Trends in Diverting Loop Ileostomy vs Total Abdominal Colectomy as Surgical Management forClostridium difficileColitis

Abstract

IMPORTANCE Diverting loop ileostomy and colonic lavage has generated much interest since it was first reported as a potential alternative to total abdominal colectomy for treating Clostridium difficile colitis in 2011. To our knowledge, few studies have validated the benefit reported in the initial description, and the association of this new approach with practice patterns has not been described. OBJECTIVE To examine the national adoption pattern and outcomes of diverting loop ileostomy vs total abdominal colectomy as treatment for fulminant C difficile colitis. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from hospitals participating in the National Inpatient Sample database across the United States from January 2011 to September 2015 and included 3021 adult patients who underwent surgery for C difficile colitis during the study period, comprising 2408 subtotal colectomies and 613 loop ileostomies. The data were analyzed between November 2018 and April 2019. EXPOSURES Loop ileostomy as surgery of choice. MAIN OUTCOMES AND MEASURES In-hospital mortality. RESULTS Of 2408 participants, 1416 (58.8%) were women, 1781 (78.4%) were white, and 627 (21.6%) were individuals of color and the mean (SD) age was 68.2 (14.8) years. During the overall study period, 613 patients (20.28%) underwent diverting loop ileostomy without total abdominal colectomy. The annual proportion of patients undergoing only diversion increased from 11.16% in 2011 to 25.30% in 2015. Significantly more loop ileostomies were performed within the first day of hospitalization, in contrast to subtotal colectomies (23.31% vs 12.21%; P < .01). There was no significant difference in in-hospital mortality rates between the 2 groups (25.98% vs 31.18%; P = .28). CONCLUSIONS AND RELEVANCE This study demonstrates the adoption of diverting loop ileostomy to treat C difficile colitis across the United States. While fulminant C difficile colitis remains a condition with high mortality rates, no significant difference in this outcome was observed between loop ileostomy and total abdominal colectomy. Loop ileostomy may represent a viable surgical alternative to total abdominal colectomy, although the grounds for selection of treatment need to be clarified.

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

“…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. Perioperative factors reported in each study are listed in Table 2.…”

“…The original study by Neal et al 9 offered the only prospective data for DLI, but used historically matched retrospective data for their TAC group. The 2 largest and most recent studies used national administrative databases, 14,15 while the rest were either single or multi-institutional cohort studies. All studies were comparative, comparing outcomes between DLI and TAC.…”

“…18 Although there have been significant improvements in recognition and treatment of fulminant C. difficile colitis, it remains a life-threatening condition disproportionately affecting older adults. 1 Despite an unclear benefit in mortality associated with DLI for fulminant CDI, Juo et al 15 showed that there has been an increased adoption of DLI as a surgical technique in the United States (11% in 2011 to 25% in 2015). With the surgical community moving forward with DLI as an option for fulminant CDI without robust clinical evidence, a careful examination of the available data is necessary.…”

“…Despite these initial promising findings, no other study has been able to replicate as dramatic of an effect on mortality as Neal et al In 2017, Ferrada et al reported a decreased adjusted overall mortality for DLI (17.2% vs. 39.7%) in their multi-institutional study; however, no other reports have been able to demonstrate this effect. 17 Recently, Juo et al 15 published the largest study to date using the Nationwide Inpatient Sample and found no difference in in-hospital mortality between the 2 operations. Differences in mortality may be partially explained by differences in patients' preoperative condition, acuity level, and comorbidities (ie patient selection bias favoring DLI).…”

“…The percent of adverse events for DLI vs. TAC is shown in the last two columns. Juo et al 15 reported a significantly higher rate of wound and infectious complications in the DLI group. Conversion to colectomy in the DLI group was reported by all 5 studies and ranged from 0 to 14%.…”