By Will Boggs MD
NEW YORK (Reuters Health) - 11/7/2019
Diverting loop ileostomy (LI) is increasingly favored over total abdominal colectomy (TAC) for the surgical management of patients with fulminant Clostridium difficile colitis, according to a new study.
Surgical management of C. difficile colitis is reserved for patients who do not respond to nonoperative interventions. Compared with TAC, LI offers a less invasive and organ-preserving approach, and a recent study found no mortality differences between these surgical approaches.
Dr. Peyman Benharash and colleagues from the University of California, Los Angeles, used data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample to examine the national trends in the use of LI for treating fulminant C. difficile colitis and compared its outcomes with those of patients receiving TAC.
From 2011 to 2015, 3,021 patients underwent surgery for fulminant C. difficile colitis, including 79.7% who received TAC and 20.3% who underwent LI.
Total annual operations performed declined from 831 in 2011 to 445 in 2014, a period during which the proportion treated with LI more than doubled, from 12.9% to 26.5%, the researchers report in JAMA Surgery, online July 3.
Compared with TAC, LI was performed on younger patients with fewer comorbidities and was more commonly performed in hospitals with more beds and in urban teaching hospitals.
Significantly more patients undergoing LI (21.2%) than undergoing TAC (11.4%) had surgery on hospital day 0, although there was no difference in median hospital day at which the operations occurred.
In-hospital mortality did not differ significantly between LI (26.0%) and TAC (31.1%, P=0.28), and there were no significant differences between the groups in length of stay or postoperative hemorrhage.
Surprisingly, the rates of operative wound disruption (5.6% for LI vs. 2.3% for TAC) and surgical-site infection (8.9% vs. 3.6%) were significantly higher for LI than for TAC.
Higher age, Medicaid coverage, and higher comorbidity index score were associated with higher in-hospital mortality, whereas having received surgery at a hospital in the western United States and experiencing wound disruption or infectious complications were associated with lower postoperative mortality.
The authors speculate that the paradoxical association between complications and lower mortality was attributable to the longer time at risk for patients who survived the operation, as patients who died during hospitalization died early following surgery and had a shorter time at risk for experiencing such complications.
"While results from randomized clinical trials and a better understanding of functional outcomes are both needed, it appears that LI is (a) viable alternative for acute care surgeons during management of fulminant C. difficile colitis," they conclude.
"Selection bias is the main pitfall of the study," writes Dr. Marja A. Boermeester from Amsterdam University Medical Centers in an accompanying editorial.
"Whether loop ileostomy represents a promising surgical alternative to total abdominal colectomy is verifiable only if we understand the determinants that lead to the choice of either ileostomy or colectomy," she says. "We need to understand in more detail what directs treatment choice and how this reflects treatment outcome, because in-hospital mortality is comparable among the 2 treatment groups."
"Loop ileostomy treatment of fulminant Clostridium colitis deserves more attention, and that underpins the merit of this study, but we are still in need of a better understanding of what would work best in which patient profile," Dr. Boermeester concludes. "Also, we need long-term results of proportionate stoma reversal and associated complications."
Dr. Brian S. Zuckerbraun of the University of Pittsburgh School of Medicine, in Pennsylvania, who has studied the surgical management of complicated C. difficile infection, told Reuters Health by email, "I think the results of this study and one other database study reinforce that this is an alternative therapy in most cases, with at least on par outcomes to total colectomy in the short term and perhaps improved long-term outcomes given the fact that patients keep their colons."
"From our experience with over 100 patients now, diverting loop ileostomy and colonic lavage is an option for most patients," he said. "Total abdominal colectomy would be preferred in patients that have abdominal compartment syndrome or any evidence of colonic vascular compromise or perforation."
"I believe the most important take-away lessons from our growing experience with this and other surgical procedures is that early surgical consultation and the decision for early surgical management in patients that are critically ill or whose condition is worsening saves lives," said Dr. Zuckerbraun, who was not involved in the new study.
Research from another group recently showed lower mortality with LI than with TAC in patients with C. difficile-associated disease. Dr. Paula Ferrada from Virginia Commonwealth University, in Richmond, who worked on that study, told Reuters Health by email, "Early surgical consultation, increased awareness, and early initiation of maximum medical treatment, as well as a multidisciplinary approach, helps our patients survive."
The "incidence of C. difficile is increasing internationally; establishing and following guidelines is a priority for improved patient outcomes," she said.
Dr. Benharash declined to comment on the findings.
JAMA Surg 2019.