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Diverting loop ileostomy with colonic lavage as an alternative to colectomy for fulminant Clostridioides difficile: a systematic review and meta-analysis

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Abstract

Purpose

Surgical consultation is recommended for all patients with fulminant Clostridioides difficile infection (CDI). If surgery is required, total abdominal colectomy (TAC) is most commonly performed. However, diverting loop ileostomy and colonic lavage have been recently developed as a potential colon-sparing approach to fulminant CDI. The aim of this review is to compare TAC and diverting loop ileostomy with colonic lavage for fulminant CDI.

Methods

Search of MEDLINE, EMBASE, CENTRAL, and PubMed was performed. Articles were eligible for inclusion if they compared TAC and diverting loop ileostomy with colonic lavage. The primary outcome was postoperative mortality, and the secondary outcome was postoperative complications. Quality of included studies was assessed using Newcastle-Ottawa Scale.

Results

From 64 relevant citations, 5 studies (4 retrospective cohorts, 1 case series) with 3683 patients were included. Compared to TAC, diverting loop ileostomy with colonic lavage did not significantly reduce overall mortality (RR 1.10, 95% CI 0.60 to 1.99, P = 0.77), rate of reoperation (RR 1.02, 95% CI, 0.63 to 1.63, P = 0.94), or overall postoperative complications (RR 0.51, 95% CI, 0.22 to 1.17, P = 0.11). Rates of colonic preservation with the use of diverting loop ileostomy with colonic lavage ranged from 76% to 100%.

Conclusion

There does not appear to be a survival advantage with the use of diverting loop ileostomy with colonic lavage compared to TAC for fulminant CDI. However, diverting loop ileostomy with colonic lavage results in increased rates of colonic preservation, restoration of intestinal continuity, and laparoscopic surgery. This review is limited by the small number of included studies.

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References

  1. Steele SR, McCormick J, Melton GB, Paquette I, Rivadeneira DE, Stewart D, Buie WD, Rafferty J (2015) Practice parameters for the management of Clostridium difficile infection. Dis Colon Rectum 58(1):10–24. https://doi.org/10.1097/DCR.0000000000000289

    Article  PubMed  Google Scholar 

  2. Bagdasarian N, Rao K, Malani PN (2015) Diagnosis and treatment of Clostridium difficile in adults: a systematic review. JAMA 313(4):398–408. https://doi.org/10.1001/jama.2014.17103

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Gerding DN, Gelone SP, Cornely OA et al (2014) Vancomycin, metronidazole, or tolevamer for Clostridium difficile infection: results from two multinational, randomized, controlled trials. Clin Infect Dis 59(3):345–354. https://doi.org/10.1093/cid/ciu313

    Article  CAS  PubMed  Google Scholar 

  4. Halabi WJ, Nguyen VQ, Carmichael JC, Pigazzi A, Stamos MJ, Mills S (2013) Clostridium difficile colitis in the United States: a decade of trends, outcomes, risk factors for colectomy, and mortality after colectomy. J Am Coll Surg 217(5):802–812. https://doi.org/10.1016/j.jamcollsurg.2013.05.028

    Article  PubMed  Google Scholar 

  5. Joseph B, Azim A, Zangbar B, Bauman Z, OʼKeeffe T, Ibraheem K, Kulvatunyou N, Tang A, Latifi R, Rhee P (2017) Improving mortality in trauma laparotomy through the evolution of damage control resuscitation: analysis of 1,030 consecutive trauma laparotomies. J Trauma Acute Care Surg 82(2):328–333. https://doi.org/10.1097/TA.0000000000001273

    Article  PubMed  Google Scholar 

  6. Sailhamer E, Carson K, Chang Y (2009) Fulminant Clostridium difficile colitis: patterns of care and predictors of mortality. JAMA Surg 144(5):433–439. https://doi.org/10.1001/archsurg.2009.51

    Article  Google Scholar 

  7. Byrn J, Maun D, Gingold D (2008) Predictors of mortality after colectomy for fulminant Clostridium difficile colitis. JAMA Surg 143(2):150–154. https://doi.org/10.1001/archsurg.2007.46

    Article  Google Scholar 

  8. Dudukgian H, Gonzalez-Ruiz C, Etzioni DA, Kaiser AM (2010) C. difficile colitis—predictors of fatal outcome. J Gastrointest Surg 14(2):315–322

    Article  PubMed  Google Scholar 

  9. Hayden DM, Pinzon MCM, Francescatti AB, Edquist SC, Malczewski MR, Jolley JM, Brand MI, Saclarides TJ (2013) Hospital readmission for fluid and electrolyte abnormalities following ileostomy construction: preventable or unpredictable? J Gastrointest Surg 17(2):298–303. https://doi.org/10.1007/s11605-012-2073-5

    Article  PubMed  Google Scholar 

  10. Neal MD, Zuckerbraun BS, Hall DE, Simmons RL, Alverdy JC (2011) Diverting loop ileostomy and colonic lavage. Ann Surg 254(3):423–429. https://doi.org/10.1097/sla.0b013e31822ade48

    Article  PubMed  Google Scholar 

  11. Hall BR, Leinicke JA, Armijo PR, Smith LM, Langenfeld SJ, Oleynikov D (2019) No survival advantage exists for patients undergoing loop ileostomy for clostridium difficile colitis. Am J Surg 217(1):34–39. https://doi.org/10.1016/j.amjsurg.2018.09.023

    Article  PubMed  Google Scholar 

  12. Fashandi AZ, Martin AN, Wang PT, Hedrick TL, Friel CM, Smith PW, Hays RA, Hallowell PT (2017) An institutional comparison of total abdominal colectomy and diverting loop ileostomy and colonic lavage in the treatment of severe, complicated Clostridium difficile infections. Am J Surg 213(3):507–511. https://doi.org/10.1016/j.amjsurg.2016.11.036

    Article  PubMed  Google Scholar 

  13. Ferrada P, Callcut R, Zielinski MD, Bruns B, Yeh DD, Zakrison TL, Meizoso JP, Sarani B, Catalano RD, Kim P, Plant V, Pasley A, Dultz LA, Choudhry AJ, Haut ER, EAST Multi-Institutional Trials Committee (2017) Loop ileostomy versus total colectomy as surgical treatment for Clostridium difficile-associated disease: an eastern association for the surgery of trauma multicenter trial. J Trauma Acute Care Surg 83(1):36–40. https://doi.org/10.1097/TA.0000000000001498

    Article  PubMed  PubMed Central  Google Scholar 

  14. Juo Y-Y, Sanaiha Y, Jabaji Z, Benharash P (2019) Trends in diverting loop ileostomy vs total abdominal colectomy as surgical management for Clostridium difficile colitis. JAMA Surg 90095(10):899–906. https://doi.org/10.1001/jamasurg.2019.2141

    Article  Google Scholar 

  15. Moher D, Liberati A, Tetzlaff J, Altman DG, Prisma Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 151(4):264–269. https://doi.org/10.1371/journal.pmed.1000097

    Article  PubMed  Google Scholar 

  16. Wells GA, Shea B, O’Connell D, J Peterson, V Welch, M Losos, P Tugwell (2009) The Newcastle-Ottawa scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa Hospital Research Institute. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp

  17. Wan X, Wang W, Liu J, Tong T (2014) Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 14(1):135. https://doi.org/10.1186/1471-2288-14-135

    Article  PubMed  PubMed Central  Google Scholar 

  18. Higgins J, Green S, Jüni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JA (2011) Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. Br Med J. https://doi.org/10.1136/bmj.d5928

    Article  PubMed  PubMed Central  Google Scholar 

  19. Justiniano C, Temple L, Swanger A, Xu Z, Speranza JR, Cellini C, Salloum RM, Fleming FJ (2018) Readmissions with dehydration after ileostomy creation: rethinking risk factors. DCR. 61(11):1297–1305. https://doi.org/10.1097/DCR.0000000000001137

    Article  Google Scholar 

  20. Anaraki F, Vafaie M, Behboo R, Maghsoodi N, Esmaeilpour S, Safaee A (2012) Quality of life outcomes in patients living with stoma. Indian J Palliat Care 18(3):176–180. https://doi.org/10.4103/0973-1075.105687

    Article  PubMed  PubMed Central  Google Scholar 

  21. Arsan C, Gonzalez OY, Gillespie TL (2016) A fatal case of Clostridium difficile enterocolitis following diverting loop ileostomy reversal. Surg Infect Case Reports 1(1):16–18. https://doi.org/10.1089/crsi.2016.29004.ca

    Article  Google Scholar 

  22. Fashandi AZ, Ellis SR, Smith PW, Hallowell PT (2016) Overwhelming recurrent Clostridium difficile infection after reversal of diverting loop ileostomy created for prior fulminant C. difficile colitis. Am Surg 82(8):E194–E195

    PubMed  Google Scholar 

  23. Braga M, Vignali A, Gianotti L, Zuliani W, Radaelli G, Gruarin P, Dellabona P, di Carlo V (2002) Laparoscopic versus open colorectal surgery: a randomized trial on short-term outcome. Ann Surg 236(6):759–767. https://doi.org/10.1097/00000658-200212000-00008

    Article  PubMed  PubMed Central  Google Scholar 

  24. Gash K, Chambers W, Ghosh A, Dixon AR (2011) The role of laparoscopic surgery for the management of acute large bowel obstruction. Color Dis 13(3):263–266. https://doi.org/10.1111/j.1463-1318.2009.02123.x

    Article  CAS  Google Scholar 

  25. Farinella E, Cirocchi R, La Mura F et al (2009) Feasibility of laparoscopy for small bowel obstruction. World J Emerg Surg 4(1):1–9. https://doi.org/10.1186/1749-7922-4-3

    Article  Google Scholar 

  26. Tseng J, Loper B, Jain M, Lewis AV, Margulies DR, Alban RF (2017) Predictive factors of mortality after colectomy in ischemic colitis: an ACS-NSQIP database study. Trauma Surg Acute Care Open 2(1):e000126. https://doi.org/10.1136/tsaco-2017-000126

    Article  PubMed  PubMed Central  Google Scholar 

  27. De Silva S, Ma C, Proulx MC et al (2011) Postoperative complications and mortality following colectomy for ulcerative colitis. Clin Gastroenterol Hepatol 9(11):972–980. https://doi.org/10.1016/j.cgh.2011.07.016

    Article  PubMed  Google Scholar 

  28. Bhangu A, Nepogodiev D, Gupta A, Torrance A, Singh P (2012) Systematic review and meta-analysis of outcomes following emergency surgery for Clostridium difficile colitis. Br J Surg 99:1501–1513

    Article  CAS  PubMed  Google Scholar 

  29. McEllistrem MC, Carman RJ, Gerding DN, Genheimer CW, Zheng L (2004) A Hospital outbreak of Clostridium difficile disease associated with isolates carrying binary toxin genes. Clin Infect Dis 40(2):265–272. https://doi.org/10.1086/427113

    Article  PubMed  Google Scholar 

  30. Rubin M, Bodenstein L, Kent K (1995) Severe Clostridium difficile colitis. DCR. 38(4):350–354

    CAS  Google Scholar 

  31. Belmares J, Gerding DN, Parada JP, Miskevics S, Weaver F, Johnson S (2007) Outcome of metronidazole therapy for Clostridium difficile disease and correlation with a scoring system. J Inf Secur 55(6):495–501. https://doi.org/10.1016/j.jinf.2007.09.015

    Article  Google Scholar 

  32. Van Der Wilden GM, Chang Y, Cropano C et al (2014) Fulminant clostridium difficile colitis: prospective development of a risk scoring system. J Trauma Acute Care Surg 76(2):424–430. https://doi.org/10.1097/TA.0000000000000105

    Article  PubMed  Google Scholar 

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Acknowledgments

We thank Jo-Anne Petropoulos, an expert medical librarian, for her assistance with the literature search development.

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Author notes

  1. Tyler McKechnie and Yung Lee contributed equally to this work.

Authors and Affiliations

  1. Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, L8N 4A6, Canada

    Tyler McKechnie & Yung Lee

  2. Division of General Surgery, Department of Surgery, McMaster University, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada

    Tyler McKechnie, Yung Lee, Jeremy E. Springer, Aristithes G. Doumouras, Dennis Hong & Cagla Eskicioglu

  3. Division of General Surgery, Department of Surgery, St. Joseph Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada

    Aristithes G. Doumouras, Dennis Hong & Cagla Eskicioglu

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  1. Tyler McKechnie
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Contributions

Study concept and design – Eskicioglu, Hong, McKechnie, Lee

Acquisition of data – McKechnie, Lee

Analysis and interpretation of data – All authors

Drafting of manuscript – Doumouras, Springer, McKechnie, Lee

Critical revision of the manuscript for intellectual content – All authors

Final approval of version to be published – All authors

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Correspondence to Cagla Eskicioglu.

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Tyler McKechnie and Yung Lee joint first authors.

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McKechnie, T., Lee, Y., Springer, J.E. et al. Diverting loop ileostomy with colonic lavage as an alternative to colectomy for fulminant Clostridioides difficile: a systematic review and meta-analysis. Int J Colorectal Dis 35, 1–8 (2020). https://doi.org/10.1007/s00384-019-03447-3

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