Colectomy for Fulminant Clostridium difficile Colitis: Predictors of Mortality

Abstract

The purpose of this study was to define clinical and radiographic variables associated with postoperative mortality after urgent colectomy for fulminant Clostridium difficile colitis. Data were obtained regarding patients undergoing colectomy for fulminant C. difficile colitis at two institutions (1997-2005). Univariate analysis of factors predicting 30-day mortality was performed using χ2 and Student's t tests. Multivariable logistic regression was done to include all variables whose P value was < 0.20. Clinical variables analyzed included: age, gender, recent operation, comorbidities, preoperative multisystem organ failure, vasopressors, symptom duration, time to surgery, serum albumin, change in serum albumin, serum creatinine, white blood cell count, and extent of colectomy. Computed tomography variables included: ascites, megacolon, and extent of colitis. Thirty-five patients (mean age 70 years, 46% male) underwent urgent colectomy for C. difficile colitis. The 30-day mortality rate was 45.7 per cent (16/35). The only clinical variable associated with mortality was preoperative multisystem organ failure (non-survivors 9/16 vs survivors: 4/19; P = 0.037). None of the three patients undergoing partial colectomy survived, although the difference in survival versus those undergoing subtotal colectomy was not significant. Patients with fulminant C. difficile colitis undergoing colectomy have a high mortality rate. Preoperative presence of multisystem organ failure was independently predictive of mortality.

Comparison of Outcomes Between Total Abdominal and Partial Colectomy for the Management of Severe, Complicated Clostridium Difficile Infection

“…5 Superiority of TAC over segmental-based (partial) colectomy (PC) for management of fulminant CDI has been attributed to disease control, given the diffuse colonic involvement that theoretically results in overall lower rates of mortality. 6 However, a few studies have reported that salvage of some of the colon may produce equivalent outcomes to sub-total colectomy in patients with severe, complicated CDI. 7 This is particularly interesting because total abdominal colectomy usually results in end ostomies, which are fraught with complications.…”

“…These findings suggest that a PC may be a viable surgical alternative to the widely held gold standard of TAC. 6 Recent reports have suggested that surgical management of severe, complicated CDI provides a survival advantage over medical therapy. 8 In our sample, the 30-day mortality rate was 35.2% (n 258), which is consistent with mortality estimates ranging from 35% to 80%.…”

“…8 In our sample, the 30-day mortality rate was 35.2% (n 258), which is consistent with mortality estimates ranging from 35% to 80%. 6,[9][10][11] Previous studies have indicated that partial colectomies are associated with decreased survival as compared with total colectomies. [12][13][14] However, existing literature has not retrospectively compared the 30-day mortality of partial vs TAC in a large, well-curated national cohort.…”

Clostridium Difficile Colitis in the United States: A Decade of Trends, Outcomes, Risk Factors for Colectomy, and Mortality after Colectomy

“…Among these methods are limited colon resections, which are rarely used because they have been shown to be associated with unacceptably high mortality and recurrence rates. 23,71,72 Details such as leukocytosis and requirement for vasopressors were found in multiple studies to be associated with mortality. 11,15,18,21,22,61 These variables, unfortunately, are not available in the NIS dataset.…”

“…[11][12][13][14][15][16][17][18] So it becomes important to identify patients with CDC who are likely to progress to fulminant colitis and subsequent colectomy, as well as patients at high risk for fatal outcomes after surgical management. Although these factors have been analyzed in small single-center series with significant disparities in the results, 9,11,[19][20][21][22][23] there are currently no population-based studies analyzing these factors in different settings. Moreover, there are no recent population-based studies examining the trends of CDC and the associated colectomy rates in the United States.…”