Role of Surgery in Clostridium difficile Infection

Abstract

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.

Danish national guideline for the treatment ofClostridioides difficileinfection and use of faecal microbiota transplantation (FMT)

“…An alternative to total colectomy or subtotal colectomy with blind closure of the rectum is the presentation of a loop ileostomy with the possibility of antegrade lavage with fluid, vancomycin or possibly FMT. The procedure of laparoscopic loop ileostomy, perioperative rinsing with fluid followed by rinsing with vancomycin is not inferior to colectomy in terms of mortality [66][67][68][69][70][71][72]. To date, antegrade lavage with donor faeces has not been described in the literature.…”

Defining the black box: a narrative review of factors associated with adverse outcomes from severe Clostridioides difficile infection

“…As Vely states in their discussion of the role of surgery in the treatment of CDI: ‘Resuscitation to euvolemia, early aggressive treatment with the appropriate antibiotics, and early surgical intervention are pivotal factors for better outcomes’. 100 …”

“…The most common surgical procedure performed is a total abdominal colectomy with end ileostomy. 94 , 100 Colectomy with end ileostomy has an estimated mortality rate of 34–71% which is significantly influenced by how well the patient is doing leading up to surgery. 14 In one systematic review of patient outcomes following emergency surgery for CDI, the frequency of surgery for patients with severe CDI (as determined by the original authors) was 29.9% (2.2–86%).…”

“… 94 The drawbacks associated with this procedure could lead clinicians to delay surgery in favor of giving medical therapy more time, but delaying surgical intervention can lead to worsening clinical status and then, in turn, worse surgical outcomes. 100 …”

“…14 Loop ileostomy with colonic lavage is one such procedure but does have limitations – it cannot be used if there is transmural necrosis, perforation or distal blockage. 100 One study comparing diverting loop ileostomy with colonic lavage demonstrated a reduced mortality rate when compared to a historical colectomy cohort. 94,104 A retrospective study did find this procedure was associated with less blood loss, shorter OR time and decreased mortality.…”