beneficial" bacteria (Faecalibacterium prausnitzii, Bacteroides, and Ruminococcaceae) in BP relative to his brother, AP. Conclusion These findings implicate the NOD2 signaling pathway in the pathogenesis of pouchitis. Differences found in the microbiome of pouchitis patients may be due to alterations of host innate immunity, including the NOD2 pathway.
SSAT Abstracts
Tu1736 CLOSTRIDIUM DIFFICILE INFECTION: NO LONGER THE INFECTION OF ANTIBIOTIC ASSOCIATED DIARRHEA Yizhi Shan, Prabhu Senthil-Kumar, Mark Zebley, Fernando Bonanni, Michael Nussbaum, Thai Vu, James Yuschak, Orlando Kirton, Ryan Shadis Clostridium difficile infection is traditionally taught to be an antibiotic associated diarrhea. This diagnosis is based on the presence of clinical symptoms (usually defined as more than 3 watery, loose or unformed stool within 24 hours) coupled with a diagnostic test. There is now a new presentation of C. difficile infection, including progression to toxic megacolon, in patients without diarrhea. We report a case series of 9 patients in a single institution who developed C. difficile infection without preceding diarrhea, and 4 patients needed a total colectomy. All 9 patients had colitis with positive laboratory testing for C difficile toxin. They, however, presented with a lack of or minimal bowel movements. 6 patients had rapid development of abdominal distention. 7 patients received stool softeners, suppositories and/ or enemas for presumed constipation. 4 patients had a mild course of infection and were successfully treated medically. The other 5 patients progressed rapidly to multisystem organ failure, and eventually required total colectomy. Out of the 5 patients that required total colectomy, 2 expired. For patients who rapidly develop abdominal distention, especially if coupled with multi-system organ failure, C difficile infection must be part of the differential regardless of the presence of diarrhea.
Tu1737 ENHANCED RECOVERY PATHWAY USE REDUCES POSTOPERATIVE ILEUS AFTER ILEOSTOMY CLOSURE Michael Deutsch, Hae Soo Joung, Prashant Sinha, Paresh C. Shah Introduction: Postoperative ileus (POI) following loop ileostomy closure is a common and persistent problem which can prolong hospitalization. Enhanced Recovery Pathway (ERP) use has been demonstrated to improve peri-operative outcomes after colo-rectal resections. We sought to identify whether the systemic implementation of an ERP would also improve outcomes after ileostomy closure. This study reports the experience of a high volume, quaternary care, academic medical center where >70% of primary colo-rectal surgery is performed using laparoscopic or robotic techniques. Methods: All adult patients undergoing elective ileostomy closure at our center from 1/1/2013 through 5/31/2016 were reviewed. Cases with multiple major procedures, ileo-colonic anastomosis and incomplete medical record data were excluded. Closure technique was per surgeon preference. Pre-and postoperative variables were captured as part of our ERP monitoring program. Postoperative
S-1303
SSAT Abstracts
ileus was defined as (re)placement of a nasogastric tube in the postop period, no bowel function for more than 6 days, or diet cessation due to distension. An ERP for elective colorectal surgery was implemented at our institution in 3/2015. Outcome variables assessed included postoperative ileus (POI), time to diet, time to flatus, length of stay, mortality, 30 day readmission, and reoperation. Results: Eighty-one patients were identified who met the inclusion criteria. There were 41 males and 40 females. Demographic variables are detailed in Table 1. The most common diagnosis was colorectal cancer (49%) and the most common ileostomy creation procedure was a low anterior resection with ileostomy (43%) (Table 2). Ileostomy reversal was performed after a median interval of 96 days. Median operative time was 81 minutes, and 82.7% (n=67) were stapled closure while 17.3% (n=14) were handsewn. POI occurred in 19.8% (16) of patients. POI was seen more often in diabetics (50% vs 17%, p=0.05) and in hand-sewn closure (50% vs 13%, p=0.001). POI was significantly reduced in the ERP era (after 3/2015) than before (7% ERP era, vs 33% before ERP, p= 0.003). POI was lower when the ERP order set was used (7% with ERP vs 27% no ERP, p=0.023). Length of stay was shorter with ERP (3.1±1.8 vs 5.0±4.5, p=0.026). The readmission rate was higher in the POI (31% vs 8%, p=0.01). Re-operation was 2.5% (n=2) for anastomotic leak, with one death. Conclusions: Implementation of an Enhanced Recovery Pathway significantly improves POI after ileostomy closure. Diabetes and technical factors ( sutured vs stapled ) may increase the risk of POI, however the effect of the ERP appears to improve outcomes even in those patients. The effect may be cumulative from the index procedure as well as the ileostomy closure itself.
NOD2 ALLELE VARIANT AND MICROBIOME DIFFERENCES CONTRIBUTE TO THE OCCURRENCE OF POUCHITIS IN ONE OF TWO FAP SIBLINGS FOLLOWING ILEAL POUCH-ANAL ANASTOMOSIS Kathleen M. Schieffer, Justin Wright, Leonard Harris, Sue Deiling, Gregory S. Yochum, Regina Lamendella, Walter Koltun Introduction Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is a common surgical method for treatment of familial adenomatous polyposis (FAP) and ulcerative colitis (UC). Inflammation of the ileal pouch reservoir, termed pouchitis, is common in UC patients but rare in FAP. This differential disease outcome is thought to be related to both microbial and genetic factors. In 2009, due to a family history of FAP, siblings AP (18 yo) and BP (16 yo) underwent IPAA surgery. Patient BP developed severe pouchitis within 3 months of surgery and has intermittently since, while patient AP has remained pouchitis-free. The mother, CP, also had IPAA surgery and has not developed pouchitis. A remote family history of Crohn's disease was identified, so we investigated this pedigree to elucidate the possible genetic and microbial differences that might explain this unusual picture of pouchitis in a single FAP patient. Methods The family pedigree is shown in Figure 1. The two brothers (AP and BP) were investigated, in addition to their parents (CP and DP). Due to its role in innate mucosal host defense in recognizing bacterial antigens, SNPs in the NOD2 gene [rs2076756, rs17221417, rs2066844, rs2066847] were interrogated using a custom Illumina array. Risk allele variants identified were subsequently confirmed by Sanger sequencing. The composition of mucosa-associated bacteria was defined using 16S rRNA gene sequencing on terminal ileum and rectal tissue obtained immediately after surgical resection from the two brothers (AP and BP) using the Illumina MiSeq and analyzed using QIIME 1.9.0. Results The sibling with pouchitis (BP) carried a single CD-associated risk allele for NOD2 (rs17221417 G), whereas his brother and mother did not. Microbiome sequencing found reduced levels of what has been suggested to be in other studies "beneficial" bacteria (Faecalibacterium prausnitzii, Bacteroides, and Ruminococcaceae) in BP relative to his brother, AP. Conclusion These findings implicate the NOD2 signaling pathway in the pathogenesis of pouchitis. Differences found in the microbiome of pouchitis patients may be due to alterations of host innate immunity, including the NOD2 pathway.
SSAT Abstracts
Tu1736 CLOSTRIDIUM DIFFICILE INFECTION: NO LONGER THE INFECTION OF ANTIBIOTIC ASSOCIATED DIARRHEA Yizhi Shan, Prabhu Senthil-Kumar, Mark Zebley, Fernando Bonanni, Michael Nussbaum, Thai Vu, James Yuschak, Orlando Kirton, Ryan Shadis Clostridium difficile infection is traditionally taught to be an antibiotic associated diarrhea. This diagnosis is based on the presence of clinical symptoms (usually defined as more than 3 watery, loose or unformed stool within 24 hours) coupled with a diagnostic test. There is now a new presentation of C. difficile infection, including progression to toxic megacolon, in patients without diarrhea. We report a case series of 9 patients in a single institution who developed C. difficile infection without preceding diarrhea, and 4 patients needed a total colectomy. All 9 patients had colitis with positive laboratory testing for C difficile toxin. They, however, presented with a lack of or minimal bowel movements. 6 patients had rapid development of abdominal distention. 7 patients received stool softeners, suppositories and/ or enemas for presumed constipation. 4 patients had a mild course of infection and were successfully treated medically. The other 5 patients progressed rapidly to multisystem organ failure, and eventually required total colectomy. Out of the 5 patients that required total colectomy, 2 expired. For patients who rapidly develop abdominal distention, especially if coupled with multi-system organ failure, C difficile infection must be part of the differential regardless of the presence of diarrhea.
Tu1737 ENHANCED RECOVERY PATHWAY USE REDUCES POSTOPERATIVE ILEUS AFTER ILEOSTOMY CLOSURE Michael Deutsch, Hae Soo Joung, Prashant Sinha, Paresh C. Shah Introduction: Postoperative ileus (POI) following loop ileostomy closure is a common and persistent problem which can prolong hospitalization. Enhanced Recovery Pathway (ERP) use has been demonstrated to improve peri-operative outcomes after colo-rectal resections. We sought to identify whether the systemic implementation of an ERP would also improve outcomes after ileostomy closure. This study reports the experience of a high volume, quaternary care, academic medical center where >70% of primary colo-rectal surgery is performed using laparoscopic or robotic techniques. Methods: All adult patients undergoing elective ileostomy closure at our center from 1/1/2013 through 5/31/2016 were reviewed. Cases with multiple major procedures, ileo-colonic anastomosis and incomplete medical record data were excluded. Closure technique was per surgeon preference. Pre-and postoperative variables were captured as part of our ERP monitoring program. Postoperative
S-1303
SSAT Abstracts