Transoral Incisionless Fundoplication With EsophyX for Gastro-Esophageal Reflux Disease: Long-Term Results and Pre-Procedure Findings Affecting Outcomes

Background & Goal: Patients commonly are exposed to various medications during the incubation period and time of diagnosis of C. difficile infection. Our hypothesis is that exposure to specific medications during C. difficile infection is predictive of different outcomes in pts with CDAD than in patients without CDAD. Methods: We retrospectively identified consecutive pts who had a C. difficile toxin assay obtained at Montefiore Medical Center. Our case group (Grp 1) included all pts with a positive toxin assay. Our control group (Grp 2) consisted of age-, sexand Charlson co-morbidity score-matched controls with diarrhea and negative toxin assay(s). We recorded various demographic factors and medication exposures during the incubation period and at the time of toxin assay for C. difficile. Acid suppressive medications, antibiotics, anti-fungal and anti-viral agents, NSAIDS and opiates (82 total medications) were considered. Our primary end-point was 30-day mortality and secondary end-points included ICU stay, surgical intervention and whether the patient remained hospitalized 30 days after toxin assay. Outcome analyses were performed for each medication considering each end-point and statistical analysis completed using SPSS (16.0) software. Results: Grps 1 and 2 consisted of 1096 and 1065 pts, respectively. Grp 1 had a higher mortality rate (15.3% vs. 10.8%, p < 0.01) and rate of pts remaining hospitalized for >30 days after toxin assay (11.9% vs. 6.7%, p < 0.001). There were no significant differences between groups 1 and 2 of rates of ICU stay and surgical treatment. After considering age, Charlson co-morbidity score and all medications that independently predicted 30-day mortality with statistical significance, significant multivariate predictors included: Grp 1: age (p<0.001), acetaminophen (p= 0.002), aztreonam (p= 0.002), piperacillin/tazobactam (p=0.001), gentamycin (p<0.02), oxycodone/acetaminophen (p<0.05) and fentanyl (p=0.02); Grp 2: Age (p<0.001), Charlson score (p<0.001), vancomycin IV (P= 0.001), cefipime (p<0.01) and fentanyl (0.013). When a similar analysis was performed using ≥30-day hospitalization after toxin assay as its end-point, significant multivariate predictors included: Grp 1: Acetaminophen (p=0.002), oxycodone/acetaminophen (p<0.05), fentanyl (p<0.01), PPI use (p<0.02) and vancomycin IV (p<0.01). Grp 2: Fentanyl use (p= 0.02) and vancomycin IV (p<0.001). Conclusions: Patients with CDAD were hospitalized for > 30-days more frequently and had higher mortality rates compared with non-CDAD patients who had diarrhea. Acetaminophen, certain antibiotics and fentanyl administration predicted short-term mortality in patients with CDAD compared with patients who had symptomatic non-CDAD diarrhea. The use of acetaminophen and proton pump inhibitors are unique predictors for prolonged hospitalization in patients with CDAD.