Neal MD, Alverdy JC, Hall DE, Simmons RL, Zuckerbraun BS, et al.
Annals of surgery. Date of publication 2011 Sep 1;volume 254(3):423-7; discussion 427-9.
1. Ann Surg. 2011 Sep;254(3):423-7; discussion 427-9. doi:
10.1097/SLA.0b013e31822ade48.
Diverting loop ileostomy and colonic lavage: an alternative to total abdominal
colectomy for the treatment of severe, complicated Clostridium difficile
associated disease.
Neal MD(1), Alverdy JC, Hall DE, Simmons RL, Zuckerbraun BS.
Author information:
(1)Department of Surgery, University of Pittsburgh School of Medicine,
Pittsburgh, PA, USA.
Comment in
Can J Surg. 2014 Jun;57(3):214-6.
OBJECTIVE: To determine whether a minimally invasive, colon-preserving approach
could serve as an alternative to total colectomy in the treatment of severe,
complicated Clostridium difficile-associated disease (CDAD).
BACKGROUND: C. difficile is a significant cause of morbidity and mortality
worldwide. Most cases will respond to antibiotic therapy, but 3% to 10% of
patients progress to a severe, complicated, or "fulminant" state of
life-threatening systemic toxicity. Although the advocated surgical treatment of
total abdominal colectomy with end ileostomy improves survival in severe,
complicated CDAD, outcomes remain poor with associated mortality rates ranging
from 35% to 80%.
METHODS: All patients who were diagnosed with severe, complicated ("fulminant")
CDAD and were treated at the University of Pittsburgh Medical Center or VA
Pittsburgh Healthcare System between June 2009 and January 2011 were treated with
this novel approach. The surgical approach involved creation of a loop ileostomy,
intraoperative colonic lavage with warmed polyethylene glycol 3350/electrolyte
solution via the ileostomy and postoperative antegrade instillation of vancomycin
flushes via the ileostomy. The primary end point for the study was resolution of
CDAD. The matching number of patients treated with colectomy for CDAD preceding
the initiation of this current treatment strategy was analyzed for historical
comparison.
RESULTS: Forty-two patients were treated during this time period. There was no
significant difference in age, sex, pharmacologic immunosuppression, and Acute
Physiology and Chronic Health Evaluation-II scores between our current cohort and
historical controls. The operation was accomplished laparoscopically in 35
patients (83%). This treatment strategy resulted in reduced mortality compared to
our historical population (19% vs 50%; odds ratio, 0.24; P = 0.006). Preservation
of the colon was achieved in 39 of 42 patients (93%).
CONCLUSIONS: Loop ileostomy and colonic lavage are an alternative to colectomy in
the treatment of severe, complicated CDAD resulting in reduced morbidity and
preservation of the colon.
DOI: 10.1097/SLA.0b013e31822ade48
PMID: 21865943 [Indexed for MEDLINE]
