EP366 - X Marks the Spot - an ACS-NSQIP Analysis of Who Gets Stoma Marking in Proctectomy Patients

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Purpose/Background: All patients undergoing operations with the possibility of stoma creation should have pre-operative marking. Marking is associated with reduced stoma-site complications and improved ostomy education. However, there is a lack of understanding as to who does not get marked to better target future interventions. This study evaluated pre-operative and demographic factors associated with marking using the Proctectomy procedure-targeted National Surgical Quality Improvement Project (NSQIP) database.

Methods/Interventions: Patients were identified from current procedural terminology (CPT) codes for pelvic exenteration, colostomy, or ileostomy. The proctectomy-targeted and general NSQIP databases from 2016-2022 were merged. The primary outcome was pre-operative stoma marking, which is explicitly captured. Demographic and clinical variables of interest were selected a priori. Univariable and multivariable logistic regressions were performed.

Results/Outcomes: A total of 22,394 patients met inclusion criteria – 12,088 (54%) with end colostomy and 10,306 (46%) with ileostomy or diverting ostomy. Of these patients, 9,826 (44%) were female, 14,904 (67%) were white, and median age was 58 (IQR 45-68). Indications for surgery were as follows: 13,660 (61%) cancer, 6,256 (28%) inflammatory bowel disease (IBD), and 2,487 (11%) other benign. Most patients [20,920 (93%)] were elective.

Overall, 17,194 (76.8%) patients received pre-operative marking. Marking varied by indication: cancer (82%), IBD (71%), and other benign (62%, p< 0.0001). Males received marking 77.4% and females 76% of the time (p= 0.01). White patients were marked 78% of the time, American Indians 76.8%, Asians 80%, Blacks 78%, Hispanics 71%, Pacific Islanders 67.6%, and other race 73% (p < 0.0001). Elective patients were marked 78% of the time, while non-elective patients were marked 61% (p < 0.0001). Patients undergoing surgery on the day of admission were marked 77% of the time while those undergoing surgery on days 1 through 5 were marked 71% and those having surgery after 5 days were marked 70% (p < 0.0001).

On multivariable analysis, compared to cancer patients, patients with IBD had 42% lower odds of marking and other benign diseases had 61% lower odds. Compared to White patients, Hispanic patients had 35% lower odds of marking. Patients undergoing non-elective operations had 55% lower odds of marking. Patients undergoing operations resulting in ileostomy or diverting ostomy had 27% lower odds of marking than those receiving an end colostomy.

Also on multivariable analysis, odds of marking increased with patient age (3% with each 10-year increase) and with year of surgery (4% increase every year between 2016 and 2022). Relative to patients undergoing surgery on the day of admission, patients undergoing an operation between one and five days of admission or greater than five days of admission had 28% and 52% greater odds of marking, respectively.

Conclusion/Discussion: We found that roughly one quarter of patients did not receive pre-operative stoma marking, though the number of patients marked is increasing over time. After controlling for pre-operative and demographic variables with multivariable logistic regression, IBD or other benign diagnoses, Hispanic ethnicity, younger age, non-elective operations, same-day operations, and ileostomy or diverting ostomies were associated with lower stoma marking rates. Future studies should focus on the reasons for reduced marking in these at-risk populations and may inform initiatives to improve adherence nationwide.