An institutional comparison of total abdominal colectomy and diverting loop ileostomy and colonic lavage in the treatment of severe, complicated Clostridium difficile infections

Fashandi, Anna Z.; Martin, Allison N.; Wang, Patty T.; Hedrick, Traci L.; Friel, Charles M.; Smith, Philip W.; Hays, Rachel; Hallowell, Peter T.

doi:10.1016/j.amjsurg.2016.11.036

Cited by 31 publications

(21 citation statements)

References 11 publications

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“…Furthermore, there are findings in at least one small series which describes CDAD recurrence after re-anastomosis (13). Recently, Fashandi et al published a case series showing no difference in mortality between LI and TC, but a higher recurrence rate of CDAD with colon preservation (14). …”

Section: Introductionmentioning

confidence: 99%

Loop ileostomy versus total colectomy as surgical treatment for Clostridium difficile–associated disease

Ferrada

Callcut

Zielinski

et al. 2017

Journal of Trauma and Acute Care Surgery

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Objectives The mortality of patients with Clostridum Dificile Associated Disease (CDAD) requiring surgery continues to be very high. Loop ileostomy (LI) was introduced as an alternative procedure to total colectomy (TC) for CDAD by a single center study. To date, no reproducible results have been published. The objective of this study is to compare these two procedures in a multicentric approach to help the surgeon decide what procedure is best suited for the patient in need. Methods This was a retrospective multicenter study conducted under the sponsorship of the Eastern Association for the Surgery of Trauma (EAST). Demographics, medical history, clinical presentation, APACHE score, and outcomes were collected. We used the Research Electronic Data Capture (REDCap) tool to store the data. Mann-Whitney (continuous data) and Fisher’s Exact (categorical data) were utilized to compare TC with LI. Logistic regression was performed to determine predictors of mortality. A propensity score analysis was done to control for potential confounders and determine adjusted mortality rates by procedure type. Results We collected data from 10 centers of patients that presented with CDAD requiring surgery between July 1of 2010 to July 30 of 2014. Two patients died during the surgical procedure leaving 98 individuals in the study. The overall mortality was 32% and 75% suffered postoperative complications. Median age was 64.5 years, 59% were male. Concerning preoperative patient conditions 54% were on pressors, 47% had renal failure, and 36% suffered respiratory failure. When comparing TC and LI, there was no statistical difference regarding these conditions. Univariate pre-procedure predictors of mortality were age, lactate, timing of operation, vasopressor use, and acute renal failure. There was no statistical difference between the APACHE score of patients undergoing either procedure (TC=22 vs LI= 16). Adjusted mortality (controlled for pre-procedure confounders) was significantly lower in the LI group (17.2% vs. 39.7%, p=0.002). Conclusions This is the first multicenter study comparing TC with LI for the treatment of CDAD. In this study LI carried less mortality than TC. In patients without contraindications, LI should be considered for the surgical treatment of CDAD. Level of evidence prognostic retrospective multi-centric level III

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Section: Introductionmentioning

confidence: 99%

Loop ileostomy versus total colectomy as surgical treatment for Clostridium difficile–associated disease

Ferrada

Callcut

Zielinski

et al. 2017

Journal of Trauma and Acute Care Surgery

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“…Where specified, DLI was performed laparoscopically 73% of the time (range 64-83%). 9,14,16 Patients undergoing DLI tended to be younger; however, this was only reported as significant in one study. 15 No differences were reported by gender.…”

Section: Resultsmentioning

confidence: 90%

Diverting Loop Ileostomy for Clostridium Difficile Colitis: A Systematic Review and Meta-analysis

Shellito

Russell

2020

The American Surgeon

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Diverting loop ileostomy (DLI) with colonic lavage has been proposed as an alternative to total abdominal colectomy (TAC) for fulminant Clostridium difficile infection (CDI). Controversy exists regarding the mortality benefit and outcomes of this surgical approach. We conducted a MEDLINE database search for articles between 1999 and 2019 pertaining to DLI for the surgical treatment of CDI. Five articles met the inclusion criteria. Four studies were retrospective and one was a prospective matched cohort study. 3683 patients were included in the 5 studies; 733 patients (20%) underwent DLI, while 2950 patients (80%) underwent TAC. The only shared outcome measure across all 5 studies was mortality. The overall mortality rate for the entire cohort undergoing both procedures was 30.3%. There was no statistically significant difference in pooled mortality between DLI and TAC (OR: .73; 95% CI, .45-1.2; P = .22). Reporting of other postoperative outcomes was variable. Fulminant CDI remains a life-threatening condition with high mortality. Loop ileostomy may be a viable surgical alternative to total colectomy with similar mortality; however, further work is needed to determine specific patient characteristics that warrant routine use of DLI.

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“…Lack of adherence to the protocol or the prescience of a distal obstruction are two factors that can be corrected by the treating team. 26,27 Hypervirulent strains of Clostridium and resistance to the treatment are other considerations. 28 In our experience, when this procedure is performed patients start improving within 48 hours.…”

Section: Failure Of Loop Ileostomymentioning

confidence: 99%

“…Some recurrences of CDI or reinfections can be seen when the continuity of the bowel is reestablished. [26][27][28] Fecal transplant could be a consideration before reanastomosis in these patients to help prevent recurrence. [29][30][31]…”

Section: When To Reverse the Loop Ileostomy?mentioning

confidence: 99%

Role of Surgery in Clostridium difficile Infection

Vely

Ferrada

2020

Clinics in Colon and Rectal Surgery

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Clostridium (reclassified as “Clostridioides”) difficile infection (CDI) occurs as a chronic or an acute illness with intensity varying from mild to severe. Although most cases of CDI can be managed with antibiotics and supportive care, when the patient presents with fulminant disease, the early decision to perform surgery is imperative for survival. The current standard of care is the subtotal colectomy. However, loop ileostomy with vancomycin enemas delivered into the colonic mucosa has been described as a viable option on selected patients.

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An institutional comparison of total abdominal colectomy and diverting loop ileostomy and colonic lavage in the treatment of severe, complicated Clostridium difficile infections

Cited by 31 publications

References 11 publications

Loop ileostomy versus total colectomy as surgical treatment for Clostridium difficile–associated disease

Loop ileostomy versus total colectomy as surgical treatment for Clostridium difficile–associated disease

Diverting Loop Ileostomy for Clostridium Difficile Colitis: A Systematic Review and Meta-analysis

Role of Surgery in Clostridium difficile Infection

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